EPtalk by Dr. Jayne 12/21/23

I’ve spent the majority of my career helping people use healthcare technology as efficiently as possible. It gets under my skin when clinicians report wildly inefficient workflows and I always want to dig in to see if I can fix them.

The grating example this week occurred in an article featured in a communication from the American Medical Association. In the piece, the AMA’s vice president of professional satisfaction, Christine Sinsky, MD, claims that workflows for immunization ordering had gone from a verbal order to “21 clicks… to order a flu shot for one patient.”

Although I understand the sentiment, I’m wondering if this isn’t a bit of an exaggeration. There are now thousands of clinical informaticists out there who have dedicated their careers to stamping out what can only be considered a horrific workflow if it actually exists. I’m wondering if she’s not referring to the entire immunization documentation process, which is more than simply placing an order and had a significant number of steps in the paper world if practices were doing it properly.

I don’t think examples like this are helpful, especially if they are inaccurate or if people are comparing apples to oranges. If your workflow for ordering (and not administering) an immunization is really 21 clicks, I encourage you to reach out. Let’s name and shame organizations where this is happening.

The AMA was busy this week, also publishing an article about EHR usability and safety challenges. The article cites a 2018 report looking at EHR safety. I’ve seen some significant improvements in the base versions of EHRs in the last few years and I don’t think it’s necessarily fair to regurgitate data from a half decade ago.

I think also when we look at EHR safety and efficiency, it’s important to note that many clients are not using their vendors’ systems out of the box. I’ve watched client after client configure perfectly good EHRs into the stuff of user nightmares. This typically occurs when those responsible for installing and implementing the EHR don’t understand clinical workflow, don’t have adequate clinical governance, and/or don’t have adequate clinical and end user participation. Usually, these deficiencies are directly related to budget, timing, and politics, a sad combination that often sabotages projects before they start.

Unfortunately, some of the concerns do still exist a half decade later. Physicians and other clinicians are doing too much non-value-added data entry, they’re encountering too many alerts that don’t improve patient care, and they’re dealing with content, including drug databases, that isn’t updated with the appropriate frequency. Couple that with inadequate training and rising expectations for patient throughput and you have a recipe for unhappiness all around.

There are also rising expectations for care quality. When you looked at physicians in practice 25 years ago, they were tracking health maintenance screenings and chronic care management elements, but they weren’t necessarily being graded (or paid) based on their outcomes. Now, insurance contracts have added bonuses and penalties for performance, and regardless of EHR use, there is simply more expected of physicians and clinicians. It’s easy to blame the EHR and to wax nostalgic about the good old days of paper charts, but there are so many more complicated factors at play. I watched two more of my family medicine colleagues retire this month and miss them already.

From ShowMe: “Re: the go-live of the Missouri Prescription Drug Monitoring Program (PDMP) last week. I was able to log in through my existing credentials with the St. Louis County PDMP, although I did have to accept new state-level terms and conditions. On the previous system, I had requests for midlevel providers to become delegates under my license that had been pending since I left a previous employer in 2017. They were still there on the new system, but I was finally able to figure out how to decline them. As expected, there were two major inconveniences: the absence of information from surrounding states, and the loss of records of past searches. It will take time for the new system to build up a history on some patients and it still feels a little like two steps forward but three steps back.” Missouri is the last to deploy a statewide solution, and I wish all the clinicians the best as they navigate the transition.

From Internet of Things: “Re: the proliferation of web-connected devices. It’s cool until it’s not. Healthcare isn’t the only single-threaded industry in which connectivity issues can bring everything to a screeching halt. The local school district has lost all internet communication and phone lines due to a fiber-optic cable being cut somewhere, although they don’t know where yet. They have learned that literally everything is tied to the internet, including the bell to start and end classes and the automatic motion-detection light switches. For two days (so far), the kids have been sitting in the intermittent dark, with administrators using an air horn to announce the beginning/end and periods at school. It’s so loud I can hear one school’s horn blow every 42 minutes. They can’t assign, grade, or update any work and it’s finals week. Did I mention that even the photocopiers are internet-based, and they can’t print out worksheets or paper tests?” I come from a long line of teachers and I bet the ones who are having to teach in that environment are losing their minds. It’s already a rough time of year, with many students dealing with end-of-semester anxiety, too much holiday excitement, or increasing levels of family dysfunction. Here’s to those courageous souls that need to make it through just a couple of more days before break starts.

The holiday season is also a time when companies occasionally behave badly. One colleague reported that his hybrid employer took all in-town employees out for lunch, but completely ignored the remote team. I guess management has never heard of sending Uber Eats or DoorDash? Holiday gifts abound, often with company logos and questionable usefulness. Among the best I have received during my career: a Total Wine gift card, small picnic cooler, a $100 bill, and jumper cables. Among the worst: a Santa hat with a company logo, a vanity-published book written by the company founder, framed pictures of the CEO, a rock with an inspirational word carved into it, and nothing.

Does your employer give holiday gifts that put them in the hall of fame? Or are they more deserving of admission to the hall of shame? Leave a comment or email me.

Email Dr. Jayne.