Curbside Consult with Dr. Jayne 1/20/25

Several of my primary care friends got together tonight to drink margaritas. Partly because we’ve all got cabin fever from the weather, and partly to commiserate about our worries about what’s about to happen to public health in the United States.

We did the math and estimated that the group has easily spent over half a million hours in scheduled patient care during the last 25 years. If you figure a conservative four patients per hour, that’s more than two million times we’ve walked into an exam room asking, “How can I help you today?” and creating an individualized care plan for the patient in front of us. Some of the group have been practicing medicine for longer than 25 years, and especially once the tequila was flowing, the good stories started coming out.

On the whole, we think we have some well-founded fears. One member of the group has spent her career working in public health and is worried about the gag clauses that some states have put in place that prohibit conversations about vaccines, even ones that have been around for decades. As one does when one is a clinical informaticist and having drinks with other physicians, I asked my favorite generative AI tool to list the top 10 public health achievements.

Vaccinations are right up there, along with fluoridated drinking water and family planning. These have been under fire for years and the administration that takes office this week has them in their crosshairs. Also in the top five are tobacco control, which we’re improving upon in the US, and improvements to maternal and infant health, where we’re not doing well compared to other developed nations.

Another top item is workplace safety, where I agree that in thinking back over a century, we’ve come a long way. However, healthcare folks are still at high risk when they go to work, facing everything from infectious diseases and radiation exposure to musculoskeletal injuries and workplace violence. Families of police officers and firefighters have long faced the possibility that their loved ones might not come home from their scheduled shifts, but now healthcare workers are starting to have the same conversations. Additionally, physicians and emergency medical services staffers are more likely to die by suicide than the general public. I’m hoping that sobering statistics will lead lawmakers to allocate more resources to care for the caregivers, but I’m not sure how much state governments or our national legislature will take this on.

A couple of us had recently been at a former colleague’s retirement party and shared what we heard in his retirement speech. He was leaving primary care after 20 years in the patient care trenches, which seems short based on how much training you have to do to become a physician, but which can seem like an eternity when you’re working in a demanding, production-based environment where moral injury is occurring daily.

He finally decided to leave after a series of administrative disasters in his health system-owned practice, such as penalties for physicians who run late with their office schedules. The idea that patients should be scheduled for 10-minute slots and that spending 15 minutes on a visit was too much time was more than he could personally take.

Although a couple of us knew the full story behind his decision, most of the people at the retirement party didn’t. We expected him to throw at least a little bit of shade at his soon-to-be former employer. We were pleasantly surprised when he gave a recap of some of the things he’s been through in practice and some of the good things that have happened over the last two decades, reminding us that physicians have traditionally persevered during times of adversity.

Some of the notable events he mentioned included increases in discussions of end-of-life care following some dramatic court decisions and the creation of Medicare Part D. He talked about severe challenges physicians have faced, such as Hurricane Katrina, when patients were stranded in hospitals without electricity, water, or sanitation. He reminded us that it wasn’t just lobbyists that pushed for electronic health records, but patient safety advocates who saw what happened with that hurricane as well as Hurricane Rita, which came just a month later and where tens of thousands of patient records were damaged or lost.

As expected, he had a few choice words about Meaningful Use and excessive clicking in EHRs, but reminded us of some good things that have come with technology, such as no longer having to take our board exams in a convention center with hundreds of other test takers bearing handfuls of sharpened number two pencils. He reminded us that physicians have historically risen to the occasion when it seemed like the world went sideways, and that the majority of us had survived a global pandemic together. It was a nice reminder that although we may be facing difficult conversations with our patients about vaccine safety, fluoride in the water, and the risks of drinking raw milk, at least we don’t have a novel pathogen stalking the globe at the moment.

He told the assembled crowd that he plans to do volunteer work in a part of the world that has few medical resources. He hopes to regain some of the joy found in caring for patients, even though it will be a physically and mentally challenging environment. I’ve known him for a long time and am very glad to hear that he isn’t hanging up his stethoscope just yet, but based on his career and his involvement in medicine outside his practice, I know that both his patients and the community are going to miss him.

My margarita-drinking colleagues enjoyed hearing about some of the things we mentioned from the speech. Especially since for many of us, some of those events have moved to the far reaches of our memories or have been suppressed as a coping mechanism. Any that any time someone talks about the pandemic, I’m still prone to flashbacks of how I felt coming home from the emergency department, changing clothes in the garage, and trying desperately to not bring home a virus that could kill my family. Still, there were some good reminders that things have been worse and that there are still plenty of people out there who respect physicians, public health workers, and the experience and expertise that we bring to the table.

I’m sure things will look a bit less rosy when the tequila wears off, but we’ve agreed to try to get together regularly to support each other in the months to come. We also created a buzzword bingo card to help us find some humor to go along with the feelings of futility some of us are likely to feel. It will be interesting to see how many more of us retire early or move to a different type of practice with the continued evolution of healthcare. Some of the group are exploring alternatives, but given my work in clinical informatics, I don’t think I’ll be writing a retirement speech anytime soon.

What are you seeing in your healthcare crystal ball for 2025? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/16/25

For many readers, CES will always be the Consumer Electronics Show in our heads, no matter what kind of branding updates the conference receives. It’s been on my bucket list for years, although I’ve never quite gotten around to attending.

Planning travel in January is always tricky for those of us who live in states where snow and ice happen. Had I planned to attend this year, it’s doubtful that I would have been able to get there due to snowpocalypse. Regardless, I’m still a fan, and get plenty of press releases related to the event. A couple of things caught my eye this year.

The first is robot vacuums and their continued evolution. Companies used CES to launch products that media folks are referring to as butlers since they have the ability to retrieve items. Roborock and Dreame have units with graspers that can pick up items so that they can vacuum, adding them to a bin for later human intervention. The former can pick up a 300-gram item, while the latter can lift up to 500 grams. This puts a lot of pet toys in the pickup range, so I can see the utility. Other units have been enhanced with capabilities that let them go up and down floor transitions, and apparently Samsung has one that can identify unexpected movement and notify the owner.

I also was drawn in by the press releases from Withings, which released its Omnia product at CES. The solution goes beyond the smart scale platform to incorporate a so-called smart mirror that can deliver health insights and wellness recommendations based on data from Withings devices and third-party apps. The Cardio Check-Up feature can enable reviews of heart-related data by cardiologists, although I’m sure any end user agreement will include plenty of disclaimers about this not being intended to form a physician-patient relationship. I’ve used a wi-fi enabled Withings blood pressure cuff for years, and not only is it accurate, it has outstanding battery life. I’m not quite ready for a smart scale or a smart mirror yet, unless the latter can help me apply eyeliner when I don’t have my contact lenses in.

HIMSS is emailing members to promote its new membership program, trying to convince us it brings value other than a discounted admission to the annual conference. It promises “tailored professional resources” and “expanded networking opportunities” in a vague and unenticing way. I’m sure some of us remember its ill-fated online engagement platform, which disappeared after fizzling in a noticeable way. The email urges recipients to stay tuned for more information, but honestly I’m not sure what is being offered that wasn’t already present.

I’m on a local committee to try to improve health outcomes for the young people in our community, so I was eager to read the most-viewed articles of 2024 list from JAMA Peds. I wasn’t surprised at all that some of the pieces that topped the list were tech related. These are the articles that pediatricians are reading the most, so if you have small children in your life (or care about the health outcomes of all small children), it’s good to take note. Here’s the highlight reel:

• “Screen Time and Parent-Child Talk When Children Are Aged 12 to 36 Months.” Validating what I see nearly every time I travel, the authors conclude that “screen time is a mechanism that may be getting in the way of children experiencing a language-rich home environment during the early years.” It doesn’t take a high-powered study to see that when parents are glued to their phones and their toddlers are glued to tablets, no one is having a conversation.
• “Early-Childhood Tablet Use and Outbursts of Anger.” Tablet use contributes to a cycle of frustration as “child tablet use at age 3.5 years was associated with more expressions of anger and frustration by the age of 4.5 years. Child proneness to anger / frustration at age 4.5 years was then associated with more use of tablets by age 5.5 years.” If you want your child to have greater skills for emotional regulation, tablets are not the way to go.
• “Early-Life Digital Media Experiences and Development of Atypical Sensory Processing.” Higher levels of early exposure to digital media correlate with “specific sensory-related behaviors, including those seen in autism spectrum disorder.” The authors propose additional research to understand why as well as to determine whether limiting media exposure can improve outcomes.

Lake Superior State University, which I’ll admit that I hadn’t heard of prior to this week, released its 2025 list of words that should be banished. Mr. H and I both have words that are on our pet peeve lists, and some of these are a definite overlap for me:

1. Cringe.
2. Game changer.
3. Era.
4. Dropped.
5. IYKYK (if you know, you know).
6. Sorry not sorry.
7. Skibidi.
8. 100%.
9. Utilize.
10. Period.

The list of words began in 1976 when the university’s public relations director and his team released its first “List of Words Banished from the Queen’s English for Mis-Use, Over-Use, and General Uselessness.” The list’s popularity has grown and the University now receives suggestions from around the world. If you have a few minutes to visit the site, it’s worth your time since they provide specifics on why the words were included. Overuse is a prime reason.

For some of the words, alternatives are offered, reminding us that as our elementary school teachers always said, the thesaurus can be our friend. General annoyance was also cited several times, including for skibidi, and in that case, I wholeheartedly agree. The word utilize has long been on Mr. H’s pet peeve list, so I’m glad it was called out. Next year will be the 50th anniversary of the list, so I can’t wait to see what makes the cut for such a momentous occasion. If you’ve got a word you want voted off the linguistic island, you can submit it here.

What are your top picks for words that are weak, pitiful, wretched, cheesy, uninspired, or warmed-over? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/13/25

I’ve worked in two different situations where the arrival of private equity funding dramatically changed the patient care environment.

The first was when I was working in the emergency department. Although I was a contractor, I worked for a physician-owned organization that treated us fairly and was overall pleasant to work for. Unfortunately, our contract ended, and rather than renew it with us, the hospital went with a private equity-backed firm that promised to onboard the existing staff so that there would be no problems with quality of care. As one can guess, this didn’t happen. Although the full-time physicians were hired, none of the part-time physicians were offered contracts. Instead, we were replaced by midlevel providers, some of whom were brand new to the safety net hospital environment.

Since I was also working on the informatics team, I saw that in the first six months, there were spikes in emergency department wait times, an increase in patient complaints, and a host of other data findings that supported concerns about how the new provider group was operating. We went from having zero administrative leadership meetings where the emergency department was a topic to having to address issues at nearly every session. Hundreds of hours of administrative time were spent dealing with all of the complaints and issues and threatening the new group with contractual penalties. They would improve just enough to get our leaders to back off, and then things would slide again. After three years of this, their contract ran out and they were replaced with another group. I can’t help but think about how many hours were wasted dealing with their nonsense and how that time could have been better spent on patient-centric initiatives.

The next time I encountered private equity folks in the clinical space was in the urgent care setting, when the physician founders sold a 51% stake to a private equity organization. There was a lot of cheerleading when the announcement was made on our 7 a.m. provider call. I was fortunate to be at home during that call and not at one of the facilities, so I could immediately dig up some information on who had just bought us.

It turns out that although they were an established organization, they were just starting to get into the healthcare space. Their experience had been with multiple franchises of a chicken wing restaurant, although they had a couple of imaging center acquisitions under their belts. Although we had been pressured previously to maximize billing and promote our highly profitable in-house pharmacy, the pressure to focus on these measures rather than actual patient care outcomes was intense. I ended up resigning not long after the private equity firm took control, but had to work out a 90-day notice period, which was far more painful than I would have imagined.

It was with these experiences in mind that I saw an original investigation piece that was published in JAMA this week, directly addressing the topic of “Changes in Patient Care Experience After Private Equity Acquisition of US Hospitals.” The authors looked at 73 private equity-acquired hospitals alongside 293 control hospitals, finding that “global measures of patient care experience worsened after private equity acquisition of hospitals, as did patient-reported staff responsiveness.” Additionally, the changes in these measures continued to increase with each year following the acquisition.

In digging deeper into the research, I found that it looked at data from 2008 to 2019 and looked specifically at patient experience measures from three years prior to an acquisition to three years after. The primary outcomes of the study were part of the standardized Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey, namely the overall hospital reading and patient willingness to recommend the facility. Secondary outcomes were also assessed from among the remaining HCAPS measures and included those on clinical process, communication, and environmental measures. It should be noted that this goes beyond patient satisfaction – bad experiences have been associated with longer times to recover from an illness, failure to follow treatment plans, and increased utilization of healthcare resources.

The authors followed a thorough process in matching the acquired hospitals with relevant controls, looking at bed count, whether or not the facility was a teaching hospital, metropolitan versus non-metropolitan, safety status, geographic region, and year. In their discussion, they review a number of reasons why care experience might change as a result of private equity ownership of hospitals. The first one is fairly straightforward – nurse staffing. There is a strong association with staffing ratios and patient care experience, and one of the first things that private equity-led organizations do when they come in is to reduce the nurse-to-bed ratios. In states where there are no laws addressing this, conditions can become downright dangerous. I’ve heard horror stories from my peers at large for-profit organizations, and concerns that leadership just becomes desensitized to the fact that patients are actual human beings and not just nebulous “consumers.”

These organizations also institute cost-cutting measures that span all aspects of patient care, from the supply chain to housekeeping and facilities management. The authors note that such strategies “may not be aligned with clinician and health system efforts to improve patient care.” They go on to call upon policymakers to consider a higher level of oversight for private equity acquisitions and to consider minimum staffing ratios to further protect patients. The authors note that there are some limitations to the study, one being the relative opacity on data surrounding private equity acquisitions. In my experience, however, when PE comes to town, all you have to do is talk to the people caring for the patients because they’re highly motivated to share what is going on. They also start buffing up their resumes and may ask if you’re hiring within your competitor organization. It doesn’t take much to figure out what is going on.

Large numbers of my physician colleagues are burned out and quite a few continue to choose early retirement. When you ask them what the most significant issues are, inability to do the right thing for their patients tops the list, along with lack of physician autonomy. The problem of administrators who are more focused on profits than patients is right up there, and depending on the facility, might be cited as the primary problem. As long as our healthcare system is for profit (we all know the non-profits are making buckets of cash too, they’re just not calling it a profit) I don’t see anything changing.

What do you think about the continued movement of private equity into the healthcare space? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 1/9/25

The hot topic around the virtual water cooler this week was the push to use real-world evidence (RWE) while caring for patients. This topic has become more relevant as increasing number of clinicians have access to RWE while caring for patients.

This kind of data can have particular strengths, including demonstrating how medications and other treatments actually work with real patient populations versus those found in clinical trials. It can also be used for post-marketing surveillance of new drugs and treatments.

However, there can be challenges depending on how clinicians are looking at the data. For example, if you’re looking at how clinicians are treating certain types of patients, one has to still understand why they might be choosing those therapies and whether those patterns are consistent with the evidence from rigorous clinical trials.

If you don’t take that into consideration, there can be a slippery slope where “everyone’s doing it, I should too” overrules graded recommendations. Depending on how data is sourced, there’s the potential for RWE to function as an echo chamber.

For example, if a large health system is pulling RWE data from their EHR, it’s going to be influenced by the formularies that are in place at its facilities. One might not see more appropriate treatment patterns that better match conventional evidence because the majority of drugs that are being prescribed for a given condition are done so in order to achieve formulary compliance and to avoid prior authorizations or additional work.

The consensus among physicians in the discussion was that real-world evidence has its place, but it shouldn’t overshadow the recommendations that are gleaned from robust clinical trials or gathered through expert consensus.

Mr. H. mentioned it earlier this week, but I would be remiss if I didn’t include my own mention of the Lown Institute’s 2024 Shkreli Awards, recognizing “the worst examples of profiteering and dysfunction in healthcare.” The list is named after so-called pharma bro Martin Shkreli. If you’re not familiar with his exploits, I would recommend spending a minute or two with your favorite search engine.

There have been a number of terrible individuals and organizations in healthcare over the last several decades. I might have reconsidered my career choices had I known how bad it could be. My academic advisor had a sweet job lined up for me in the world of publication, and although I’m sure it would have been interesting, I can’t imagine it would have been as much of a thrill ride as healthcare has been.

For people who are new to the industry, I would encourage you to look at previous iterations of the Awards. Many of you are inspired and altruistic, and previous lists will provide some clues about things to watch out for.

This year’s list includes a medical school that failed to notify the next of kin before selling the body parts of the deceased, inappropriate procedures to “treat” infant tongue ties, exorbitant air ambulance bills, the focus on profits of private equity hospitals, and insurance companies behaving badly. Although it only ranked fourth on the list of 10, my personal pick for the worst of the worst is an oncologist who recommended unnecessary cancer treatment for patients. Let me know if you have other callouts for folks that should have made the list but didn’t.

Speaking of tacky behavior, I recently received a so-called “grateful patient” solicitation from an organization where I recently received care. The problem is that the care I received was not in keeping with the standard of care and left me confused, concerned, and a witness to a HIPAA violation. I reported these issues to the provider at the time of care and was asked to reflect them in my patient survey when I received it. I did that and have had exactly zero contact from the institution. Let’s see if attaching a summary of my recent visit to the grateful patient response card inspires anyone there to reach out.

I admit that I fall victim to clickbait-style headlines as much as the next person, so this one caught my attention: “Hospital at home needs an ‘Uber app,’ Mayo Clinic leader says.” The piece features comments from Michael Maniaci MD, chief clinical officer of advanced care at home for the organization. He notes that Mayo Clinic can’t scale beyond its current volume of 30-35 patients per day due to lack of coordination for staffing, supply, and other patient needs. He states, “Imagine an Uber app where the car chassis, the tires, the fuel, the engine, and the driver all show up separately. You have the tubing coming from someplace, prescription medication coming from another place, the nurse coming from one place, the DME and the pump coming from another place — and they all have to show up at the same time.”

Sounds a bit like what healthcare organizations have been doing in other developed countries for years, minus the “we need an app” bit. I have a medical school classmate who worked for an organization in Germany that provided care to patients in their homes. It sent out a fully equipped medical vehicle that was stocked with almost everything you could receive from a high-acuity urgent care or freestanding emergency department. Another classmate who worked in the United Kingdom was partnered with public health nurses who rounded on patients and provided care beyond what we consider typical nursing care in the US.

For these models to be successful, you need a certain degree of vertical integration that we don’t typically have in our fragmented healthcare system. When your insurance contracts with a home care agency that isn’t affiliated with the hospital from which you were just discharged, there will be disconnects. I’m not convinced that an app is the answer, and would instead put my money on concepts that align all facets of care with the patient and their outcomes rather than aligning with profit motives or passing the buck to other agencies.

Another article that caught my eye this week was a viewpoint piece in the Journal of the American Medical Association that addressed health privacy and the use of synthetic data. Although this approach can help mitigate issues with insufficient private health data, it introduces additional challenges due to the fact that healthcare is a complicated and highly regulated environment. The authors note difficulties in creating data points that accurately represent rare conditions or highly complex clinical presentations such as scenarios that take place in the intensive care unit. There is also the risk of bias with synthetic data particularly when it is used at scale.

They go on to state the need for standards to generate and evaluate synthetic data. I woud be interested to hear from readers who are involved in organizational use of synthetic data and the approaches that are being taken to ensure that the promise is fulfilled.

Shortly after many people around the world rang in the New Year with a cocktail, US Surgeon General Vivek Murthy released a recommendation that alcohol products receive a warning label that advises consumers of the increased cancer risk associated with alcohol consumption. This would literally require an act of Congress. As we head towards HIMSS and another year of conferences, it will be interesting to see if health-forward organizations continue hosting alcohol-laden happy hours in their booths or if they use it as an opportunity to trim budgets as well as to promote health.

Will you reduce or eliminate alcohol consumption based on these recommendations? Whether yes or no, what’s your favorite beverage pick for 2025? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 1/6/25

Since the Snowpocalypse is upon large portions of the US, I decided to show solidarity by staying home, making baked goods, and working on my reading list.

I’ve gravitated towards audiobooks in a big way. They have become my preferred way to consume fiction because I can enjoy them while doing household tasks, driving, and in many more situations than I can enjoy a paper book or even one on my trusty Kindle. For non-fiction, I still like to have a physical book in hand, especially one that references previous sections or chapters since it’s so much easier to flip back and forth.

This weekend’s paper read was one I had picked up from the library a number of weeks ago. I decided to finish it so that it could go back into circulation. I was originally drawn to the book through a reference in an article I was reading that talked about how the internet is responsible for making people “dumber.”

Barely into the first chapter, I was seeing parallels between the book’s discussion of how true expertise is being devalued and the conversation I had recently with a colleague who cited “patients arguing with me all the time” as the chief source of her burnout. The first chapter addresses the idea of differentiating “experts” from “citizens” and the role that each has played in society. Experts typically have specific credentials, although the book identifies different levels of experts bearing credentials: those with aptitude or talent or experience in the field who also have credentials, and those who just have credentials.

We see the latter in medicine and I see it often in the startup world. People who have the MD or DO degree decided to go into business rather than completing a residency, and thus have never cared for patients independently or learned to bear the direct individual responsibility for another person’s life. It’s different when you’re talking about lives in the abstract or in the aggregate than when you’re sitting at the bedside with a patient and family whose treatment didn’t go the way they expected. Those with credentials but not experience or aptitude may be charismatic and may be recognized as entrepreneurs, but they will never be recognized in the same way as a physician who actually went through the steps to be board certified and to carry that kind of a load personally.

Partway through the first chapter, I had to check on its publication date. The copy I had in hand was a first edition version from 2017. On one hand, I was relieved, because reading about the debacle that was the first couple of years of COVID is still triggering for me as a frontline provider who had COVID deniers coughing in my face during the 12-hour shifts that were nearly always 14 hours long.

A lot of us who went through that experience felt at the time that COVID had magnified the willingness of patients to argue with us, largely due to conspiracy theories and medical misinformation that was found all around us. But the book reminds us that it was happening well before then, which reminds me of a patients who would arrive with stacks of pages printed from internet blogs that they would cite as evidence for the treatments they were demanding.

The book also talks about influencers and uses Gwyneth Paltrow and her GOOP brand as a prime example. I’ll admit my bias upfront here – it is my strong personal belief that “influencers” will be the death of Western Civilization as we know it. I remember when I was a kid, and there was such a focus on the idea of peer pressure and how it was something to be avoided, and that people should be critical thinkers and use their own values rather than doing something just because their friends were doing it.

The in-your-face nature of influencers and the rise of social media and TikTok have been terrible for many segments of the population, whether it’s because they wind up in the emergency room after doing some inane TikTok Challenge or whether they waste their money on unproven treatments or so-called wellness products that are more multilevel marketing than evidence-based.

The book has a short section on conspiracy theories that made me chuckle. At least to me in hindsight, the conspiracy theories that were out there in 2017 were far more benign than some of those we hear today. There’s an interesting section on how changes in higher education have led to the death of expertise, including the up-branding of small local colleges to universities without a commensurate change in the education they’re delivering, along with an attitude that people attend college or university because they are pressured to do so or feel they have to as a next logical step in their lives.

The author talks about the difference between “having a college experience” and “getting an education” and how the former has changed attitudes at institutions of learning. We’ve definitely seen this in healthcare and I’ve seen it quite a bit in the for-profit healthcare training programs out there. Graduates come out of some of these programs with no experience other than shadowing, which is truly a travesty.

My favorite chapter is the one titled “Let Me Google That for You,” which really should be the anthem for my generation. I run into a lot of people who think that because it’s on the internet it must be true, and I agree with the author that many people don’t have the skills to critically appraise their sources and to determine whether they should be trusted. Honestly, if I see one more friend posting on “cough CPR” — which is where if you think you’re having a heart attack while driving you are supposed to cough forcefully while driving yourself to the hospital — I am going to scream. This is a myth and that has been debunked by numerous reputable sources. I always post links to those sources when I see that post and remind people that if you think you’re having a heart attack while driving, you should pull over and dial 911 or hit the emergency button on your phone rather than trying to drive yourself and risk the lives of those around you.

Even in 2017, the author touches on Robert F. Kennedy, Jr. and vaccines and other medical misinformation. He reminds us that “a search for information will cough up whatever algorithm is at work in a search engine, usually provided by for-profit companies using criteria that are largely opaque to the user.”

He notes that “The deeper issue here is that the Internet is actually changing the way we read, the way we reason, even the way we think, and all for the worse. We expect information instantly. We want it broken down, presented in a way that is pleasing to our eye – no more of those small-type, fragile textbooks, thank you – and we want it to say what we want it to say.”

People do not do research so much as they “search for pretty pages online to provide answers they like with the least amount of effort and in the shortest time.” The resulting flood of information, always of varying quality and sometimes of uncertain sanity, creates a veneer of knowledge that actually leaves people worse off than if they knew nothing at all. It’s an old but true saying: “It ain’t what you don’t know that will hurt you. It’s what you do know that ain’t so.”

He also tackles the evolution of journalism (fun fact: I now know the origins of the TV show “Nightline”) and reviews some specific studies from the University College of London about how people often interact with the internet by “reading” articles by consuming the first few lines or sentences and then going on to the next thing.

The phrase “power browse” was used and I definitely see that in some of my own behavior, usually when I’m trying to cull through all the noise out there in order to write for HIStalk. It’s useful in that context, but might be dangerous if I’m trying to read about patient care or learn the nuances about a specific course of treatment. It makes me wonder how easily people can shift between those approaches in the fragmented timeline of a day caring for patients.

The book is a relatively quick read at 230 pages, and of course you can power browse it if you’re not quite ready for a deep read. I’d encourage the latter, however, because they author has a couple of really funny statements in there that I would have missed by skimming.

Have you read it and what did you think? Any other good reads you’d recommend for 2025? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/30/24

The end of the year is within striking distance. I was fortunate to have a nice break since nearly everyone who I work with was taking time off.

Running your own business can be labor intensive, so now it’s time to finish up those end of year accounting reports and get ready to open the books on a new one. I enjoy opening a nice, clean spreadsheet, probably a holdover from the heady days of picking out school supplies and having brand new Pink Pearl erasers at your disposal. Maybe I should start the new year with some brand new shoes as well. I’m sure there will be something sparkly in the post-New Year’s sales that would be suitable for HIMSS. 

Plenty of people ask me what I predict will happen in healthcare and healthcare IT in the coming year. I think we are going to see a lot more conversation about the role of insurance in the healthcare system and how it needs to change. Unfortunately, I think it’s going to be all talk and little action, as powerful lobbying forces work to prevent any kind of substantive change. Profit is a powerful motivator, and shareholders aren’t going to stand for lower returns when more dollars are spent on patient care.

There will also continue to be resistance to any kind of universal healthcare, despite the fact that other developed nations do a pretty good job at it, with better clinical outcomes at a lower overall cost. Anecdotal stories about people who had to wait for care in Canada will continue to sway opinions, despite the fact that care rationing and delays have been the norm in the US for years if you don’t have “good” insurance that comes at a hefty price.

One prediction that I think many of us would agree with is that Epic will continue to grow market share. Given the uncertainties at Oracle Health, Epic is a safe bet when you’re about to open your wallet to the tune of tens or hundreds of millions of dollars. Small to mid-sized practices might continue to select niche EHR vendors for a particular specialty, especially if they have a low need to integrate with the local health system, but everyone else is gravitating towards the folks in Wisconsin.

Hopefully, this leads to more patients demanding full use of the Epic solutions, including self-scheduling or the lower-key ticket scheduling option, which would allow patients to have greater control over the services they receive without having to make inconvenient phone calls to try to book appointments. I still marvel at the number of organizations that haven’t implemented these features and am always happy to have a conversation with the physicians who are typically blocking their implementation.

Another prediction: physicians will continue to leave medicine earlier than they planned, particularly if they are in primary care. I hear from a number of former colleagues who are trying to find non-patient-care roles and who think that informatics is a logical jump. I advise them that it takes more than being an EHR user to be a successful informaticist and recommend that they do some formal coursework before they decide that it’s the next phase of their career.

It feels like the majority of physicians I know have some kind of side hustle (including real estate, life coaching, crafting, baking, and photography) that they are hoping to grow to a point where it can generate income if they are too burned out to practice. I’ve already received notice of three retirements this year, along with one offer to buy a practice for an insanely low price that I gently declined.

As for non-physician workers, I think we’ll continue to see more of the so-called “quiet quitting” and “coffee badging” phenomena. People are continuing to realize that employer loyalty is a thing of the past in many areas. They will work the amount that they feel is appropriate for what they are being paid.

I think we’ll see this more in people who feel they have been forced to be physically present in the office when it does nothing for their productivity. It’s hard to build culture when you demand that people interact just because they receive a paycheck from a common employer even though they don’t even work in the same sector as others who are also forced into the office. I have a couple of friends that drive 20 to 30 minutes to their offices every day to engage in back-to-back Zoom meetings with team members who are located in other states. One goes to an office that is a non health-related division of a large corporation, but it has the same logo as their paycheck and is within 60 miles, so it’s required. Based on our conversations it’s not making for a happy work environment and employees will do the bare minimum in person so as to not be penalized. 

My final prediction is that we’ll continue to see companies try to enter the health sector because they think that they are smarter than everyone else who has been there before, which positions them uniquely to solve problems that are significantly more complex than they think. They will raise a fair amount of money along the way by convincing people that they are unique or have special skills, but I think we’ll see the majority of these companies fizzle out in the same way as their predecessors. I’m hoping that they’ll be smarter about how they operate than the last crop of startups, but I guarantee that we’ll see plenty of them blowing through cash and parading around at the trade shows. It’s what makes the industry interesting at times, and even though you want to look away, you can’t, because it’s just such a spectacle.

I’d be remiss if I didn’t end 2025 with a mention of the passing of former US President Jimmy Carter, who reached age 100 and died at home after choosing hospice care over more invasive treatments. His desire to pass with grace and dignity is admirable and resonates in a particular way with those of us who have had to perform so-called heroic measures on patients who most likely would not have wanted them had they fully understood what was involved. Carter is remarkable less for his presidency than for what he did following it, working to advance the democratic process around the world and to demonstrate a culture of service at home. He embodied service throughout his life, from his time with the US Navy to the White House to Habitat for Humanity and beyond. There’s a lot of talk about servant leadership out there, but he embodied it. Today’s leaders could learn a lot from his example. My condolences to his family and loved ones.

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Curbside Consult with Dr. Jayne 12/23/24

I enjoyed Mr. H’s recent survey asking, “Which winter holiday is most important to you?” It came at a time when someone had sent me a meme about how to best leverage holidays in 2025 for long-weekend travel, and my first thought about it was “yeah, if you’re not a frontline healthcare provider.”

In my first job as an employed physician, we received the minimum holidays: New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving, and Christmas Day. The rest of the time, I was expected to have my office open and available to see patients, regardless of whether my entire staff wanted to take time off or not. There wasn’t any such thing as flexible holidays and the physicians had no autonomy to modify the schedules in a way that suited them. I’m glad to see that many organizations have evolved from this approach, although I’m sure there are some that still only recognize a minimum number of holidays.

When I moved from traditional primary care into the emergency department, we were assigned to Holiday Track A or Holiday Track B, which alternated years and made it clear which holidays you would be working each year. Honestly, it made things more straightforward and I enjoyed the predictability of the schedule. I suppose that’s why I selected New Year’s Day as my survey response. I’m nothing if not predictable, and I enjoy starting the year with fresh new spreadsheets to track my household budget, fitness goals, and various other things. I use some online tools as well, but there’s just something about seeing my data in the same format I’ve been using since 2009 before wearables and linked software really changed the game.

If your favorite holidays involve snow and you’re a physician, Epic is hiring for its physician team. It’s a relatively small team and I’m not sure if someone is leaving or if they’re expanding, but the job posting was shared in one of my online physician forums. Unlike other physician informaticist job postings I’ve seen over the years, this one doesn’t have a lot of detail as to the actual job description. It focuses on the positive aspects of working for Epic, including the campus, the food, and Epic’s sabbatical program for workers who stay at least five years. The posting received some scathing reviews on the forum where it was shared, primarily because the requirements specify “MD with several years of inpatient and/or outpatient experience” which raised the hackles of physicians who are DOs. I’m not sure if that’s an oversight or if Epic believes the MD credential is more relevant to the work. Others pointed out the fact that it requires COVID-19 vaccination, which isn’t something you often see in job postings in 2024. Let’s just say it was a lively discussion.

Although some people love the holiday shopping experience, I’m not one of them, so I made sure to time my Target run for 10 p.m., which seemed to work out well. In addition to the bathmat that I was in search of, I was surprised to see Oura rings for sale. It’s the first time I’ve seen them in person and the finishes available seemed nice. The store was sold out of sizing kits, so I’m guessing it’s likely to be a popular holiday gift.

Whoever does the merchandising at my local store has a sense of humor. There was an entire endcap display of “things you need to make fudge” but without any kind of signage or display. I only recognized what was going on with those particular shelves because I had just made a batch. I’m not sure others would make the connection. The Christmas section of the store was picked almost clean, but there were still a few things left in the Hanukkah section. I didn’t see specific areas for any of the other winter holidays and observances. Based on my recent mood, if they had anything for Festivus I would likely have considered it.

I wrote a couple of weeks ago about my decision to be part of a clinical trial, and I’ve just completed my first round of testing. Although completing the tests was straightforward, I’ve been told to expect to wait four to six weeks for release of my results. That experience is a departure from what we’ve all become used to over the last decade, with near-instant release of most labs performed locally. Even those that are send-out or complicated typically result within a week or so, unless they’re something really unusual.

It’s a good reminder of the progress we’ve made in healthcare, even when a lot of the other aspects of care delivery seem to be undesirable. Once the test results are back I’ll find out which of the screening interventions I’m assigned to. Not sure how long that piece will take, but at least it gives me something to look forward to in my email other than solicitations by other LinkedIn members looking to sell me something.

I receive hundreds of press releases each week and I admit I probably miss a lot of interesting news because there is just so much junk out there. I did enjoy reading a recent release that covered Providence Mission Hospital’s efforts to provide concierge services as an employee benefit. The goal is “to make life easier for hospital staff by helping them tackle everyday tasks so they can focus on what they do best: providing exceptional care to patients.” Services offered include running errands, scheduling personal appointments, arranging travel, shopping and gift wrapping, and managing household tasks. I’m sure the devil is in the details, but this sounds like a great benefit to me. I know I’m not the only one that puts off straightforward tasks because I don’t have the time to make phone calls during the day and can’t make appointments online – things like having my car’s tires rotated or scheduling a chimney inspection.

I know a lot of corporate employers offer conveniences at the office to increase employee willingness to work long hours, including dry cleaning services as well as discounted meals, gyms, and fitness classes. I’m wondering how many offer this kind of personal concierge service and how it’s working out. Does your employer offer unique benefits? Which is your favorite? Leave a comment or email me.

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EPtalk by Dr. Jayne 12/19/24

The US Congress is delivering an end of year cliffhanger in the form of expansive legislation designed to fund the government so that there’s not a shutdown when current funding runs out on December 20. The continuing resolution that is under consideration is over 1,500 pages and includes some healthcare tidbits, including the extension of some Medicare telehealth flexibilities for another year and the extension of acute hospital at home flexibilities through the end of 2029.

The continuing resolution took a beating on the platform formerly known as Twitter this week, with Elon Musk personally posting about it more than 100 times. My heart goes out to all the families that will be impacted if there is indeed a government shutdown, especially essential workers who are expected to continue working but who might not be paid in a timely fashion. National parks and monuments will close in the event of a shutdown, so if those activities were in your holiday plans, stay alert. Even if the resolution passes, it will only cover the nation through March 2025, so there are plenty more budget conversations to come.

From Rotisserie Gal: “Re: predictions. I always make an email folder where store predictions that caught my eye, or announcements of seemingly hot new tech that I want to watch over time. With that, I give you a prediction from CES 2024 – the macrowave oven. I haven’t seen a word about it since then.” Looking back at the article, the device was called “the Tesla of kitchen appliances” and there was plenty of gushing over its ability to revolutionize cooking. I guess it wasn’t that revolutionary though, because an internet search today only brought up articles mentioning the CES debut. I even went to the manufacturer’s website and couldn’t find anything about it, so unless someone else informs us to the contrary, it seems to be a prediction that fizzled.

In addition to looking at predictions for 2025, I’m also a sucker for “year in review” articles covering the one that’s winding down. JAMA Health Forum released its list of most viewed articles for 2024. The titles are telling and align with the hot topics I’ve heard discussed in the physician lounge, whether virtual or in person:

• “Changes in Permanent Contraception Procedures Among Young Adults following the Dobbs Decision.”
• “US State Restrictions and Excess COVID-19 Pandemic Deaths.”
• “What Would Another Trump Presidency mean for Health Care?”
• “Evaluation of Changes in Prices and Purchases Following Implementation of Sugar-Sweetened Beverage Taxes Across the US.”
• “Differences in Home Health Services and Outcomes Between Traditional Medicare and Medicare Advantage.”
• “Projecting the Future Registered Nurse Workforce After the COVID-19 Pandemic.”
• “What Would a Trump Administration 2.0 Mean for Health Care Policy?”
• “Job Flows Into and Out of Health Care Before and After the COVID-19 Pandemic.”
• “Patient-Level Savings on Generic Drugs Through the Mark Cuban Cost Plus Drug Company.”
• “Patient Safety and Artificial Intelligence in Clinical Care.”

Another year in review article listed the most expensive Epic EHR projects worked on or completed in 2024. Top-tier spenders were in the $800 million to $1.2 billion range, with the low-end contenders seeming rather paltry at $50 million. I’d love to see someone approach the data in a different way to see how it resonates. Although it might be interesting to see the expenditure as a percentage of net and/or gross revenue, it might be even more intriguing to see it compared to patient stats that are commonly used when discussing volumes. I can just see health system CEOs standing around comparing their “Epic dollars per licensed bed” or “Epic dollars per emergency department visit.” I know that these large numbers often represent a cost savings, especially when an Epic implementation allows retirement of multiple unwieldy systems or the efficiencies of standardization. But it doesn’t change the fact that the numbers are indeed staggering.

I recently applied for a committee position and was asked to identify whether I was an early career individual versus mid career or late career. I asked for specific criteria and found that their idea for distribution was substantially different than what I had expected. They define “early” as five years or less, “mid-career” as six to 10 years, and “late career” as more than 10 years. Thinking back, there’s so much I didn’t know before hitting what they would consider late-career. I wonder how they would describe those of us who have been at this for 25 or 30 years, which is what I would truly consider late career. I’m curious how other organizations define this and if this was just an anomaly since I’ve never been asked this question.

I saw a headline about UnitedHealth’s Optum inadvertently making its internal AI-powered chatbot available to the public via an IP address, but I didn’t have time to read it. I finally circled back today and was glad I did, since the story goes well beyond the headline. The chatbot was trained on internal materials that describe standard operating procedures for managing claims. Optum claims it was a “demo tool developed as a potential proof of concept” but was never in production use by employees. That’s all pretty vanilla, but I was glad I read to the end and heard about what happened when TechCrunch asked the tool to “write a poem about denying a claim,” producing a seven-paragraph work which is featured in part at the bottom of the article. Well worth the read folks, well worth the read. I’d love to see the other five paragraphs, though.

Winter is upon us, and I’m wholeheartedly embracing the hygge lifestyle with plenty of books, sweaters, cozy socks, and of course seasonal baking. The different varieties of cookies amaze, me and whether you need a concentrated punch of chocolate in a lumpy form factor or whether you prefer a more demurely dunk able option with greater surface area, I probably have a recipe for you.

What are your favorite holiday cookies? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 12/16/24

It’s that time of year when well-known people are delivering their predictions for 2025. I’ve seen plenty of them talk about how “transformative” AI will be. The most commonly cited use cases include the nebulous “operations” and “workforce challenges.”

I’d love to see people put their nickel down and give us a tangible prediction along the lines of, “AI will help us reduce nursing turnover by 10%” or something that’s even remotely measurable. Many of us have been through a middle school science fair, either as a participant or as a parent or coach of a participant, so it shouldn’t be too hard to craft a measurable hypothesis. Unless, of course, you’re just talking to talk and to get exposure so you can “elevate your brand” and figure out how to launch yourself to the next big thing – in which case you’re better off staying in the realm of the nebulous prediction.

I saw one article where an executive was talking about how organizations are going to start collaborating with each other to create networks for delivering more holistic care for patients without having to own all the services. If I’m thinking positively, that means that we might see some health systems considering joint ventures with physician groups or other organizations that can create new options for patients to receive needed care in lower-cost environments. In many communities, though, I doubt we’re going to see much out of this due to the multi-decade turf wars that led to network monopolies with certain insurance carriers, which can make it difficult for patients to get the best care because it might be out of network.

I think of my own city, where a couple of decades ago a handful of otherwise independent hospitals came together in a loose affiliation to try to fight against the two largest players in town. That affiliation lasted less than a decade, with two hospitals spinning back to independence while the others became part of a larger multi-state system. Fast forward again and that organization now owns all but one of those former “independent” members of their alliance. Regardless of current affiliations, the quality measures coming out of those hospitals are largely the same, so I’m not sure what all the merging and unmerging did for anyone other than potentially lowering overhead costs and most assuredly causing confusion for patients.

Executive predictions can also highlight how clueless some individuals are about the current state of healthcare in the US. One mentioned the importance of ensuring that we don’t have a two-tiered healthcare system, with some patients receiving private-pay care and others receiving care paid for through governmental plans. I’m sure she was trying to draw comparisons to the UK and Canada, but it didn’t appear that she was at all aware of the fact that we currently have such a two-tier system in the US right now, in 2024. According to information from the Centers for Medicare & Medicaid Services, the 2022 breakdown for healthcare expenditures was 39% for Medicare and Medicaid and 40% for private health insurance and patients spending out of pocket.

That sure looks like a two-tier system to me, and if you ask a physician who sees the full spectrum of patients regardless of payer, they’ll quickly tell you that patients get different treatment entirely when you try to refer them for subspecialty care. Those with so-called Cadillac insurance plays that pay at the top of the fee scale often receive the quickest appointments, followed by patients with Medicare. In my city, Medicaid patients have ridiculously long waits for specialty care. This means the primary care physician has to try to muddle through and ask colleagues for informal opinions about how to manage a patient for the nine to 15 months it might take for them to actually get an appointment with the appropriate specialist.

When I was in traditional family practice, I literally had patients die while waiting to see a specialist. You can imagine how non-credible many of us find it when someone suggests that care rationing and a tiered system isn’t already here.

I’m sure that over the coming weeks we’ll see even more of these predictions pop up, and I’ll be ready to read them for amusement purposes. What I won’t be reading are content producers that start every single post with either the megaphone emoji or the emergency light emoji. (Side note: the official name of the latter is “Police Cars Revolving Light,” and is that really what you want to have at the beginning of your post?) I’ve decided to change how I’m curating my content in 2025, and anyone using those particular attempts at attention-grabbing for every single post will just go to the bottom of my list. Once in a while, I get it, but after a while it’s just distracting.

There have been a couple of predictions I’ve seen for 2025 with which I can agree. First, I agree with the prediction that while executives say that they’re going to focus on generative AI, only a fraction of them will actually make them a top priority in the next 12 months. I think there are a lot of people out there saying they’re “doing AI” because they don’t want to seem like they’re missing the boat. Or, they may have selected vendors that claim to have an AI-powered solution which is really little more than a souped-up decision tree. There are plenty of those out there, for sure. It’s also difficult to spend on AI when you have things like high nursing turnover that’s directly related to poor company culture, which isn’t going to get better by using AI.

I agree that ambient documentation will remain one of the industry’s darlings in the coming year, because physicians seem to love it. It remains to be seen, however, whether the use of it will lead to improved patient outcomes or clinical quality or true burnout reduction. I’m still skeptical about the burnout studies that I see because a portion of the most burned out clinicians have left the field, which will make the data look better regardless of the true prevalence and severity of burnout. I have a couple of colleagues who are moving away from ambient documentation due to medicolegal concerns, so it will be interesting to see how the industry addresses those.

I personally predict that people in the US will continue to spend plenty of money on unproven treatments in the name of wellness. I had the opportunity to see some financial data on a local med spa, and the amount of profit flowing through there for therapies that aren’t evidence-based is staggering. Vitamin B12 infusions, electrolyte infusions, and even therapies that have been officially debunked are all on the menu and the business is expanding rapidly. Many people don’t have the desire to investigate whether medical things they see on TikTok or other social media platforms are evidence-based and are more focused on following influencers rather than people who have spent decades in school learning the science. Having seen what I’ve seen in emergency and urgent care in the last five years, I don’t see that changing any time soon.

I also predict that the least-paid specialties will continue to be those with the most shortages, a concept which should surprise no one. I guarantee that if you paid primary care physicians based on their actual worth in being able to help prevent disease and reduce disability, and actually supported them appropriately with the ancillary services needed to help patients make lasting changes, people would flock to those disciplines, because they can be incredibly rewarding when you’re working in a supporting environment. When you’re not, though, they can be soul-sucking, and we’ll continue to see people voting with their specialty match preference lists.

Bring out your crystal ball. What are your predictions for healthcare in 2025? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/12/24

The US Department of Health and Human Services recently launched the National Healthcare Safety Dashboard that tracks patient and workforce harm. The goal is to monitor patient safety indicators so that improvement can result. It draws data from the HHS Agency for Healthcare Research and Quality (AHRQ) including its Hospital Patient Safety Indicators, Hospital Medicare Adverse Events, and Surveys on Patient Safety Culture (SOPS) Hospital Survey. It also pulls from the CMS Hospital Reporting Program Safety Measures. Hospitals and health systems have been trying to reduce preventable harms for decades and hopefully the additional transparency from such a dashboard will better support those efforts. Future plans include dashboards for other care settings including nursing facilities and ambulatory care sites.

I took a peek at the Hospital Patient Safety Culture Survey (SOPS) data, and although the results weren’t surprising, they were still disheartening. Some of the least-positive scores were around Staffing and Work Pace, Response to Error, and Hospital Management Support for Patient Safety. A number of research articles have listed topics like these as contributing to care team burnout and I hope that institutions are making plans to address them. The most recently displayed data in the dashboard was from 2022. I’d love to see more public information on what staff members think about the culture of the institutions where they work and whether hospital leadership becomes more responsive when light is shining on those kinds of concerns. If you’re working in this space, feel free to reach out.

In conjunction with HIMSS, Medscape has released its 2024 AI Adoption in Healthcare Report. I was saddened to see it delivered in a format I detest, that being a 22-item, web-based slide show. Results are from “a jointly managed survey to practicing physicians and other clinicians, practicing nurses, IT professionals, clinical leadership, and executive leadership at medical organizations” in the US. That’s pretty vague and I was looking forward to seeing increased stratification of the findings based on the type of medical organization – care delivery, payer, software developer, etc. – since all of those are technically medical organizations. Highlights from the survey that should surprise no one: AI is most frequently used with administrative tasks, it’s producing solid results for transcription for everything from meeting notes to patient documentation, and a large number of respondents are concerned about data privacy and/or ethical issues.

Other facts I wasn’t expecting: only 24% of employers are providing AI training, physicians are less likely to use AI away from the office than non-physician respondents, and 28% of physicians believe it will eventually replace the need for human doctors. Looking at respondent demographics, almost a third were nurses and nearly two-thirds worked in hospitals, so I’m not sure this is representative of medical organizations as a whole. Only 1% of respondents were healthcare IT, however. The data wasn’t further stratified by those groups, so it’s really a limited view into the issue. It was one of those attention-grabbing articles, and given the report’s sponsors, I didn’t expect much more from it than a superficial review of the topic.

From The Mitten: “Re: new scam. People are offering fake jobs.” The scam was mentioned in a security bulletin from Michigan’s Munson Healthcare. Scammers are “imitating Munson human resources’ leaders offering people false jobs and sending them fraudulent checks to purchase their own equipment.” From the information available, I can’t seem to figure out what else was involved in the scam, whether it involved theft of financial information related to the phony checks or something else. If you know more about it, feel free to share with the rest of the class.

The year is coming to a close and most of my time now is spent gearing up for 2025. A new year always brings new opportunities. I had the chance to catch up with a friend who works as a healthcare IT consultant and she mentioned that work at her current consulting gig has just about ground to a halt. It seems that all the people who didn’t take their allotted vacation time throughout the year are racing to try to take it before the “use it or lose it” deadline of December 31 and it’s a ghost town as far as finding people with whom to collaborate. It’s a bit surprising to me since this is a care delivery organization that needs to make sure that essential functions are covered, but I guess that as long as they have one person around to field support calls, they’re OK with it.

I’ve worked in organizations with all kinds of vacation policies, some of which make it difficult for employees to take time off on their preferred schedules. One employer had a strict accrual policy that started over each year, essentially preventing anyone from taking a full week of vacation in the early parts of the year. Others have had accrual policies, but allowed you to use vacation in advance of the actual accrual, adding flexibility. I’ve also worked in organizations with unlimited time off, which can be good or bad depending on the company culture and how such a program is administered.

I’m not a fan of use it or lose it plans that are tied to the calendar year since life sometimes doesn’t always deal us opportunities on that kind of schedule. I get that you don’t want people banking ridiculous amounts of vacation, which means that they’re not taking the time they should in order to relax and recharge. On the other hand, it would be great to take a multi-week trip to celebrate a marriage, milestone birthday, or other life event without having to time it to a certain part of the year.

Of all the arrangements I’ve worked under, my favorites are either a well-administered plan for unlimited time off that ensures that employees actually take it, or one that lets employees roll vacation over from year to year as long as they don’t exceed a certain number of banked hours. Either way, those require adequate involvement from managers to ensure that people are taking time away at regular intervals, and it seems that some organizations don’t want the hassle of either.

What kind of vacation or time off plan does your organization have? Does it meet your needs or do you wish you had something different? Leave a comment or email me.

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Curbside Consult with Dr. Jayne 12/9/24

It’s definitely a slow time in the healthcare technology universe. The HLTH conference is in the rearview mirror and HIMSS is still a couple of months away.

CES will happen in January, although on the healthcare side, I see more entrepreneurs there than I do those who work for hospitals and health systems. I’m looking forward to seeing cool consumer products and wearables announced at CES, although I have low expectations for anything that will truly transform healthcare. Even if there’s something useful for patients, cost is still a barrier for the majority of patients I interact with. Many of them struggle to afford their medications, can’t afford to take time off work for a physician visit, and aren’t going to pay hundreds of dollars for devices that may or may not improve their health.

One physician I spoke with recently is working extra hours trying to fit in patients who want to proceed with non-urgent procedures because they’ve met their deductibles for the year and can now afford them even though they couldn’t do so earlier in the year. He’s been in practice for a while and this isn’t a new phenomenon for him, so he avoids scheduling family vacations during November and December so that he can accommodate the needs of his patients. It creates a bit of a burden on his office staff because he has to limit their ability to take vacations as well, but that’s not an unusual situation for staff members working in a small private practice.

Several of my physician colleagues are planning to cut back on their working hours in 2025. I’m happy for them because at least one of them is experiencing severe burnout and it’s been difficult to see all that she’s gone through in the last couple of years. Depending on how physician employment agreements are structured, many physicians don’t take enough time off to allow themselves to recharge from drain caused by physical and psychological stressors on a daily basis. Some physicians don’t take time off because they don’t have appropriate coverage for patient care tasks. Others take the time off but end up working because they don’t have coverage for inbox messages or other patient care needs, and therefore don’t get a real break.

Lack of adequate coverage for physician time off is a pervasive issue and causes enough issues that the AMA recently released a module under their STEPS Forward series to address it. The webinar reviews various barriers to physicians taking time off and strategies for organizations to address them. Some of the strategies are straightforward, like making it easy for employees to track their time off and understand how much they have used versus how much remains. Especially if your organization has a use it or lose it policy for time off, this is important. Another strategy is to block physician time off well in advance so that it’s not a surprise. I’d go one step farther with that one and recommend that when the physician schedule is blocked, the scheduling team creates buffers around those blocks so that physicians can manage last-minute issues before their time out of office as well as to have additional capacity available for their return.

Other strategies are more subtle but might be more challenging, like having physician leadership model expected behavior. That might be easier said than done depending on the organization. Another example is ensuring that leadership isn’t celebrating the fact that team members are working while they’re supposed to be off. If your organization wholeheartedly endorses hustle culture, it’s unlikely that they will be making that change. Another significant change called out in the module is making it the organization’s responsibility to find coverage for clinical matters while a physician is out instead of making the physician find their own coverage, which can be a disincentive to taking time away.

The module also addresses physician compensation programs and how they might be adding to the pressures that make physicians less likely to take time off. They recommend that organizations construct productivity models to reflect appropriate time off including holidays, educational time, and sick time. As someone who has managed a consulting team, I know how important this is, because if you calculate productivity expectations based on 40 hours a week for 52 weeks per year, you’re going to make your team crazy with unrealistic expectations. In addition to time away from work, you also need to consider productivity losses for mandatory training (fraud, waste, and abuse, anyone?) as well as office and hospital closures due to holidays.

The module also challenges organizations to look at how physicians are taking time off as part of their organizational scorecard. New research has shown that physicians who have adequate time off are less likely to leave an organization, so it would make sense to look at that data in conjunction with turnover data. Especially for larger organizations that are using human resources systems to track time off, looking at this data should be fairly easy. For those of us on the administrative side, many EHR/practice management systems have stock reports that let you look at scheduled clinic hours and blocked hours, and if you’re a physician leader and you don’t have access to that data for your team, I’d recommend you track it down – you just might see some interesting trends.

As far as my colleagues who plan to cut back their working hours in the coming year, it will be interesting to see how their organizations support them in those efforts. I know of a number of physicians who are supposed to be working at 75 or 80% of their previous full time schedules, but who end up working nearly as much as they did previously due to the same kinds of organizational barriers that keep people from taking adequate time off. At least a couple of them have gone back to full time work so that they at least get full time compensation for their efforts. It’s something to think about for those looking to reduce hours.

What are your plans for time off in the coming weeks? Will your workplace be a dead zone as everyone struggles to use up their vacation time? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 12/5/24

It’s that time of year, with cybersecurity firm NordPass releasing its annual list of most used passwords. Topping the Hall of Shame list this year: secret, 123456, password, qwerty123, qwerty1, 123456789, password1, 12345678, 12345, and abc123. I didn’t have to scan too much farther down the list to find ones that were more interesting: iloveyou, baseball, princess, football, monkey, and sunshine all ranked within the top 20.

Come on, people, it’s not that hard to have at least a minimally secure password. The list can be sorted by country, and some of the international options are a bit more entertaining: liverpool, arsenal, and chelsea were popular in the UK, but hockey made the list in Canada.

From Cheer Mom: “Re: prescription drug fraud. Wise advice from Mr. H on physicians remaining vigilant around prescription drug fraud. One of our hospital’s providers recently discovered that his DEA number had been used for a number of fraudulent prescriptions for controlled substances. Too bad the patient in question was another provider at the hospital, who had been calling in her own prescriptions under her colleague’s name. The pharmacy didn’t catch the fact that the alleged prescribing physician sent every single prescription using electronic prescribing except for those called in for one single patient.” As someone who has had fraud committed against their DEA number, it’s a terrible thing when it happens. With the widespread adoption of electronic prescribing, it still amazes me that some states still permit certain levels of controlled substances to be phoned in.

A friend sent me this article from JAMA Network Open and asked my opinion on it since I’ve worked in telehealth for quite some time. It’s an original research article and looks at the rates of so-called low-value care services in primary care practices that use telehealth. The authors looked at care performed between January 2019 and December 2022 and used Medicare fee-for-service claims data for practices in Michigan. Practices were stratified as low, medium, or high users of telehealth and the low-value services were grouped as office-based, laboratory-based, imaging-based, and mixed-modality services. Over 577,000 patients were represented in the claims. Some of the low-value services avoided during telehealth visits included cervical cancer screening, PSA testing, and thyroid testing for patient groups where those tests were not indicated.

Non-clinical readers may ask why these services are considered low-value since at least some of them are marketed as potentially life-saving. In reality, it all depends on the patient, their age, and their risk factors as to whether the tests should be done. Sometimes physicians get in the habit of ordering tests across the board even when they’re not truly indicated, which makes them low value since they provide little to no clinical benefit for patients and can even cause harm or unnecessary follow-up testing. Since they require a physical exam or a blood draw, you can’t exactly conduct them during a telehealth visit, and doing so would require either a follow up-visit in office or a trip to the lab.

The authors found that practices that had high telehealth use had lower rates of low-value services performed in the office. There was no association between telehealth use and other low-value services that were not performed in the office. They concluded that, “our findings suggest the potential for telehealth to help reduce office-based low-value care and could reassure policymakers concerned about telehealth encouraging unnecessary or wasteful care due to added convenience.” One of the limitations of the study is the time period during which it was performed, which overlapped the worst parts of the COVID pandemic, when in-person visits were down across the board simply because primary care offices were closed. It would be interesting to perform a follow up on years post 2022 as well as to look at data from various parts of the country, to determine whether the results hold across time and place.

Still, I look at my own recent visit to my primary care physician. Except for a blood draw, it could have been performed via telehealth. The majority of the visit was spent discussing data gathered from home monitoring devices and updating the physician on a recent visit to a subspecialist who is not on the same EHR and who didn’t send a copy of their visit note. The blood draw wasn’t time sensitive and could have been easily done the next day since I would have to drive past the lab on a planned errand. For the labs that were ordered, it would have been easy for my physician to order a broad spectrum of labs, but fortunately he practices evidence-based medicine and only ordered the ones for which I was truly due. But for every physician who practices like that, there are twice as many who just order larger laboratory panels to “cover everything.”

There is still plenty of low-value care being performed, whether via telehealth or in-person visits. Antibiotics for viral illnesses are at the top of my list, and likely the lists of anyone who has ever worked in a primary care, urgent care, or telehealth urgent care setting during the three days leading up to Thanksgiving in the US. The number of patients who are presenting with what are almost certainly viral upper respiratory infections but who are simply seeking antibiotics is staggering. They come in with requests like, “I just want to get ahead of this because I’m having 20 people for dinner on Thursday” or “I just know this is going to turn into a sinus infection” and often haven’t tried any home care or over the counter remedies.

Frankly, writing an antibiotic prescription is a lot easier than a 20-minute conversation on why antibiotics aren’t indicated and how they can even cause harm, so you can guess how those visits often turn out, especially in practice settings where physicians are graded on patient satisfaction. I’d love to see a national public health campaign on appropriate use of antibiotics and why you don’t need to throw them at a common cold, but I don’t see that coming any time soon.

Like Mr. H, I’m migrating to Bluesky. You can find me there as @Jaynehistalkmd.bsky.social, although I’m slow to get started. I haven’t been much of a user of the platform formerly known as Twitter since its change of ownership, so maybe 2025 will be my year for returning to social media. I’m following Mr. H’s tip sheet for making the transition and looking forward to scrolling again with a more curated feed and hopefully fewer distractions.

A recent article published in Nature Communications looks at the effectiveness of an artificial intelligence system for matching patients with relevant clinical trials. Researchers from the University of Illinois and the National Institutes of Health have developed a solution called TrialGPT that was 87% accurate in matching patients with clinical trial eligibility criteria, which isn’t terribly far off from the performance level of humans. The study was limited by the fact that the system looks at written patient summaries versus lab values and imaging results, but I imagine it wouldn’t take too much work to bring structured data into the mix. I recently enrolled in a clinical trial that I only found out about through a tangential reference from one of my clinicians. It won’t yield results for five to 10 years, so it would be interesting to see what else I might be eligible for.

Have you ever participated in a clinical trial? Was there a technology component or did it involve manual data collection? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/2/24

This weekend marked the two-year anniversary of the debut of ChatGPT. This seems to be a good time to reflect on where generative AI has taken us during that interval.

When it initially launched, there were quite a few worries about AI becoming sentient and taking over the world, but it seems that we’ve been spared that. I’m not sure you’re capable of taking over the world when you can’t generate pictures of humans that have the correct number of digits per hand, so maybe we can use that as a benchmark for how worried we should be about generative AI coming after us.

Although ChatGPT is the original, there are plenty of competitors in the market. The majority of physicians I encounter cite using ChatGPT, Microsoft Copilot, Google Gemini, Meta Llama, or Perplexity. The last one has been on the rise when I ask my colleagues around the virtual water cooler, although I personally think that it’s the least capable based on my short list of medical searches that I use to kick the tires on the models over time. The last time I tested Perplexity, it gave me a clinical recommendation that was 180 degrees from standard care for a patient with a particular genetic variant, which if followed would likely have led to negative outcomes (such as preventable death).

Healthcare organizations see the risk that AI can bring to our environment are joining together to provide guidelines for development and use of AI in healthcare in a responsible manner. The Coalition for Health AI (CHAI) is looking at safe and equitable implementation of AI in healthcare and has information on model evaluation and standards on its website. Google, Microsoft, and Amazon are among the founding members, as are care delivery organizations, academic centers, professional organizations, retailers, payers, and standards organizations. The Coalition recently hosted CHAI on the Hill Day to educate lawmakers on healthcare AI, although it sounds like the event was heavy on developers and industry folks and light on care delivery organizations.

Care delivery organizations are also doing their own deep dives into AI, including Mass General Brigham, which recently announced its Healthcare AI Challenge Collaborative. Additional members include Emory Healthcare, the University of Wisconsin School of Medicine and Public Health, the American College of Radiology, and the University of Washington School of Medicine. Researchers will have access to an environment that includes AI solutions to “assess for effectiveness on specific medical tasks, such as providing medical image interpretation, in a simulated environment.” Users can provide feedback and the Collaborative is planning to use a crowdsource methodology for healthcare professionals “to create continuous, consistent and reliable expert evaluations of AI solutions in medicine.”

The Challenge will look first at radiology-related use of AI, which makes sense given that AI has been used in varying degrees in that field for years. It’s important to understand that fact, especially given the scare factor behind the use of the AI label since the emergence of ChatGPT. In my conversations, I find that people don’t really understand that there are different types of AI, many of which have been in use for a long time across a variety of industries. It’s only generative AI that is relatively new to the dance, but it has unfortunately triggered the creation of AI policies and AI review committees that have the chance to become cumbersome if they can’t differentiate between established low-risk AI solutions and higher-risk generative ones.

When I have this conversation with people, I point out the kinds of AI that we’ve all grown to depend on as examples of why not all AI is bad. These include spam filters, fraud detection and identification of suspicious transactions, sales forecasting, behavior analysis, and predictive models for a variety of things, including public health.

In my workplace travels, I’ve seen some of those go awry. One organization that I was consulting for had their email spam filter dialed up so high that anything with an outside address immediately went to junk mail with no way to add to a safe senders list. I asked for an in-house email address so that I could work effectively, and it took more than a month to get that provisioned. That kind of inertia didn’t make for a productive consulting environment, so my work with them was short lived.

Other health systems have jumped into creating AI centers to test and develop tools. New York’s Mount Sinai has opened the Hamilton and Amabel James Center for Artificial Intelligence and Human Health, which focuses on patient care such as diagnosis and treatment. Vanderbilt University Medical Center is creating the AI Discovery and Vigilance to Accelerate Innovation and Clinical Excellence center. That’s definitely a mouthful and doesn’t appear to be any kind of acronym or initialism, so I wonder if the name will be whittled down to something punchier. Hartford HealthCare is creating a Center for AI Innovation in Healthcare that includes research, development, education, training, ethical, and regulatory aspects of AI.

As a clinician, the biggest risk I see of AI in healthcare is for frontline clinicians who don’t have a background in clinical informatics or an understanding of the potential pitfalls of generative AI. These folks have a high likelihood to use non-medical AI solutions for clinical care support even though those solutions have plenty of disclaimers that say they shouldn’t be doing it. Get a group of physicians together and they’ll talk openly about what they’re using and how they’re using it, and there’s often little realization of the risks.

These physicians are the same ones who are also likely to not proofread their AI-generated notes before they go out, but then again, they’re also the ones who didn’t read their dictated notes either. They also have a high likelihood of using templated notes and not updating them consistently for the patient in front of them, so it all goes to a pattern of behavior. Still, there are too many clinicians taking this cavalier attitude for me to be comfortable with their ability to effectively and safely incorporate additional AI solutions into patient care.

I’m not worried about AI taking over my life, at least in the short term. No online presence is going to come into my house and create delightful baked goods such as the dinner rolls that I crafted for Thanksgiving. I appreciate that AI can make some tasks faster so that I have time for things like baking and creating, but there is still plenty of busy work that I’d like to offload to AI sooner than later, and I wish developers would get to work on that.

What are your favorite holiday foods? Care to share a recipe? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/25/24

At several conferences I’ve attended lately, there has been discussion among clinical informaticists about how increasing use of technology might be affecting our ability to process information and retain items in memory.

In speaking with medical students, it’s clear that they are learning in ways that are dramatically different from the options that we had when I was in school. At that time, the primary method of teaching was lecture based, with or without slides or visuals. Accompanying paper textbooks had chapters that roughly aligned with the material that was being presented in the lectures, but sometimes presenters would go deep into their own personal research areas, which left students scratching their heads trying to figure out what was important. Not only for testing purposes in a highly competitive environment, but for the not-so-distant future when we would actually be expected to care for patients.

If you didn’t want to go to lectures or wanted supplemental materials for the fast-paced sessions, each medical school class ran its own transcription service. Designated people agreed to attend each lecture and record audio cassettes of the content, then placed them in the mail slots of other students who had agreed to listen to and create transcripts of the lectures. Other students printed those transcripts and took them to the local copy shop, returning with paper copies that they dutifully stuffed into those mail slots for the rest of us to gather. For those of us who attended class, this was a great backup for the times that content was going over our heads or for when we inevitably zoned out due to information overload.

The only time we ever had lectures that were formally recorded by the university was for those classes that were presented during certain religious holidays. In those situations, videos were made, but they were only available to the students who observed those holidays. I remember wondering what it would be like if they just recorded all the lectures and made them available to everyone so that those who learned differently could use that modality, but the university said it would be cost prohibitive to do so. Thinking back, these were the days when we thought Lotus Notes was the be the end-all of software suites, so it’s hard to know what the true cost would have been when looking through the lens of today.

Fast forward to my 20-year medical school reunion, where a student tour guide told us that the university was recording all lectures and making them immediately available. At least in her class, she said very few students attended lectures, with most learning from videos that they watched at 1.5x or greater speed. It sounded like the focus of learning had changed, too. Since they weren’t “wasting time in class” they could spend more time studying for the medical licensing exams, which were viewed as being more important for the ability to match into a competitive residency training program.

I’ve learned that in recent years that they have added AI-assisted transcription to the recordings. I wonder if students even take notes anymore or just highlight and annotate those transcripts. I haven’t seen any of those materials myself, so I don’t know how well the transcription does with medical words and complicated scientific concepts.

When I was a student, we still carried pagers. I remember that when the Motorola text-based pagers came out, we thought we had really arrived. Cell phones were still a rarity. Now, every medical student holds the entirety of human knowledge in their hands on a near-continuous basis. It’s easy to look things up and we’ve become dependent on always having that ability, at least until it comes crashing down during a hack or other loss of service.

Students still memorize things, especially if they know they will be on a test. Some information becomes ingrained because of common use, such as the ability to quickly recall certain clinical formulas or calculations. Depending on how those resources might be presented in an EHR or online resource, it’s likely faster to be able to do them yourself, although accuracy is always a risk (but then again, it can be a risk in the EHR as well).

There are studies that look directly at how the internet may be changing our ability to think — attention spans, memory processes, and understanding social interactions both online and in person. I’ve done a lot of work during my career on understanding learning styles and trying to maximize how patients receive information, and much of that applies to understanding how clinicians receive information. The major differences are overall educational level and health literacy. I’ve spent more than 20 years working with teams to create training materials for EHRs and HIEs as well as patient-facing educational materials that address procedure preparation and chronic conditions.

Requests for specific lengths of training segments have decreased over time. When I first began working in educating clinicians, classes were way too long. We thought that we were progressive when we reduced them to 90-minute blocks, knowing that anything presented after that mark was unlikely to be absorbed. From there, we worked to shorten courses to 60-minute blocks. When technology evolved enough to be able to do recordings that we could park on our learning management system, our goal was to have 10- to 15-minute segments that went together to form a larger body of material. Since the advent of social media, the push has been to get those down to 3-5 minute blocks.

Now I’m starting to see requests from physicians for TikTok-style videos for continuing medical education, and I struggle to see how that might work. Healthcare concepts are often complex and I don’t know how you can even explain them in 30 seconds or less, let alone do so in a way that allows the learner to achieve mastery.

I also worry that the shift towards that style of learning will penalize those of us who learn best through the written word, even if it’s via digital media. I’ve always been a reader and use a variety of paper and digital sources. I find that if I’m in “hey, let’s learn something” mode, I do best with a traditional paper book. If I’m reading for leisure, either paper or electronic is fine. If I’m traveling, I’m not going to read it unless it’s on my Kindle since I’m a fast reader and tend to devour novels (I love a good mystery) and there’s not enough luggage space to accommodate paper for a long trip. I also love audiobooks and am trying to embrace those for learning as well as for entertainment. As someone who learns through written language, I’m grateful that my organization has digital transcription enabled for recorded meetings, because often I’ll turn off the audio and just read the transcript along with viewing the slides.

I’m curious how other informatics and educational experts have perceived this shift, and what other perspectives might be. Hopefully readers will weigh in. I’m happy to share comments, whether attributed or anonymous.

In the mean time, I’m making my reading list for 2025. What’s the best book you’ve read recently, and why? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/21/24

The number one topic of discussion at a recent meeting of primary care physicians that I attended was how their health systems are using AI to help with documentation. The majority of the conversation was around using AI to create draft responses to inbox messages.

One physician was vocal when speaking of a specific vendor’s AI technology: “I don’t know who this guy is, but he seems to think I give out controlled substance refills like candy.” Apparently a lot of the inbound messages are asking for refills, but I would think it would be fairly easy to tune the algorithm to have different responses for controlled substances versus those that aren’t, especially since the medications are represented by discrete data in the EHR. I’ve not used the technology from that specific vendor personally so I can’t comment on it, but I suggested that he reach out to his IT department and provide feedback.

Although AI can be part of the plan, there are some fairly straightforward non-technical tactics that can help with inbox management. The American Medical Association summarized these in a recent piece on creating a “saner” inbox. The suggestions were not surprising:

• Set clear expectations for patients.
• Give new patients a printed handout that outlines reasonable expectations for responses and guidelines for portal use.
• Restrict the ability to send messages to patients who have seen the physician within a certain time period.
• Maintain uniform workflows and avoiding exceptions.

I have not seen anything like a printed handout in any of the practices where I’m a patient, but it seems like an inexpensive intervention that could help. It gets even cheaper when you send the document through the patient portal. The article also recommends discussing excessive portal usage directly with patients and setting boundaries if needed. Low tech as well, but also likely effective.

As more AI-enabled tools are brought into regular clinical use, finance types are going to look for ways to pay for them. A CPT code was recently issued for Eko Health’s AI-powered Sensora cardiac screening tool. The tool is designed to identify heart disease by detecting certain heart murmurs and irregular heart rhythms. It works with one of the company’s advanced digital stethoscopes that has built-in EKG functionality. Physicians can use the billing code starting July 1, 2025, although it’s unlikely that it will result in payments without buy-in from insurance companies.

From Greek Islands: “Re: consulting firms. I’m in all-day meetings with one that is trying to earn our business. I’m watching the high-priced consultant sitting nearby access various websites, including online bill pay. Not a good look.” Like they say, you only have one chance to make a first impression and this certainly was not a good one. I am reminded of the time when I was doing an EHR optimization project for an urgent care where the physicians complained bitterly that they didn’t have enough time to get their notes done. During a single day of workflow observations, I watched one of the most vocal members of the group look at over 200 offerings on the website of a major footwear retailer. If you are a compulsive multitasker, learn to close your laptop or take notes on paper so that you avoid doing something you might regret later.

I’m a nice, compliant patient with a well-controlled chronic condition, so I only have to see my care team once a year. Following best practices for ensuring patient follow up and reducing future phone calls, they schedule your next visit before you leave the office. When I get home, I download the appointment through the patient portal and add it to my trusty Outlook calendar.

This year when I went for my visit, I got a surprise. I discovered a sign on the darkened office door that they had moved up the street to a new building. Although I was plenty early for my appointment, I wasn’t early enough to backtrack to my car and drive to a different parking garage, so I had to hoof it down the block.

I looked at recent communications from the practice and found that some of them had the new address and some had the old address, but in none of them was it called out that the practice was moving or had moved. My primary method of contact for this practice is patient portal and none of its messages talked about the move. It takes at least 90 to 120 days to do a build-out on a new medical office, so it’s not like the practice made a spur of the moment decision to relocate.

Since they moved up the street, I suspect that many people won’t notice the address difference on a reminder message. When you have been going there for a decade, would you notice a change from 5200 Maple Lane to 5300 Maple Lane on the fourth line of the text message? Are you likely to plug the address into your GPS for a trip that you have made over and over? Some might, but it didn’t cross my mind, and I suspect that for many patients with varying levels of health literacy, it won’t cross their minds either.

Knowing how easy it is to send a blast message to all the active patients in a practice via a patient portal, I wondered why in the world they wouldn’t have done so. As I sat in the waiting room, the receptionist fielded a call from a patient saying that they were going to be late because they were in the wrong building, so at least I know it’s not just me. I provided feedback to the office that it would be useful to send a message to patients, especially those who only come in once a year, but they didn’t seem to be interested in improving their patient satisfaction scores in that way.

There were plenty of other unsavory things about the visit, so I’m eagerly awaiting my post-visit survey. Things I’ll be specifically mentioning besides the office relocation issue: failure of patient care team members to introduce themselves, lack of confidentiality of staff conversations in the waiting room, incorrect taking of vital signs, and inappropriate comments added to patient chart during medication reconciliation.

And one more thing – the colossal HIPAA violation when the medical assistant accessed the practice’s secure messaging app while doing my intake, allowing me to see other patients’ full names and medical information on the very large wall-mounted monitor. Not to mention her failure to lock the computer when she left the room. At least the rendering provider was appropriately horrified by that when she came in, so that’s something.

I tried to offer additional feedback in person during the visit and was directed to “include that in the patient survey when you get it.” Obviously people in the office don’t understand how those surveys work and how it would have been easier to take my feedback real time then for me to put it in writing. Or maybe they just don’t care.

What kind of communications do you do for your clinicians when their offices relocate? Should I plan to plug every visit into my GPS for the next 30 or 40 years? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/18/24

The practices in which I’ve spent the majority of my clinical time over the past few years don’t use AI-assisted or ambient transcription technologies. One uses human scribes, while the other leaves physicians to their own devices for finding ways to become more efficient with their documentation.

In the urgent care setting, my scribes have always been cross trained. They started out as patient care technicians or medical assistants, and if they had excellent performance and a desire to learn, they could request to enter the in-house scribe training program. During that multi-month period, they received additional training in medical terminology, clinical documentation, regulations and requirements, and understanding the physician thought process for history-taking, creating a differential diagnosis, and ultimately creating and documenting a care plan.

Many of our human scribes had the goal of attending medical school or PA school, so they had a strong drive to learn as much as possible while doing their job. As they learned our habits for seeing patients and describing our findings, they would sometimes prompt us for something that we might have forgotten to mention or might not have performed during the exam. Because of the level of cross training, they could also assist us with minor procedures during the visit rather than just standing there and waiting for us to describe some findings.

Towards the end of the visit, when the physician typically summarizes the findings for the patient and describes the plan of care, the scribes would review and clean up the notes so that they were ready for our signature as soon as the patient disposition was complete. I would often be able to sign my notes in real time, and even if I had to wait until the end of the day, it might take me less than a minute to review each note because of the diligence they used capturing the visit.

Human scribes are also helpful when conducting sensitive visits, which often happen in the urgent care environment as we discuss a patient’s sexual history or perform sensitive portions of the physical exam. In those situations, our scribes served as both chaperones and assistants, providing support to patients when needed and assisting with specimen collection – uncapping and capping jars and tubes, ensuring accurate labeling, etc. I’ve had scribes help patients take their shoes and socks off and assist them in getting on the exam table and returning to a chair. When contrasting a visit that uses a human scribe to one where the physician has to perform their own documentation, there’s a substantial difference in the time that it takes to complete the visit, and not just from a documentation standpoint.

In speaking with my colleagues who have transitioned from human scribes to either virtual scribes or AI-assisted technologies in similar practice environments, they note that they miss the physical assistance of the scribe. No one is in the room with them who can step out and grab supplies or equipment when a situation occurs where it would be more efficient to do that instead of the physician stepping out to get what they need. There are also flow issues when chaperones are needed or when assistance is needed during a procedure, which can make the day bumpier.

Some colleagues with whom I recently discussed this mentioned that their organizations didn’t consider these workflow changes when moving to non-human documentation assistance strategies. One said that he felt that everyone thought it would be so much cheaper to not pay a person that they forgot to calculate in the time physicians would now be spending doing things that they didn’t have to do in the past.

It’s a classic parallel to what we experienced back in the early days of EHR implementation, when there were constant encounters with unintended consequences. One example: in a paper-based workflow where no one reconciled medications, implementing an EHR that requires medication reconciliation is going to increase visit duration, whether it’s done by an assistant or the physician. They should have been doing medication reconciliation in the first place because it’s a patient safety issue, but the EHR took the blame as forcing them to do something they didn’t think was important. Now we have different unintended consequences when we layer on more sophisticated technologies such as AI-assisted documentation.

One colleague described the problem of excessive summarization, where his organization’s AI documentation solution took a lengthy physician / patient discussion that included detailed risks and benefits of treatment or lack thereof and condensed it down into two sentences. When that happens, one has to consider the downstream ramifications. Will a physician even see that it’s been condensed in that way, or are they just signing notes without reviewing them to keep their inbox clear? That situation happens more than many would think. If a physician catches the issue, will they spend the time editing the note or will they just move on because they’re pressed for time? And if they do take the time to edit the visit note, will they capture all the nuances of the discussion exactly as it had occurred with that particular patient?

Another colleague, who is also a clinical informaticist, mentioned that having AI documentation solutions doesn’t fix underlying physician behavior challenges. The physician who never finished his notes at the end of the day and instead left them for Saturday mornings still leaves them for Saturday mornings, which means that he’s reviewing documentation that’s up to five days old and for visits that are no longer fresh in his mind. It’s creating issues with the technology platform, since recordings have to be kept until the notes are signed, and it’s skewing metrics for chart closure that were important to measure the success of the project. 

The team that implemented the solution could have anticipated this had they looked at baseline chart closure rates, but they were in such a hurry to get the solution rolled out that now they’re having to go back and examine that data retrospectively. They also missed the opportunity to coach those physicians during the implementation phase about the patient safety value of closing notes in a timely manner.

Others have noted issues with using AI solutions to examine documentation after the fact, such as only using data from structured fields. This is great when you have a specialty that does a lot of structured documentation, but doesn’t work well in one where the subtleties of the patient’s story are largely captured via free text.

I recently attended a lecture where they discussed the hazards of using AI tools in the pediatric population, since so much of the language used in capturing a child’s status varies based on the age of the patient. For example, saying a patient is “increasingly fussy” has a meaning that goes beyond the words themselves and has a different impact when treating an infant versus an older child or a teenager.

The pediatricians also mentioned the difficulty in obtaining consent for use of AI tools during visits, especially when only one parent is present or when the child might be brought to the office by a caregiver such as a nanny or sitter. Although those individuals may have capacity to consent to treatment, they may not have specific ability to consent to the use of AI tools. There is also the issue of the child’s consent to being recorded. Although the laws generally allow parents to consent on behalf of their children, obtaining the permission of an adolescent patient is an ethical issue as well, and one which physicians may not have the time to address appropriately due to packed schedules.

The dialogue around use of AI solutions has certainly changed over the last year, and we’ve gone beyond talking about how cool it is to addressing the questions it has raised with expanding use. It’s great to see people asking thoughtful questions and even better to see vendors incorporating ethical discussions into their implementation processes. We’ll have to see what this landscape looks like in another year or two. I suspect that we will have found many other areas that need to be addressed.

How is your organization balancing the addition of AI solutions with the need for human assistants and the need to respect patient decisions? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/14/24

I have a couple of medical licenses that expire at the end of the year, so I spent some time taking care of those renewals. Failing to renew on time is an expensive mistake that can cause issues with credentialing and can result in disciplinary action if you inadvertently practice in a state where you’re not current. Although I rely on my clinical employer’s credentialing team to remind me, I also have appropriate reminders on my personal calendar to ensure I don’t miss a critical deadline. Most states where I’m licensed allow online renewal and the process takes only a few minutes, as long as there are no changes to your address, no new criminal convictions or malpractice claims, and you have a valid credit card.

As I was wrapping up it was a good reminder to make sure that all my professional memberships were renewed as well, so that they could be in the books for the 2024 fiscal year. Although most of those run January through December, I realized that my HIMSS membership had expired during the summer and either I missed it, or I didn’t receive a reminder. I guess I didn’t notice because I receive plenty of emails from HIMSS on a near-daily basis, and wouldn’t one think they’d suspend communications if you’re not paying dues? I would also think they’d send multiple reminders before expiration and continue to send reminders after, since HIMSS membership renews on a rolling basis. There was no penalty for late renewal and in fact my expiration date shifted, so it was like getting four months of membership for free since nothing had changed, at least in my opinion. I suspect that individual memberships like mine are the lowest thing on the organization’s priority list, so I shouldn’t be surprised. I’m not sure how valuable a HIMSS membership is anymore – maybe some readers should weigh in on how I could be getting more from my money than a discounted HIMSS conference registration rate.

From Jersey Girl: “It’s not just the WNBA – a health system logo is going to be featured on an NBA jersey for the first time.” Congratulations to Memorial Hermann Health System, whose patch will appear on Houston Rockets jerseys this season. The system already owns naming rights for the team’s training center, so it’s not surprising. A quick assist from Chat GPT tells me that patch rights go for $7M to $10M each year, so I hope the health system is going to get some significant return on its investment. That’s a lot of community health screenings or discounted health services that could be provided with that kind of money. Are you a health system exec willing to speak off the record about what these deals mean to your institution? Feel free to reach out anonymously.

AI is everywhere, so I was interested to see this recent JAMA Viewpoint article titled “Translating AI for the Clinician.” Most of my local colleagues think of AI as “using Chat GPT to write patient letters,” but don’t think too far beyond that. The authors note the need for a framework “for clinicians and patients to understand AI in the context of clinical practice, including the evidence of efficacy, safety, and monitoring in real-world clinical use.” I’ve been on the patient side of AI-augmented patient portal responses and ambient documentation, and during zero of those encounters has there been any mention to me as a patient about the use of AI or the risks and benefits of consenting to it being used as part of my care. As a clinical informaticist I know better – but the situation illustrates the need to better educate clinicians on the need to have some kind of a consent process around the use of these tools. The authors call for organizations to spend time considering the different activities inherent in patient care – elements such as interacting with patients, creating visit notes, interpreting tests, and delivering treatments – and to think about the best ways to leverage AI in those scenarios. This sounds like a rational approach to me – actually identifying a problem to solve versus creating a solution in search of a problem. Although many of the current uses of AI are well-reasoned, there are still a number of startups addressing the latter.

I’ve not used ambient documentation solutions as a clinician, so I reached out to a couple of friends to find out how their organizations are handling consent. One admitted that they addressed it during the pilot phase, but that by and large physicians just want it installed and are assuming that it’s addressed in the standard “consent to treat” forms that patients sign at the front desk or online via the patient portal. The only person who is actively having a consent conversation is a pediatrician, where the idea of consent is a big issue in general due to nuances of privacy and confidentiality when you’re caring for adolescents. Learning more about this topic reminded me how broad of a field clinical informatics has become and how one informaticist can’t possibly know everything. Although most large institutions have entire teams tackling these issues, the average physician trying to purchase an individual contract from one of the AI documentation vendors probably doesn’t know what questions to ask. The authors call for organizations to treat AI like they treat new drugs or medical devices – with testing and follow up to ensure that treatments are effective. Unfortunately, millions of patients are already part of a large experiment without even knowing it.

The Anchorage Daily News reports that nurses are concerned about the implementation of virtual nursing in their communities. I’ve worked on a couple of virtual nursing projects in the last few years, and they’ve generally been well received, so I was interested in the specific concerns. Nurses are concerned that having virtual colleagues managing discharge planning and patient education will concentrate additional work on the bedside nurses, stressing an already burdened work force by driving up patient-to-nurse ratios. The nurses’ union has filed a complaint with the National Labor Relations Board alleging unfair labor practices, so it’s not a concern that will go away any time soon. Hospital nursing has changed dramatically during the time between when I was a student and today, and frankly the only constant about patient care is that it will continue to change. The article notes that unlike some states, Alaska does not have a mandated patient-to-nurse ratio. I’ll be keeping an eye on this one to see how the labor complaint plays out.

Do you have virtual nursing at your institution and if so, how has it been received? Leave a comment or email me.

Email Dr. Jayne.