Curbside Consult with Dr. Jayne 10/7/24

I had several friends attending the Becker’s Health IT + Digital Health + Revenue Cycle conference last week in Chicago. In sending me some impressions and notes, they all mentioned conversations around the topic of whether health systems should be able to monetize patient data.

Key areas where organizations might use de-identified patient data include generative AI, genomics and precision medicine, and pharmaceutical drug discovery. When I’ve discussed this with fellow physicians in the past, the question of ethics was usually at the top of the list. In recent months, however, the focus seems to have shifted to whether organizations can truly protect patient data, and whether or not there is a risk of it becoming re-identified by someone intent on doing harm.

Putting on my patient hat, the first issue I have with using patient data beyond the actual patient care is that of consent. Organizations may claim that they received patient consent, but did they really? Most large health systems are giving patients multi-page documents to read when they arrive. Those documents include a multitude of topics, from data sharing to billing assignment to consent for treatment. I’d be hard pressed to find 10 patients in the lobby at my local academic medical center who know definitively whether they have signed a consent for dissemination of their de-identified data or not.

At my last mammogram visit, the facility didn’t even offer me copies of the Notice of Privacy Practices or Consent for Treatment documents to review. The registration clerk simply pointed to a signature pad and said, “Now you’re going to sign indicating you received this and agree to it” and became irritated when I asked for copies of the documents prior to signing.

In my book, consent that is obtained in that manner is in no way a valid consent of any kind. Not to mention, the patient really has no other choice but to consent, in many cases. With insurance companies building narrow networks, patients may not really have a choice as to where they receive treatment and end up agreeing to whatever is put in front of them because they need care. One never hears the word “coercion” uttered when patients are at the check-in desk, but that’s essentially what is happening.

Another major issue for patients is the general lack of understanding of what HIPAA covers and doesn’t cover. Most people don’t know that consumer devices collect clinical information, but it’s not at all protected, and companies can do whatever they want with it for the most part. There have been recent concerns following shakeups at genetic testing company 23andMe as far as to what will happen to their data in the event of an acquisition or changes in leadership. With changes in state abortion laws, there are increasing worries about period tracker apps, fertility tracking apps, and other ways of capturing reproductive data. Between those two catalysts, I’m hoping that patients become more aware of the fact that their information is just out there. We all know that no one reads the terms and conditions when they sign up to use a new app.

Changing to my clinical informatics hat, I absolutely agree with the concerns around organizations’ inability to protect patient data. Recent cybersecurity events have shown that they struggle to protect fully identifiable data used for direct patient care, so what makes us think they’re using an equivalent level of rigor for de-identified data? There are plenty of articles out there that describe how easy it is to re-identify patient data, going back as far as 1997 from what I could identify with some quick searching. There are plenty of data-rich sources that are publicly available, such as voter registration lists.

Several colleagues posted to a local physician forum after they received data breach notifications stemming from the Change Healthcare hack. The words used by these physicians, who were impacted as patients, caught my attention. They were “crushed” and “stunned” that their information could have been impacted. It was an eye-opener for them, I guess. 

We have all worked for, and been patients at, the same healthcare system over the last couple of decades. I know that my data has been impacted at least a half dozen times, including when a research coordinator had a non-encrypted laptop in the trunk of her car and it disappeared. It made me think that our organization probably does a bad job of making physicians aware of these incidents, when in reality, we are going to be a point of contact for concerned patients whether we like it or not. I’m trying to give them the benefit of the doubt, but at this point in the game, we need to all assume that none of our healthcare data is private or truly protected.

Speaking of privacy and confidentiality, fall is when many organizations require completion of annual compliance training updates. Although I’ve been through HIPAA and other compliance training in several dozen organizations over the last decade, I have yet to see one that addresses the fact that ease of access with phones and tablets has led to physicians accessing patient information in all kinds of places and with minimal privacy protections. I was sitting in a restaurant booth with a colleague a couple of weeks ago. She was waiting for some lab results on a patient and kept pulling out her phone to check and see if they were back. She generally has a hard time disconnecting from the office due to her specialty, and in a matter of minutes, I saw her entire patient schedule, several other patients’ labs, and some imaging go by.

I made sure I paid detailed attention to my salad while this was going on, but was flabbergasted that she thought it was OK to do this. Maybe she felt safe because I am a fellow physician, but given her overall track record of how she uses her phone, I would guess that she does this in other environments.

I mentioned it to her and she shrugged it off, saying she was sure “no one is looking at my phone” and justifying her behavior due to being in a high-stakes surgical subspecialty and needing to check in on patients. But it’s a snapshot into the cavalier attitude that many in healthcare have around protecting patient information. I’m sure she once watched a video that said “screens should be pointed away from prying eyes” but maybe making mention of specific environments where clinicians access patient data on their phones might be more impactful.

It will be interesting to see how patient privacy, consent, and monetization of patient information plays out over the coming years. In the meantime, think twice before you’re hitting the EHR during your kids’ soccer game.

What do you think about the monetization of patient data? Does your organization have a stance? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/3/24

The American Medical Informatics Association has given a shout-out recognizing the 10-year anniversary of Clinical Informatics Fellowships and Clinical Informatics Board Certification. I still remember sitting through the all-day informatics exam the first time it was offered, finding it much more terrifying than my clinical board exam. No one knew what to expect, so a lot of us decided to give it the “full send” and sign up since if we didn’t pass we could blame it on the fact that it was new. There are now 60 accredited Fellowships and 2,700 clinical informatics diplomates certified by the American Board of Preventive Medicine or the American Board of Pathology.

DirectTrust recently held its annual conference themed “The Future of Trust in Health.” Hot topics included patient matching, cybersecurity, identity matching, and of course interoperability. The agenda included a who’s who of healthcare technology, including Susannah Fox speaking about the patient-led data revolution, Micky Tripathi discussing digital infrastructure, and Greg Garcia presenting on cybersecurity. DirectTrust is a non-profit alliance that is working to build trust in healthcare-related data exchange and focuses on developing standards and accreditation. It has strategic partnerships with organizations like The Sequoia Project to help promote TEFCA-facilitated FHIR and convenes workgroups around topics like cybersecurity and innovation priorities.

The reader mailbag has been rich this week:

From Greek Gastronome: “Re: Hotmail HIPAA. A family member had a video visit with her physician, who needed a copy of some lab work that another physician had ordered. Apparently it wasn’t available through the group’s interoperability solutions, so the physician instructed the patient to email it to a Hotmail account. I didn’t realize that Hotmail was HIPAA compliant.” There are some days when I simply run out of words to describe the madness that is the US healthcare system, or non-system, as it is on most days.

From Return to Office: “Re: RTO. Since my company started pushing its return-to-office efforts earlier in the year, I have noticed an uptick in meetings that don’t start on time. It seems like it’s become the norm to ‘just give people a few minutes to hop on.’ My last call had 37 people burning time while we waited for a few more people. It was particularly annoying because it was also being recorded, so latecomers could have easily accessed what they missed.” I’ve worked from home since before working from home was a thing, so I’ll have to hypothesize on this one. Since returning to a corporate office likely means having to deal with traffic and parking or having to cross a cube farm to use the restroom between calls rather than going 10 feet down the hall at home, those might be contributing factors. I also suspect people might be getting waylaid in the corporate kitchen and finding it difficult to extract themselves, especially when they’re under the microscope to demonstrate that they’re collaborating with others. I would be interested to see what those of you who have had to return to office think about the phenomenon.

From Jean Claude: “Re: AI. I just read something that made me wonder if patients have anything to worry about with AI and the documentation of clinical (outpatient and inpatient) visits? Just curious on your thoughts.” For me, the major risk is when providers use AI tools to create documentation but don’t proofread their notes before signing. Any errors can be propagated downstream (such as when a consultant reviews an inaccurate history but doesn’t verify it with the patient) and can be compounded when people make decisions on those errors. However, playing devil’s advocate, I have to wonder if it’s any riskier than when we had handwritten illegible notes, or dictated notes that weren’t reviewed after being transcribed. My concern is less with AI-assisted documentation and more with using AI to try to summarize existing documentation or to generate a diagnosis or a treatment plan. Those areas seem much riskier to me.

From Patient Safety Fan: “Re: surgery gone wrong. “Did you see this article about the surgeon who confused the liver and the spleen during a surgery, removing the wrong organ? We need some AI tools to prevent that kind of mistake.” It’s been a long time since I ran the camera in a laparoscopic surgery, which was a prime medical student and intern job where I trained. The patient died after having his liver removed, with the surgeon having been found to have had a similar surgical misadventure in 2023. How cool would it be to have an AI-assisted superimposed surgical map as part of the camera feed for a procedure, similar to some of what can be delivered through military heads-up displays? Now that’s an AI startup I could get behind.

From Race Fan: “Re: branding. I know you aren’t thrilled about hospitals paying for exposure for sports teams and such, but check out this partnership between WVU Medicine and auto racing.” I agree that this partnership is pretty cool, with pediatric patients at the health system helping create designs for a race car. The design, created by three patients, appeared during a September 19 race at Bristol Motor Speedway. Other events at the race were designed to raise funds for WVU Medicine Children’s and to raise awareness of the hospital’s role in caring for the community. The driver’s racing suit will go under the auctioneer’s gavel at the hospital’s gala in February.

Conference season is upon us, and The Hustle had a great post on “Corporate swag will never die.” The piece has some outstanding examples of swag gone wrong, but I appreciate the entertainment value of some of the options. For those of you trying to figure out what you’re going to feature in your booth for upcoming conferences, may I suggest the beer burro, as shared by an intrepid reader who spotted it roaming the aisles at the recent American Academy of Family Physicians FMX conference in Phoenix. As a connoisseur of booth décor and giveaways, I can pretty much guarantee it would drive traffic.

We’ve all seen popcorn and stress balls, but what’s the best swag or best booth giveaway you’ve seen at a conference? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/30/24

A care delivery organization recently asked me to work on an AI project. They are looking at ways to incorporate generative AI into the clinical process, but didn’t want to use an off-the-shelf solution due to concerns around cost and clinical quality. Instead, they set out to create their own solution, which I suspect was in part a way to justify the recent creation of an innovation team, which hadn’t yet produced anything mind-blowing despite being a significant cost to the organization.

Although I sympathize with their desire to have a system where they can work behind the scenes and ensure the validity of the data being used and the outcomes, I could have told them months ago that they would spend way more money taking the do-it-yourself approach instead of working with someone who already had expertise in this area.

Their solution is pretty far along in the development process. They have had a single physician who is providing input. They are ready for more physicians to be involved, and because they are a care delivery organization, they assumed that physicians would be clamoring to be part of the project, either in providing clinical scenarios or being beta testers.

However, they didn’t budget compensating those physicians for their time, which given the tone in their physician group, was a significant oversight. Physicians who are already feeling burdened and burned out are less likely to give freely of their time to an organization that they feel is not working in their best interests.

I started my work with them by attending an onsite meeting where the team was strategizing on how to convince providers to be more involved. They asked me to go around to offices and try to convince physicians to participate.

It quickly became clear to me that many of the people on the innovation team had not worked in healthcare. They thought that it would be great to just show up during office hours and try to get people’s attention. I had to do a little explaining about how physicians are so protective of their time that many of them have eliminated the presence of non-essential people in the office during the day – no drug representatives, no lab representatives, no med students, etc. They were surprised by this, so I got to share how COVID really changed this landscape and how once clinicians realized how nice it was to not be interrupted, they weren’t going back.

It turns out that during the development process, no one had been working with physician leaders to talk about the project and to build consensus around its use. I found that pretty remarkable since most organizations have by now learned the value of buy-in.

I asked to meet with physician leaders so I could build an understanding of the physician group’s culture and whether there were people who would be willing to participate and what kind of compensation or reward might be needed. Everyone is motivated a little differently, and some will respond to non-monetary incentives like being the first practice to use a new tool or being bumped up in the line for enhancement requests that they’ve already entered. Others do want to participate in making things better, so I thought we should learn about any existing physician wellness committees where we might find willing participants.

I also suggested that since there is a corporate IT department, it might be interesting to pull search histories on some of their clinical users to determine what kinds of things they might be asking Dr. Google. There was a lengthy conversation about this being a violation of user privacy, which surprised me. How many annual compliance training sessions have I been through that explained that nothing that is done on a company-owned device or on a company network is private? Had I stumbled into an alternate universe where people had no fear of corporate types seeing what they were doing on their work laptops?

Although they agreed in principle that it would be an interesting approach, they said that they would have to take it through various approval processes. It was a non-starter in the short term.

In the meantime, while we were working through that issue as well as working with physician leaders to find clinical testers and potential beta sites, I agreed to create some testing scenarios across various specialties. I drafted some requests to pull diagnosis data from their EHR to better understand what kinds of conditions were being treated. My thoughts there were twofold. First, I wanted to find out the most common conditions for which there might be a need for generative AI around patient-facing communication, clinical documentation in the EHR, or other use cases. Second, I wanted to understand the least common conditions for which users might be seeking additional information, either about other similar conditions or about treatment of a condition once they had narrowed it down.

I was a bit surprised that their in-house lead clinician hadn’t suggested these things, and it became more clear in some of those conversations why the organization wanted to bring in someone a bit more seasoned to assist.

I decided to start building test scripts around the organization’s genetics clinic since physicians are seeing increasing numbers of patients who are asking for full-panel genetic testing to try to understand their cancer risk. These tests can be expensive and are often not covered by insurance. They also test for genes that the average primary care physician doesn’t necessarily encounter on a daily basis, figuring there would be searches about them. I developed a test plan and got ready to kick the tires.

The first test scenario I did was with a condition that I thought would be an easy one since it’s fairly common and testing has been around for more than a decade. I asked the system what the clinical implications were for a patient who was a homozygous carrier of the condition, since the answer should be straightforward about early screening. The answer was anything but straightforward, with the system taking me on a wild ride that ultimately ended in a recommendation to do nothing. I was stunned.

I tried quite a few more test scenarios and the system performed as expected, but I was left with a bad feeling about how to proceed. The engineers who had been following my testing didn’t think that one miss was a big deal, but to me as a clinician, the miss was a very big deal. I knew I would have another topic for my meetings with clinical leaders as we would need to discuss what the organization’s tolerance was for misses and near-misses, and also whether there were ethics committees that we could bring to the table.

I was starting to feel like this project was one of those “on the back of a napkin” efforts that hadn’t been fully fleshed out and would ultimately need more discussions than I was prepared to lead as part of my engagement.

We’ll have to see how this shakes out over the next few months, but it left me wondering how many other organizations are in positions just like this, taking projects forward when they don’t have the right stakeholders at the table or an understanding of the true clinical implications of the technology they’re trying to add to the mix. I suspect we’ll have a lot of uncomfortable conversations, and some folks won’t be happy that this outsider is poking holes in their project. Alas, that’s all in the fun of being a consultant, so I’ll just keep putting one foot in front of the other and try to navigate them in the right direction.

What is your organization’s process for ensuring clinical stakeholders are involved in clinical technology projects? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/26/24

The hot topic around the virtual physician lounge this week was an article from the American Medical Association (AMA) that identified “Five physician specialties that spend the most time in the EHR.”

Physicians were whipped into a frenzy by the statistic that ambulatory care physicians spend an average of 5.8 hours in the EHR for every eight hours of scheduled patient care time. Even if you adjust for the time one spends in the EHR while you’re seeing a patient – for example, when you’re reviewing the chart, capturing the patient’s story, and writing prescriptions – that means a lot of clinicians are still doing loads of documentation during non-scheduled working hours.

The article cites a study that was published in the Journal of General Internal Medicine that found the highest EHR times per eight hours of scheduled patient care were: infectious disease (8.4), endocrinology (7.7), nephrology (7.5), internal / family medicine (7.3), and hematology (7.2). The lowest EHR times were: dermatology (4.3), surgery (4), ENT (4), orthopedics (3.3), and anesthesiology (2.5).

The study’s lead author, Christine Sinsky, MD, is vice-president of professional satisfaction at the AMA. She notes that, “These are specialties with complicated patients with multiple medical conditions for whom there’s a lot of visit-note documentation, lots of orders, and require a lot of communication between the patient and the physicians or the team between visits, so the inbox time is highest among those five specialties as well.” That inbox time was noted as 0.8 hours of work per eight hours of patient care, on average, but primary care, infectious disease, and endocrinology were at 1.2 hours per eight hours of patient care.

Since orthopedics spends only 0.4 hours in the inbox per eight hours of patient care, she hypothesizes that, “Many of the procedural specialties have hired staff who assist with some of the tasks of order entry, visit-note documentation and being the first responders to the inbox.” Even the lowest-paid orthopedists in my area make twice what a family physician does, so it’s a little easier for them to afford the staff to help them get through the day.

I dug into the article itself and found that it used data from more than 200,000 physicians at 400 organizations. The source was Epic’s Signal platform, which measures physician activity both within and outside scheduled working hours.

Sinsky calls on EHR vendors to reduce the burden of documentation, including the number of screens and clicks that it takes to perform specific tasks. She cites the click count that is needed to document ordering and administering a single vaccination at 32, which I agree is a tragic level of clicks. My favorite EHR took three to order (launch immunizations, click influenza, click order) and six to administer (open the order, side/site picklist, manufacturer, lot/expiration picklist, checkbox to confirm the Vaccine Information Statement publication date, click save) with an optional click or two if you needed to change the sequence number on a vaccination for a patient who had received previous doses elsewhere. I’d be interested to hear from readers how many clicks it takes in your system, and what they are beyond the basics noted above.

It will be interesting to see what this data looks like in the future, when we can have before-and-after studies that follow the implementation of ambient/AI documentation solutions. We also need to continue to look at payment models that deliver enough revenue to primary care and other specialties with complex patients so that they can hire adequate support staff. I worked for many years with a human scribe in a practice and I can vouch for the difference that it makes in how you spend your day.

I was also fortunate enough to spend a good chunk of my career working for an organization that felt that physicians needed to be seeing patients and not doing other tasks, so it was rare that a phone or inbox message came to me. When it did, it had already been managed by staff as much as possible. Not every organization shares this belief, though, and many rely on the after-hours labor of their physicians to keep the practice running.

One of the physicians in the discussion said, “They know we’ll do it even when they cut our pay, because we care about our patients even when the hospital doesn’t.” That provides more than an inkling of the level of moral injury our physician colleagues are experiencing. Another noted that her practice’s own Signal data showed that primary care physicians are doing an additional 3-4 hours of charting each night at home. She concluded, “Why are they going to pay a scribe $15 per hour when they know we’ll do the work for free?”

From there, the conversation hopped to topics such as overthrowing corporate overlords and whether lottery tickets might be a good investment for the physician on the go, so I stopped following. If you’re from an organization that’s aggressively addressing these concerns, I’d love to hear more about your efforts and what you’ve learned to date.

NCQA has released health plan ratings that might be helpful to individuals as they go through employer open enrollment plans. The ratings include 1,000 health plans, including commercial payers, Medicare, and Medicaid options. Data is from the 2023 calendar year and plans are rated on a five-point scale. The quality measures contributing to the ratings, include those on clinical quality, patient experience, and health plan structure and quality processes.

This year includes expanded quality measures that assess whether health plans capture race and ethnicity data for their members in an effort to provide relevant services. Notable quality improvements were seen in reported control of hypertension and diabetes, as well as appropriate testing for patients with sore throat. One concerning quality indicator was a decline in childhood immunizations, which should be worrisome across the board.

I looked up my own plan and found that they have 3.5 out of 5 overall, with only 2.5 for patient experience. Childhood immunizations were at 4 stars, adolescent immunizations at 3 stars, and there were plenty of 4-star scores for prenatal / postnatal care, breast and cervical cancer screening, diabetes care, and appropriate use of antibiotics.

Those scores are due to the diligence of the providers who are enrolled in the plan rather than the plan itself, so it seems weird to see the plan taking credit for it. I’ve never received any kind of health communication from my plan, and I also know that my physicians participate in plenty of other insurance plans that are also claiming credit for their good work. Only in the US do we see this kind of fuzzy logic, but at least it’s something transparent, I guess.

More stories from the patient-side trenches this week, as I started receiving bills from my healthcare adventures over the summer. I remember back in the early days of EHR/PM implementations where we were piloting real-time claims adjudication. Nearly two decades have passed and I have yet to see an office that does it.

In fact, with one of my current physicians, they didn’t send a statement to the patient until more than 60 days after the insurance posted to the account. Definitely not a revenue cycle best practice. When I received my paper bill, I looked for a way to pay it online. There wasn’t one, nor was there one on the practice’s patient portal. Not even a phone number to pay via that route. I literally had to write a paper check, which gave me a laugh when I looked at the check register and saw how long it’s been since I’ve written one, coupled with the fact that the calendar on the back of the register dates to 2017. Fortunately, the pathology lab associated with the procedure had an online payment portal, and it took me less than 90 seconds to pay up.

How long has it been since you’ve written a paper check? How old is the calendar in your check register? Leave a comment and let’s see who gets the bragging rights.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/23/24

I spent several hours this weekend fighting with healthcare technology systems that haven’t been adapted to play nice with the new ways that some of us work as physicians.

In the past, many physicians left training and took jobs with a private practice, an employed practice model, or with an academic medical center. If they saw patients at a hospital, they likely went through a credentialing process that involved voluminous paper forms and actual humans that read through the applications and resolved any questions or discrepancies. There was likely a designated person who managed physician credentialing with the insurance plans that the practice worked with. In my experience, they typically worked from the hospital’s credentialing forms, but may have had supplements of their own. Once again, there was someone you could contact who would be shepherding your applications through the system.

As healthcare organizations started to get squeezed in the 1990s and began participating with more insurance plans, organizations started turning to third-party credentialing services as a way of economizing. Rather than paying someone in the practice to run credentialing efforts, they could pay an outside company to do it, hopefully faster and cheaper. The better companies assigned a designated person or two to work with a specific practice, but others just assigned credentialing tasks to a pool of people who may not have any kind of ongoing relationship with a practice.

Still, most physicians had a primary practice location and a couple of hospitals, so it wasn’t that complicated. Some physicians might have done moonlighting work at other facilities, but that was an exception rather than a rule.

Fast forward a couple of decades. A significant proportion of physicians are not employed in the traditional sense. Hospitals and staffing organizations are doing everything possible to try to not have their workers classified as employees even though they probably should be. Many more 1099 jobs are out there.

Some physicians prefer the 1099 world. They enjoy working as locum tenens physicians for the flexibility in time and location of different contracts. In the telehealth world, the majority of physicians who are doing the work are 1099 contractors, and many work for multiple platforms in trying to cobble together enough work to support themselves. That means that the burden of managing credentialing across multiple organizations falls to the physicians themselves, often without any specific training for it.

I’m dealing with three credentialing systems. All assume that I have a traditional office practice and that they are my sole side gig. The systems ask for different documents, but don’t necessarily have a mechanism to upload multiples of the same document, such as copies of medical liability coverage.

They are relatively inflexible with managing employment date information. Many of my clinical positions have not specifically been employment, and positions overlap when you’re a gig worker. The systems don’t account for this, resulting in discrepancy flags. The systems sometimes don’t understand that your medical liability insurance policy is only in effect on the days you work and isn’t in force all the time when you’re working infrequently at an urgent care or emergency department.

These systems are technically part of the healthcare IT ecosystem because they are mandatory if you’re a physician who is going to see patients, but they make even the worst EHR look like a walk in the park. I’m sitting here wishing we could have the health information exchange equivalent for credentialing, with some kind of interoperability so I could port data from one system to another without having to do triple entry.

Maybe there could be just a single system that I interact with and that can route the information to the different provider systems. Who knows, maybe something like that is already out there and I just don’t know it. I’m just trying to stay active as a physician and I’m not a credentialing professional.

None of the systems offer online chat or resources outside of business hours. One of them allows you to send emails to a generic mailbox with the hopes that your question will get to the right person. The other two require questions to be submitted through a ticketing system, and I’m not even sure if I’m choosing the right descriptors or qualifiers to get my issues to the right person. Either way, there isn’t a single person at any of these organizations who knows me from anybody, so I’m not hopeful that my issues will be resolved.

I spend the majority of time in my clinical informatics work, but I felt that even as a part-time clinician, I could provide deliver solid care to patients and allow busy primary care physicians to offload some straightforward acute patient needs. But I’m coming to realize that it might be time to hang up my stethoscope. There’s a bit of an existential crisis that goes along with that, but I know plenty of clinical informaticists who no longer practice.

I’ve reached out to some of my colleagues about what it might mean to stop practicing and have heard interesting stories about their own decisions. One stopped practicing at a time when his certifying board still required a single-day examination in person. He knew that seeing patients sporadically in a niche practice probably wouldn’t allow him to pass the exam without significant burden. Since most insurance companies won’t allow physicians to be on their panels if they’re not board certified, that was the end of his practice.

Another CMIO friend stopped practicing when he relocated to join a new health system that didn’t feel that medical practice was important to the role and did not offer options for patient care. His subspecialty isn’t suitable for telehealth work, so that was the end.

A third colleague stopped practicing because he felt like he was always burning the candle at both ends with both his industry job and trying to keep up patient hours without feeling fulfilled in his clinical role.

I’d be interested to hear from readers involved in credentialing. Is there some secret code that I have yet to crack, or an easier way to manage being a roving part-time physician? For physician informaticists who have given up clinical care, what was your thought process? Were there any gotcha moments that you wish you would have been warned about?

Do you have advice about continuing work versus hanging up your stethoscope? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/19/24

The Journal of the American Medical Informatics Association recently published an article that looked at whether generative AI can create discharge summaries and appropriately assign diagnosis codes for the conditions that are addressed during a hospital stay.

For readers who might not be close to direct patient care in the inpatient setting, the discharge summary is a document that should be created at the time the patient leaves the hospital. It should contain information about why the patient was admitted, what happened during their hospital course, what treatments were administered, and their outcomes. It should also include plans for follow-up care. It helps the post-hospital team understand what has been going on and what they need to do next.

Some clinicians are incredibly diligent about creating these in a timely fashion, and the outpatient world appreciates their efforts. Others do it in a haphazard manner, ranging from versions that are timely but missing information to those that don’t get created until the medical staff office threatens to revoke someone’s hospital privileges if they don’t complete their overdue charts.

For patients with shorter and more straightforward hospital stays such as uncomplicated orthopedic surgery or obstetrics, they can be created quickly using templates, dictation, or virtual scribe services. For patients who have long and/or complicated hospital stays, creating a discharge summary can be challenging since it often involves digging through scads of daily notes from everyone involved in care – the admitting physician, consultants, nurses, social workers, therapists, and pharmacists. Especially when notes have had a lot of cut and paste, it can be mind-numbing to try to pull together a coherent summary that explains what actually happened during the hospital stay.

The AMIA article looks at whether GPT 3.5 could be used to generate discharge summaries and assign diagnosis codes using ICD-10. Researchers used standardized patient data that included descriptions of patient conditions and procedures as well as history elements such as social and family history. The prompt limited the discharge summary to 4,000 words, which could either be considered long or short depending on the complexity of the hospital stay. Outputs were assessed for their level of correctness, informativeness, authenticity of the hospital course, and acceptability of the document for clinical use.

Clinical evaluators who reviewed the generated documents found some challenging areas. The tool struggled with eliminating unimportant information, such as noting a normal body mass index. It phrased diagnoses in an unnatural style and included vague phrases without supporting detail. It failed to include details, such as the nature of a traumatic event when mentioning that something occurred following it. It introduced “spurious supporting information,” such as focusing on a patient’s anxiety diagnosis when they had a facial fracture following a fainting episode. Lastly, it failed to recognize the interconnected nature of diagnoses and failed to draw attention to critical diagnoses.

As someone who has been on the receiving end of thousands of discharge summaries in her career, you come to rely on them to present the highlight reel and help you quickly get up to speed on a patient who might be coming to see you same day or very soon. A good one reduces the need to go digging in the electronic health record to figure out what happened, but a bad one will make you want to tear your hair out.

The authors conclude that the GPT-created documents “showed correctness in individual codes, yet lacked naturalness and coherence compared to real data, resulting in lower informativeness, authenticity, and acceptability scores. Synthetic summaries failed to represent holistic patient narratives or prioritize critical diagnoses.” The take-home message is that it’s an interesting concept that is not ready for prime time.

I have to admit that some of the discussion in the article is beyond my expertise in the area of large language models. It sounds like the standardized data used might have been of reasonable quality. It would be interesting to see what kinds of summaries would be created from the more monstrous examples of patient documentation that I’ve seen over the years.

Clinicians are often in a hurry, managing multiple interruptions while trying to document, and may also be struggling with computer systems and stressed out care teams. Notes may be dictated but not reviewed or edited, adding a level of junkiness to the garbage in/garbage out flow that we’ve all experienced. It would be interesting to see what is created when using real-world data rather than standardized examples. The authors mention this as a way to also add in-context support for the generation process. They also note the possibility that asking the system to organize diagnoses chronologically may help add context.

I would be interested to hear what others who are deeper into the LLM world than I am might think about the article, or what other promising work might be on the horizon. If you’re doing that kind of work, and are interested in sharing your impressions, let me know.

This year, the medical school I attended encouraged alumni to contribute a “white coat note” to be placed in the pocket of an incoming first-year medical student. During their orientation phase, new students write a class oath, receive monogrammed white coats with the school’s crest, receive their stethoscopes, and experience significantly more pomp and circumstance than we did when I started medical school. We had to buy our own stethoscopes when we got to second year, buy our own plain white coats when we got to third year – no monograms allowed and definitely no institutional logo – and were basically thrown straight into hours and hours of lectures each day with no hope of any patient interaction in sight.

I have to say I’m a little jealous of some of the experiences that today’s students have compared to what we did (advanced clinical simulators, anyone?) I wonder if there’s a way to quantify how these changes impact student education.

I asked Google Gemini to give me a picture of a white coat ceremony for reference, which it declined to do because I asked for people. However, it was happy to give me some cute animals in white coats instead.

I like the idea of giving people encouraging notes, even if they are generic. Maybe a few weeks or months down the line, one will help a student hang in there when they might otherwise be ready to give up. Maybe we should consider a similar approach in the workplace with inspiring welcome notes.

What would you write to a new person joining your company? Would you paint a rosy picture or offer specific advice? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/16/24

I haven’t heard much chatter in the informatics community about what the United States Surgeon General recently named as a public health challenge: parent and caregiver stress. Dr. Vivek Murthy called on legislators as well as business and community leaders to boost resources to support parents. He’s advocating a national paid family and medical leave program, paid sick time, and increased access to affordable mental healthcare.

When I’m mentoring young physicians, many of them are shocked to learn the limits of the current Family and Medical Leave Act in the US and how their patients may not be protected by it. They’re even more surprised to learn that they themselves might not be covered if they work for a smaller employer or haven’t been at their job for the prescribed time period.

As a physician, I see plenty of patients who don’t get paid sick leave and who earn demerits at their jobs if they don’t come to work, regardless of whether they’re seriously ill or not. I’ve also seen physician colleagues stumble into work while ill, either because they don’t have backup in the workplace or they don’t have paid leave.

One former clinical employer required sick physicians to find their own sick coverage, which is how I found myself in the emergency department in the wee hours of the night calling and texting to try to find someone to cover my morning shift because I was about to be wheeled to the operating room for an emergent surgery. That should never happen, but somehow it still does, and I’ve heard plenty of similar stories since experiencing it firsthand.

Murthy notes that the stresses of parents are passed down to children, adding to an already significant youth mental health crisis. He makes it simple: “If you really want to help kids, one of the things you’ve got to do is actually help parents.” The Surgeon General’s website goes into more detail and includes the Surgeon General’s Advisory on the topic.

Over the last several years, I’ve watched numerous colleagues and clients try to juggle work and home responsibilities, attending business calls while in the carpool line, and having children interrupt their work on a regular basis. Many people are operating without the safety nets of family and friends as job opportunities lead people across the country. He calls out the “culture of comparison” that is heightened by social media and creates unrealistic expectations for families. I tell the young parents I work with that when you have a day where your child wears clothes and is fed, you’re having a good day. They may chuckle, but I’ve seen few pictures of people just getting by on Instagram.

Many of the stressors that are specifically called out by Murthy are present in healthcare organizations, and by extension, in the technology organizations that support healthcare. He notes the difficulty in arranging childcare when you don’t have a predictable work schedule as well as the challenges in having leaders understand the complex demands that parents and caregivers face on a daily basis. Having spent a significant portion of my career working 12-hour shifts, I know how hard that juggling act can be. The fact that some healthcare and healthcare-adjacent employers expect workers to be able to compartmentalize that should be worrisome. When you find a company that truly values whole-person wellness and provides the ability to actually take time off for health and wellness without the specter of guilt hanging over it, it’s easy to see how that kind of organization can become a workplace of choice.

As organizations are finalizing their benefit plans for the typical fall open enrollment season, I encourage leaders to look at them through the eyes of various personas, much like we use personas to create software requirements. What would a benefits end user experience from your organization if they were a young single parent, a mid-career parent of busy pre-teens, or someone approaching retirement? How would those benefits feel different if one had a family member with additional needs or a significant medical condition? If there is paid time off, are there ways to creatively use it so that employees can maximize the benefit and not waste time? (Companies that require time off be taken in four-hour blocks, I’m looking at you.)

If you offer so-called unlimited time off, which I see most commonly in technology firms, is it truly unlimited or are there unwritten limits that you just don’t talk about? And regardless of how you’re tracking time off, is the culture such that people can actually take time away from work without being tethered to emails or texts? Will they have a mountain of work waiting for them when they come back, effectively discouraging them from taking time off in the future? Are there flexibilities to allow people to roll time off across calendar years so that they can bank additional time off for significant family milestones, or are they forced into a “use it or lose it” situation where they have to take time off when they don’t need it, but can’t take time when they do?

I challenge leaders to also look at the cultures of their organizations and how they may be contributing to worker stress. Do employees feel empowered to ask that meetings be rescheduled when they have conflicts, or are they encouraged to “figure out how to make it work,” which can lead to taking calls while driving, which is not only unsafe but also unproductive? Do you create a safe space where employees can share the stresses that they are under, such as creating a patchwork of summer camps and activities for their children when school is out? Do you manage meetings effectively so that people can leave on time, or are you creating an environment where people worry if they’re going to be able to pick up their children on time? There are a lot of small things that we can do to make things better for teams without spending a lot of money. Sometimes all it takes is being respectful of others and the challenges that they are facing and doing what you can to not add to the burden.

I’ve said in the past that public health isn’t sexy, and that’s why it doesn’t get a lot of funding or attention in the US. It’s not as glamorous as other medical pursuits such as curing cancer or performing a cutting edge surgery. But making changes that improve mental health is absolutely essential for our collective wellbeing. I encourage everyone to read the Surgeon General’s Advisory and to identify one thing you can do on your team, within your department, or in your organization to make things just a little bit better. All those efforts will add up, and although we may never know whose lives we’ve impacted, I guarantee we’ll make a difference.

How can we make public health the shiny object that everyone wants to pursue? Can we slap some AI on it to make it more compelling? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/12/24

AI alert. One of the topics around the public health informatics virtual water cooler this week was about whether Google’s AI Overviews are negatively impacting patients.

Physicians have had a longstanding love / hate relationship with the so-called Dr. Google as a source of health information. Although many health systems spend a lot of time and money providing high-quality patient education materials, it’s just so convenient to type a clinical question into the Google search bar and hope for the best.

One of my colleagues noted that when you get an AI Overview for certain clinical topics, there’s a disclaimer that says, “This is for informational purposes only. For medical advice or diagnosis, consult a professional. Generative AI is experimental.” When I replicated the topic he mentioned on my PC with 24-inch monitor, the disclaimer scrolled off the bottom of the window, so I doubt that people who are using devices with smaller form factors see it easily.

Health literacy is woefully low in the US, with the Office of the Surgeon General reporting that only 12% of US adults possess proficient health literacy skills. Many can’t understand drug labels or understand how to identify and access healthcare resources, so it’s not surprising that they’re going to turn to consumer-level resources. For care delivery organizations that have robust patient education solutions and consumer resources, I’m challenging you to double down on those and increase their visibility so that patients know how to access them and when to use them. It doesn’t have to be a complicated omnichannel campaign – it can be as simple as having signs in exam rooms and waiting rooms, or even those paper table tents we used to see in the hospital cafeteria in the olden days.

A recent KLAS Arch Collaborative report shows that despite interoperability advances, clinicians are still struggling with synthesizing information from disparate systems. Almost half of the 33,000 clinicians surveyed said that they found it difficult to find key patient information from outside sources, with the same proportion noting that they are challenged with addressing duplicate data.

I’m sad to say that I’ll become part of the problem in a couple of weeks when I show up for a subspecialist visit with paper copies of critical records, because I don’t trust the various providers to share what needs to be shared in a timely manner. I’ve already tried to send digital copies of a pathology report to my care team and they were rejected, so I’ll be there with my manila folder in hand.

From Jersey Collector: “Re: branding. I know this has been a hot topic for you. Hospitals and health systems are getting into the act with the WNBA, which makes sense since women make the majority of healthcare decisions for their families.” That’s certainly a valid statistic, but I’m still not sure how much seeing a hospital or health system logo on a professional athlete’s uniform impacts someone’s choice of healthcare providers. I would say that the number one driver would be insurance coverage, followed by recommendations, ratings and reviews, and also the acuity of a problem.

If a loved one is having a significant issue, people tend to go to the closest facility that accepts their insurance. They don’t care  who they sponsor or what celebrity might endorse a given hospital. Some of the jersey deals run in the millions and I’m certainly glad to see women’s sports receiving sponsorships, but I can’t help but think that nurses who are looking for raises or families who are struggling with medical bills might be less than impressed.

It’s been a while since I saw a major healthcare bombshell reported, but reports out of the University of Virginia certainly meet that description. The Cavalier Daily reports that faculty have called for the immediate removal of UVA Health’s CEO as well as the dean of the school of medicine at the University of Virginia. The letter is signed by 128 members of the faculty, who accuse the two of creating a toxic work environment that compromises patient safety and has led to “an ongoing exodus of experience and expertise.”

Additional allegations include retaliation against physicians who raised safety concerns by denying promotion, encouraging staff to bypass safety processes, harassment and bullying of trainees, and financial mismanagement. One call-out in the letter mentions “disregarding valid reports of fraudulent billing and requests by senior leaders to fraudulently modify patient records in order to obfuscate adverse outcomes and boost productivity metrics.” CMS doesn’t look too kindly on this sort of thing, so I hope the institution has its compliance auditors and attorneys on standby.

The non-profit Emergency Care Research Institute (ECRI) has released a report showing that the vast majority of diagnostic errors occur during the testing process. They reviewed 3,000 patient safety adverse events and near misses. Leading issues include technical and processing errors, lack of skill in performing a test, sample mix-ups, wrong-patient issues, and communication failures. The report specifically calls out “productivity pressures that prevent providers from exploring all investigative options or from consulting other providers” as a factor in causing diagnostic error. Time pressure is also a factor when test results aren’t reviewed quickly or when results aren’t appropriately communicated to patients.

Those of us on the informatics side should take note of their findings with regard to health equity, where women and underrepresented populations can be at greater risk for diagnostic errors. They specifically call out the potential for race-based biases in medical algorithms and communication barriers, both of which can be significantly improved by thoughtful application of healthcare technologies. For organizations looking at artificial intelligence solutions, it’s going to be critical that they appraise how systems handle these biases and how the potential for hallucinations might contribute to additional opportunities for diagnostic errors.

Speaking of patient safety, World Patient Safety Day is right around the corner on September 17th. I have yet to see anyone who I regularly interact with, including my own clinical employer, making plans to mark the day. This year’s theme is focused around improving the safety of the diagnostic process, with the slogan “Get it right, make it safe!” Although this seems like a simple concept, we’ve learned that it can be more complicated than one can imagine.

My own loved one presented for a scheduled surgery this week to find that it had been booked for the wrong side of the body, leading to confusion and delay as well as stress to the family. Fortunately, the patient safety processes in place at the hospital worked and a wrong-side surgery was avoided, but it’s staggering to know that this is still a risk in 2024.

What is your institution doing to mark World Patient Safety Day? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/9/24

As I work on optimization projects with different care delivery organizations, I’m shocked by how much waste I see within the system. Many large health systems spent a significant amount of time and money over the last two decades investigating in process improvement initiatives. However, it seems like once focus is lost, waste creeps back into the system and becomes an impediment to efficient patient care.

End users such as physicians and nurses are often experiencing some degree of burnout and may not want to spend the effort pushing back against processes that they know aren’t serving patient care. Others may experience learned helplessness, where repeated stressors cause them to feel that they have no ability to change the situation, so they don’t even try.

Some of the inefficiencies I see are caused by people over-interpreting regulations. For example, two-factor authentication for electronic controlled substances is required. However, it is not required for electronic prescriptions for drugs that are not controlled substances. Organizations that don’t understand the ability of EHRs to have different settings for different types of medications may require two-factor authentication or a password input for all medication, resulting in millions of wasted clicks each year and countless hours of frustration among clinicians.

Other inefficiencies are caused by outdated attitudes towards patient management. In past decades, some institutions taught policies that hinted at the idea that patients can’t be trusted. For example, if a patient was due to have a follow-up visit in 90 days, one shouldn’t write them a prescription with more than 90 days’ worth of refills because then the patient would be forced to come for an appointment or at least to call the office. In contrast, practice management journals have advocating for years that this approach isn’t supported in the medical literature and just creates additional risk of patients running out of their medications as well as extra work for ambulatory practices as they field refill requests.

Practice management journals have also advocated having patients schedule their follow-up appointments before they leave the office, yet many do not. My own primary care practice refused to schedule my annual appointment before I left last year, citing the fact that physician schedules weren’t open yet. They said that normally they have patients fill out a postcard that they mail when the schedules open, but that they were out of postcards and would fill one out on my behalf when they were restocked and schedules were open.

It’s been a full three months, and I have zero confidence that this multi-step process is happening in the office. Given the lag time on getting an appointment in this particular practice, I should probably call this week to set myself up for nine months from now. Of course they don’t have online scheduling open either, so it’s lots of wasted effort when you add up how many patients are impacted by this lack of process.

I also see physicians who continue to retake blood pressures on every patient, regardless of whether values are in or out of range. I would propose that if you don’t trust the blood pressure readings that your staff members are doing, you have two options. One, you could teach them to take readings exactly the way you want them to so they can perform proficiently moving forward. Or, you could have them stop altogether, freeing up their time to do other support tasks. But continuing to repeat on every single patient is just wasteful. I also see the documentation of irrelevant vital signs just for the sake of documenting vital signs. Temperature is generally irrelevant for well visits and most chronic disease follow-up visits, so why does everyone end up with a thermometer under their tongue?

On the positive side, many organizations have taken the advice of their EHR vendor to filter the number of “thank you” messages that make it to physician EHR inboxes. Although this can decrease inbox burden, some of my colleagues report that they miss those expressions of gratitude and that it feels like their inbox is now only full of demand messages. Some ambulatory organizations are focusing on routing messages to ancillary staff, such as medical assistants, before escalating to nurses and to physicians only if needed. I’m seeing a few places adopt delegated refill policies, although there is still much more hand-wringing about these types of protocols than there ought to be.

I’m also seeing more organizations configure EHR message routing so that ambulatory physicians aren’t inundated with inpatient test and diagnostic results. Some are also stopping the practice of automatically copying the primary care physician on tests that are ordered by other ambulatory physicians. This is a plus in two ways – not only does it cut down on inbox volume, but it also prevents confusion as to who is responsible for managing the test results. This creates extra work for consulting physicians, though, who may need to send a specific communication back to the primary care physician to let them know what is going on with the patient. This shouldn’t be too much of a shock to them as they theoretically should be sending a consultation letter already, especially if the primary care physician referred the patient for evaluation.

The most widespread optimization efforts that I’m seeing are in the implementation of ambient documentation solutions. Adoption was slow at first, but is really taking off. At some point, it’s going to become a requirement for facilities that want to attract top physicians. If I was a graduating resident at an institution that had implemented it and I was used to using it every day, you can bet that it would be a must-have criterion for a future workplace. Organizations that aren’t ready to go all-in on the technology should consider other bridge solutions, such as virtual scribes, or at a minimum, human scribes.

In other technology news, I was able to catch a glimpse of NASA’s Advanced Composite Solar Sail System, also known as ACS3, flying through the sky at an altitude of 600 miles on Sunday night. Temperatures have dropped into the 50s overnight here, so it was a perfect excuse to pull out the fire pit, pour an adult beverage, and chill out in a lawn chair as I prepare for the coming week. I’ll have another prime viewing opportunity Monday night, so here’s to crossing my fingers and hoping for a crisp and cloudless night. If you’re interested in trying to spot it yourself, more information can be found here.

What activities help you recharge and get ready for the busy work week? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/5/24

I enjoyed reading the results of Mr. H’s poll on company culture, where a full one-third of respondents said their company’s culture was worse today compared to a year ago. There’s always a disconnect between what employers think of their culture and what employees experience.

A recent story of culture gone wrong details a company retreat involving some hiking in Colorado. One member of the group became separated and was ultimately stranded overnight on the mountain in dangerous conditions that included freezing rain and high winds. Contributing factors included co-workers who retrieved pieces of gear that had been used to mark the way through a scree field, as well as delayed notification to search and rescue personnel.

Search efforts were pended overnight due to conditions, but the hiker was eventually found after a coordinated search effort that included nine agencies. The man sustained multiple injuries in falls as he tried to descend, and had to be carried to a point where an all-terrain vehicle could assist. I’ve done a fair amount of hiking in my time and would highly recommend always carrying the 10 essentials even if you’re in a large group.

HIMSS is starting to hype its 2025 conference, sending emails to alert members that registration opens next week. The conference is once again in Las Vegas, which I’m not thrilled about since HLTH is there also. I’d really like a break from conferences in Las Vegas and Orlando, but the lack of growth in conference facilities elsewhere makes those venues seem like a lock. Conference passes start at $995 this year with an Executive Summit pass starting at $1,445 that promises access to additional events including a reception and an evening special event.

When I first started working in healthcare IT, there was no such thing as social media, let alone the idea of digital influencers. Things have certainly changed and our industry is bursting with influencers, leading to changes in how business in certain segments is conducted. The University of Texas at San Antonio has added a major in Digital Media Influence to its lineup of degrees. Under the leadership of the Communications program, students will take production classes as well as courses that are focused on digital communication and digital audiences. They will learn technical skills as well as strategies to build and retain followers.

It will be interesting to see how many graduates complete the program and where their career paths lead. I hope they include such topics as “buy a real microphone, no one wants to watch you talking into a wadded up set of wired earbuds” and “how to film without giving your audience vertigo.”

There’s no denying that social media has changed healthcare, however. East Idaho News reports that a local hospital will convene focus groups following a complaint about delays in its emergency department that was posted on Facebook. The post received 190 replies, eventually leading the hospital to contact the author and invite her to participate in a focus group. The organization plans multiple sessions over the net few weeks and hopefully they’ll not only receive constructive feedback but will take action on it.

From The Name Game: “Re: here we go again. Did you see the reports of Jefferson Health buying its way onto the Philadelphia Eagles practice jerseys? They’ll also have their logo featured on the backdrop at press conferences.” Terms of the deal were not made public, but I suspect that they paid a pretty penny for the privilege. The article mentions that the practice jersey logo replaces that of an orthopedic group, but I wonder how many fans will actually notice, let alone care.

Bring on the creepy images and supernumerary digits: The Verge reports that Google Gemini will once again allow users to create AI-generated people, following a hiatus after the tool produced “historically inaccurate images, like racially diverse Nazis.” The tool should be available to Gemini Advanced, Business and Enterprise users quickly and is powered by Imagen 3. Guardrails will be in place to prevent users from creating realistic images of public figures, content involving minors, or sexual scenes. I recently tried Meta’s “imagine yourself” and was impressed by its ability to interpret requests for 18th century fashion, although it did give me mismatched earrings in three of three generated images.

No wonder primary care physicians are tired. A recent research letter in JAMA Health Forum looks at the impact of value-based contracting on primary care. Researchers identified 57 distinct quality measures that one health system’s physicians were expected to track based on value-based contracts with multiple payers. Medicare contracts averaged 13 measures for contract, followed by 10 for commercial payer contracts and five for Medicaid agreements. The authors’ discussion highlighted the disparities in different quality metrics, noting that not only were they addressing different conditions, but that some differed in the outcomes that physicians were expected to meet.

In other study-based news, it’s no surprise that patients report higher satisfaction levels when clinicians are seated when meeting with them. The authors specifically looked at “the effect of chair placement on length of time physicians sit during a bedside consultation and patients’ satisfaction.” Over 100 physician encounters with hospitalized patients were observed, and chairs were placed either within three feet of the patient’s bedside or at a “usual” chair location.

Outcomes included whether the physician sat or not at any time during the visit, along with patient satisfaction. The difference in physician behavior was notable, with 38 of 60 physicians in the “chair placement group” sitting during the visit but only five of 65 physicians in the “usual” chair location group sitting. During college, a friend of mine who was studying architecture used to regale me with the things that he was learning while I was suffering my way through organic chemistry. The idea that “people will sit where they are places for people to sit” appears to be as true in the healthcare setting as it is in theory.

Are your clinicians encouraged to sit at the bedside, or are they just standing at the wheeled workstation or a wall unit? Do they ask for something different? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/29/24

I’ve written previously about telehealth and the math that is needed to try to prove that it will result in overall savings to the healthcare economy. A recent JAMA viewpoint article further dissects the impact of telehealth on care delivery spending, calling out the “iron triangle” of tradeoffs where a service may improve only two of the three elements of quality, cost, and access.

The authors point out that telehealth may lead to more care, especially if preventive procedures are recommended as part of encounters. This will inherently increase spending, making suspect the claims that telehealth will reduce healthcare costs. On the other hand, that increased spending should drive value, but that value is often realized well down the line.

The authors propose that reframing the discussion around value might lead to different choices, such as only expanding telehealth services that address the areas of highest value. An example given is funding telehealth visits for federally qualified health centers in the hopes of improving quality and equity. Only time will tell, and we’ll have to wait to see what happens with federal telehealth funding in the US.

From Podcast Schmodcast: “Re: your pet peeve of being forced to use your phone for webinar links. I totally agree. Maybe I’m just a grumpy old man, but I prefer to do most of my work on a 24-inch monitor or larger but will use a laptop in a pinch. My pet peeve is written ’articles’ that are little more than redirects to podcasts, which I can’t stand. I can read much faster than many of the podcasters speak and am very much a visual learner. Podcast creators need to include a transcript so that they aren’t discriminating against what I suspect is a large part of the population that feels similarly.” I’m one of those people, so I agree. For the love of all things, please include a transcript. I’ve found that when I try to listen to recordings, I get too tempted to multitask, which results in my absorbing very little of the spoken content. When I’m consuming written documents, it’s much less likely that I’ll try to surf the internet or do any number of things that will cause me to have to skip back and listen again.

Members of the American Medical Informatics Association (AMIA) received an email this week addressing concerns about the organization’s Annual Symposium that is being hosted at the Hilton San Francisco Union Square. The hotel is apparently subject to a labor dispute and union leaders are discouraging organizations from doing business at the property. Since negotiations are ongoing, AMIA is following closely and hoping for a resolution that doesn’t impact the meeting. The hotel claims to have contingency plans to ensure service delivery in the event of a strike, but having stayed at hotels in several adverse but less-contentious circumstances (including boil orders and weather emergencies), I’m not hopeful for their ability to host the conference during a strike without some level of disruption. I’ll be following this one closely.

Speaking of meetings, Oracle has announced that its CloudWorld headliner will be legendary rock band Journey. I’ve seen them perform and it was a great show, but I’d imagine that a half century on the road might be starting to take its toll on some of the performers. Attendees can purchase a guest ticket for the show for a mere $350 while supplies last. Admission to the Oracle client conference is $2,300 with the price dropping to $1,700 for groups of five or more. The registration site includes a “Convince your boss” section complete with an email template to help workers summarize the costs and benefits of attendance.

I was back flying the friendly skies this week, enjoying some West Coast sunshine before starting a big project. Unfortunately, my seatmate made it a less than fun experience, as she constantly talked to herself, made tsk-tsk sounds when reading her emails, and laughed hysterically while marking up a PowerPoint presentation. I could see everything she was doing since she didn’t have a privacy filter. I could also see her email address and her passwords that were on a sticky note that was covered in tape applied to her laptop. I had half a mind to log in to her Concur account and enter a bunch of bogus expenses, just to prove a point.

The flight attendants had to scold her for failing to put her laptop away as instructed, after which she slammed things around trying to stuff them into her enormous bag. I normally travel with noise canceling earbuds, but somehow they got left at home, which is a mistake I won’t be making again. In fact, I might throw a pair of foam earplugs in my bag as a precaution since they weigh nothing and would have been very welcome in this situation. They say travel is broadening, but I would argue that it’s not always in the way we might want.

I’m as much at risk of being drawn in my clickbait headlines as the next girl, so I admit I was taken in by a discussion of “Death Bots.” I wasn’t even sure what the term referred, to so of course I had to follow along. The article is a transcript (yay!) of a discussion by medical ethicist Art Caplan. The concept is this: patients who know that they will be dying soon might be able to record their voices so that after they pass, family members can converse with a virtual entity that is representative of their loved one. This AI-driven entity would become part of the grief process and might also draw from other materials that are left by the deceased individual such as diaries, writings, videos, and more.

It’s very “Star Trek” to be able to have a conversation with your departed ancestors, but as a physician who has worked with patients and their families through various levels of grieving, it would need to be clear that anyone participating in this is part of an unregulated experiment that deviates from our current scientific understanding of grief. I’d feel a lot better if participants went through some kind of informed consent process, but given the fact that this is already being commercialized, that would be unlikely.

Caplan points out the risks of having an AI version of a departed person “create information that sounds like you, but really isn’t what you have said, despite the effort to glean it from recordings and past information about you. He illustrates the other ways to leave memories for loved ones, including audio / video recordings, diaries, and the like.

Caplan agrees with the need for a consent process as well as safeguards for control of the information and cessation of the service if survivors desire it to end. The comments on the piece are interesting and bring up topics including regulations and their enforcement, the impact of such a service on survivor mental health, and more. Another notes, “Hopefully I have a way to go before I am gone, which gives me a lot of time to try this out and see whether I can even tolerate my own company after I am gone, much less inflict myself on posterity.” There are numerous comments on how this might go awry. My favorite comment is this: “One character in Futurama was Nixon’s head in a bottle of preservative. It spoke, and had opinions. But of course, AI is more sophisticated now.”

What are your thoughts on so-called Death Bots? Would you make one yourself, or want to have one representing a loved one? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/26/24

The vast majority of HIStalk readers work with some of the larger or better-informed sectors of the healthcare IT industry — health systems, hospitals, large physician groups, technology vendors, governmental entities, and other similar organizations. Many of us have teams that are dedicated to keeping up with regulations and requirements and making sure that we don’t get ourselves into trouble. For those who are willing to push the boundaries, there are often legal and compliance teams that help advise prior to a decision being made.

I’m active in my local professional society, where the majority of physician members are not employed by a hospital, health system, or other large organization. They may be in a group of one to 10 physicians and generally focus the most on providing quality healthcare to the people in their community, which means sometimes that they don’t follow regulatory requirements as well as they should. EHR vendors that focus on ambulatory practices have done a good job of trying to keep them informed and explaining what components and features of their systems are designed to help with regulatory compliance, but the reality is that some of those physicians never see those newsletters. Even if they see them, their understanding of the requirements and risks is highly variable.

National specialty organizations also do a good job of advocating for and informing their members, but there is also a risk that physicians don’t see those communications either. There are consultants out there that can help, but given the small margins under which the average private practice physician group is operating, any additional expenditures seem daunting.

Because of these factors, it will be a surprise to many that physicians and other clinicians who are participating in certain Medicare programs can wind up in hot water with information blocking. Many of the physicians that I interact with at the local level don’t even know what this means. One of my own physicians is one of the biggest blockers I’ve ever met, because her patient portal is incorrectly configured and releases nonsense information rather than the required data elements.

As of July 31, the Department of Health and Human Services, via the Office of the Inspector General (OIG), will start enforcing the information blocking provisions with respect to physicians, hospital accountable care organizations, and others who had previously been excluded from the rules that are found in the 21st Century Cures Act. The OIG plans to spend most of its efforts investigating situations where information blocking is said to have caused patient harm, to have gone on for a long time, or to have had a negative financial impact on federal / government healthcare programs or private entities. To meet the standard of violating the rule, the practice has to have knowledge that their operational practices are unreasonable and are apt to interfere with or discourage patient access or use of electronic health information.

Physicians who are found to have committed information blocking can receive penalties through the Medicare Merit-based Incentive Payment System (MIPS) that will impact them for future years as well. The names of offenders will also be published on federal websites, and I suspect there may be some other downstream ramifications that are related to payer credentialing and other critical physician processes. Even though this isn’t the same as being debarred from a federal program, it’s a federal penalty, and I can foresee questions like, “Have you ever been investigated for information blocking or been subject to review by the Office of the Inspector General?” or something similar.

Physicians and those who are now subject to these rules need to educate themselves about the policies and procedures that are related to information blocking and what is required of them for patient access and use of electronic health information. This means looking at both federal and state laws. They will also need to update their practice’s policies and procedures if they don’t already address the issue, and train staff on how to deal with patient requests and how to remain compliant. If they are working with a vendor that is less than supportive as far as release of electronic health information, they may need to consider switching platforms so that they don’t place themselves at further risk. We all know how much fun switching EHRs can be, so hopefully vendors will step up where needed.

Although I don’t find enjoyment in seeing physicians subjected to additional regulatory burden, I support this as a patient. I had an episode of care last year where I saw a new provider and was reassured that my presenting problem wasn’t concerning. I also had a minor procedure performed at that time for something that was a nuisance, but not a long-term health risk. I didn’t think twice about wanting to see a copy of the office note, because the situation seemed so minimal and the physician was someone who I trusted.

Fast forward to 2024 and now that visit might be important related to a current health issue, and the office — which is subject to the provisions of the 21st Century Cures Act — doesn’t even have a patient portal where I can see my notes. They also won’t fax me a copy of the note, but offered to read it to me during what was probably one of the most ridiculous patient / office phone calls that I have ever experienced. Guess what? The note documents only the procedure, leaving the patient scratching her head as to why the other issue wasn’t documented.

You can bet that I am going to be assertive about seeing notes from every visit moving forward, and when I select new physicians, I’m going to be specifically asking about their EHR, patient portal, and how they release copies of visit notes and pathology. I’m probably going to become “that patient” who rolls in with her giant folder of information, because I don’t know if I can trust people to have the right information for the right patient at the right time in the care process – a fact that is very discouraging when living in a large US city in the year 2024.

We owe it to our patients to do better, whether we’re clinicians, solution providers, technology companies, or others that support healthcare. Even if you’re not currently a patient, some day you will be. And if that day turns out to be one where you get news that makes it seem like one of the worst days of your life, you may have a different understanding than you have now. Why not work to make things right before that time comes?

Have you, while in the patient role, experienced information blocking? How did it impact your care or make you feel? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/22/24

I’ve spent a fair amount of my career working with the underlying datasets and codes that make EHRs work, including ICD-9, ICD-10, SNOMED, LOINC, RxNorm, CPT, DSM, and HCPCS. Normally I’m not that excited about changes to the data, but I am closely following the efforts of clinicians and military personnel to advocate that the American Psychiatric Association update the name of “posttraumatic stress disorder” in the next revision of the Diagnostic and Statistical Manual of Mental Disorders. They are proposing that it be renamed to “posttraumatic stress injury” on the grounds that the current name has the potential to cause harm. Advocates note that the word “disorder” brings stigma to the condition, where “illness” frames it as something that can be treated. Considering the numbers of my colleagues who have been impacted by the condition since the COVID pandemic, anything we can to do help them heal is welcome.

The American Board of Internal Medicine (ABIM) has revoked the board certification status of two physicians who are accused of disseminating COVID misinformation through an organization that was advocating the use of ivermectin to treat viral infections. The physicians in question claim that their promotion of the treatment falls under free speech and that the ABIM’s actions were an “attack” on that. I agree with commentary in the article by a professor of bioethics that there’s a difference between free speech and practicing outside the standard of care.

From The Name Game: “Re: health systems buying sports venue naming rights. I know you’re not a fan. Did you see this article about Northwestern Medicine’s newly-named stadium?” The temporary stadium will host Northwestern University’s football, soccer, and lacrosse under the Northwestern Medicine Field name for the next two years while a permanent facility is being built. New rules on commercial advertising at the college sports level are a result of updated NCAA rules. Since Northwestern Medicine provides healthcare services to the university’s athletic programs and students, it at least makes more sense than some other facility naming agreements I’ve seen.

If you’re all about digital health and contemplating a career change, the Veterans Health Administration (VHA) is hiring for the role of chief digital health officer. The position involves a four-year appointment with the potential for reappointment. The position is open to physicians, dentists, or health science officers. Although it’s advertised as a 40-hour-per-week job Monday through Friday, I suspect the workload is likely more than that since areas of impact include “integrating and resourcing digital health functions, providing a consistent approach to digital health integration, and establishing and implementing the VHA digital health transformation strategy.”

I particularly liked the part about needing to “collaborate closely with end users in the field and VHA patients to understand their needs and how VA’s digital health solutions are and are not working for end users.” Based on the stories I hear coming out of VA digital health projects, that element seems to have been lacking for some time.

From Follow the Data: “Re: hospital error. I’d love to be part of the root cause analysis at the hospital that told next of kin that their loved one was discharged against medical advice, when in reality she had died and her body had been misplaced.” According to news reports, records indicate that the patient was discharged in April 2023. More than a year later, a Sacramento County sheriff’s office detective notified the patient of her death. The family has filed a lawsuit that seeks $5 million in actual damages and $10 million in punitive damages.

Pet peeve of the week: I was on no fewer than three webinars this week where they posted QR codes and expected attendees to use their phones to take a picture to get to a link. If your webinar platform has a chat function, please consider using it to push out your links rather than making people use their phones. Many of us will need to send the links to ourselves to view the content on a different device instead of trying to read downloaded information in a space barely larger than the palm of your hand. Webinars that put URLs on their slides but don’t share them in a clickable fashion also go on the list. An even better solution would be to send the appropriate links and downloads in a follow up email for those of us who are old school, along with a copy of the presentation and/or a link to a recording.

Bad news for all of us IT types who have had to perform overnight upgrades and installs. The journal Sleep Advances recently published an article that looks at the negative effects of even a single night of sleep deprivation. The authors analyzed 500 proteins and found that sleep disruption changed the composition of human blood. The study size was small, consisting of eight adult women aged 22 to 57 years. The participants were their own controls, with blood samples obtained after adequate sleep and then after inadequate sleep. Researchers found 66 proteins that were expressed differently after sleep deprivation, including ones that involved platelet function and blood clotting. This study wasn’t powered to find clinical impacts, but may lead to additional research and future learnings.

Some of the most fun nights of my professional career have been spent doing late night testing for projects that could only be tested on production systems, as well as performing upgrades and feature releases. In the early days of EHR rollouts, teams were small and often I was the only clinician on the team who could sign off on clinical regression testing and certify that a release met the criteria to be unleashed on clinical users the next business day. I cherish those times as well as the relationships they helped build. To this day, many of you are still on my “phone a friend” list for when the healthcare IT going gets tough. Thanks for the laughs and for teaching me about Citrix and single sign-on solutions in the wee hours of the night. We deployed Vergence with a vengeance, and I’m grateful for each of you.

Several readers sent me pictures and commentary from the Epic UGM this week. The theme was “Storytime!” and Judy Faulkner dressed as “Lady Swan,” which was her homage to Mother Goose. Supposedly this swan boat was available on one of the campus lakes for attendees who wanted to give it a gander (thanks, I’ll see myself out). It sounds like one of the key themes was the importance of childhood brain development and reading to children, and Judy shared a story about setting her family TV to PBS and hiding the remote control from her children. Other thoughts sent by readers:

• UGM is getting too big, so they’re considering strategies to split it similar to a few years ago when they spun off XGM.
• The new record for “bigger bang” go lives is upwards of 45,000 users.
• There was a lot of talk about AI-augmented responses in the In Basket, helping clinicians respond to patients more efficiently.
• Carl Dvorak stole the show with his story of flying to California for the birth of a grandchild. He thanked the clinicians for their excellent care, but apologized for looking over the nurses’ shoulders while they cared for his family.

If you attended the Epic UGM this week, what were your takeaways? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/19/24

Nearly every health system has some kind of telehealth initiative in place even though rates of growth are much slower than they were during the height of the pandemic. Many of them are cautiously watching and waiting to see if Congress will extend telehealth access provisions for Medicare patients. People in the know think it’s likely that the extension will happen, but many suspect that it won’t happen until after the upcoming US election cycle, when they are included in end-of-year legislation.

Patients have become dependent on telehealth services. It has been a huge benefit for seniors who previously had to travel large distances to see specialists at tertiary care centers, but who can now have follow up visits from the comfort of their own homes. The current provisions expire at the end of 2024, and I don’t think any health system CEOs or COOs enjoy that kind of down-to-the-wire finish.

It’s hard enough to predict your patient care volumes for January and February given the unpredictability of influenza seasons that have changed a bit since COVID has been on the scene. Those months are also challenging for elective procedure volumes because patients have yet to reach their deductibles for the year and often avoid scheduling surgeries during the first quarter of the year. What happens if you go ahead and allow scheduling of telehealth visits on your physician schedules (which sometimes are opened more than a year in advance) and changes to the rules force you to have to move or cancel all those visits? There’s not enough modeling in the world to make you feel comfortable with what might happen.

Even when looking at non-Medicare populations, health systems have gotten creative with how they deploy telehealth care. I worked with one organization that implemented telehealth in their urgent care centers, diverting patients to sign up for telehealth encounters before they had a chance to check in at the registration desk. A fair percentage of patients would return to their vehicles and access the organization’s patient portal to get in line for a virtual visit. Those who made it to the front desk were signed in for the urgent care wait list, but were also offered the option to go into the queue for a virtual visit as well. From a patient standpoint, it’s nice to have the option to hold a place on the in-person wait list in case the telehealth physician feels your condition needs in-person evaluation.

For the physicians who were working at the sites where this concept was piloted, it caused stress at the end of the shift, where they worried about a potential burst of patients deciding to go ahead and come inside before the doors closed, just in case. Policies about patient care at the end of shift vary dramatically from urgent care to urgent care, so depending on how the practice runs, I can understand their nervousness. I worked with one urgent care organization whose policy was that every patient who signed in prior to the posted closing time would be seen, which led to providers staying a couple of hours late every night. When you’re already working a 12-hour shift, that can be a significant negative. The organization that was piloting the telehealth hybrid stopped accepting registrations 30 minutes prior to closing time, which seemed to mitigate those stresses at least somewhat.

I’ve also seen a slight uptick in organizations that are implementing so-called asynchronous telehealth in states where the modality is accepted. In many states, there has to be an existing physician / patient relationship before this type of visit can be done, although some allow it for new patients. For an asynchronous visit, patients complete a symptom-based questionnaire and provide relevant medical history and then a provider — more often a nurse practitioner or physician assistant — reviews that information and determines whether the patient can be treated via a response message or whether they need to be seen for a real-time telehealth visit or referred for in-person care.

Some insurance companies don’t pay for these kinds of visits, and the situations where I’ve seen them used most are when the organization has risk-sharing contracts where they are incentivized to keep patients out of the office and manage them as cheaply as possible. That’s fine if you have a younger and healthier population, but gets trickier when you have higher-acuity patients.

Asynchronous care technically also encompasses those organizations that are billing for patient portal messages where a new condition is discussed or a new treatment is requested. It’s unclear what kind of an impact those actions will have on overall telehealth volumes. A recent study that was published in JAMA this month showed that billing for messages at UCSF Health corresponded with a slight decrease in overall message volume. Not surprisingly, in that study a significant decline was noted among self-pay patients and adult patients under the age of 50. The authors noted a study limitation in that they could not look at patient outcomes or causality, but it’s an interesting starting point. I’ll be keeping an eye out for further studies of this phenomenon as more health systems adopt the practice. If you’re doing research in this regard, feel free to drop me a line.

Thousands of leaders from Epic-using health systems are descending on Madison, Wisconsin this week for the annual Epic User Group Meeting. They’re expecting more than 7,000 attendees for sessions that range from reviews of the research and development roadmap to specialty-specific forums. The event kicks off with Sunday’s “Taste of Epic” picnic/campfire event and runs through midday Thursday. Highlights include Tuesday’s executive address and “Cool Stuff Ahead” sessions as well as that evening’s “The Very Hungry Dinner” event named to go along with this year’s “Storytime!” theme. “The Very Hungry Caterpillar” is a book that I can recite from memory, so I got a chuckle out of the agenda’s callout that attendees could “eat through one of everything until you get a stomachache.” I’m unable to make it this year due to other commitments, so if you’ve got pictures or stories to share, feel free to send them my way.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/15/24

Bain & Company recently released study findings looking at how patients perceive generative AI in healthcare. Long story short is that patients are more comfortable with AI tools taking notes during office visits or supporting analysis of radiology images. They’re less comfortable with AI running payer or provider call centers, and they’re least comfortable with AI providing medical advice, treatment plans, and prescriptions.

The authors of the piece also provided their opinions about the patient-physician relationship, which I found interesting since they differ from what I’ve seen in my own practice the last several years. In my community, we’ve seen a rise in transactional healthcare, where patients don’t seem to have a preference for seeing their own physicians and where they tend to place more value on being seen quickly or at a time that is convenient to them.

The authors feel that especially with telehealth, “the value of the relationship has prevailed,” with the majority of patients using telehealth only with their own existing providers. They also note that nearly equal numbers of physicians and patients (76% and 78%, respectively) see telehealth as complementary to in-person care, with only a small percentage eyeing it as a replacement. I suspect that varies dramatically depending on whether we’re talking about primary care or subspecialty care and the type of services that are being offered.

At my primary care physician’s office, the next available well visit for an established patient is in November 2025. The next available problem-oriented visit for an established patient is in November 2024. When you’re looking at wait times like that, I’d take telehealth as an alternative any day.

An article I read about single sign-on (SSO) technology resonated with me given the different environments in which I work. One organization has a robust SSO implementation and I literally enter zero passwords. We have card-based and biometric-based authentication, so regardless of what application I need to use, I’m good to go as long as I’m appropriately accessing the workstation.

Another facility has a hodgepodge of security solutions and I have to log in to the network then Citrix (fortunately with the same password) and then to the EHR separately. From there, I have to use different passwords to access clinical decision support tools, formulary information, and clinical quality measures dashboards. C’mon folks – if you want to make your end users’ lives easier, please implement SSO. Having all those different password entry points isn’t going to prevent you from being hacked and it doesn’t make you safer because it leads to people writing down passwords. Trust me.

From My Cousin Vinnie: “Re: the mouse. Did you see this article about the future of the mouse as a computing accessory?” I had just come home from the office supply store with a brand new mouse in hand when I saw this email. I’ve used a touch screen laptop for the last six years, but none of my company-issued devices are touch screen and I wanted a smaller mouse for travel. I have Raynaud’s Syndrome, and depending on the symptoms, a typical laptop touch pad doesn’t always work for me, despite the assurance of my health system’s ergonomics team that there is no technical explanation for what I observe, and that it should be working regardless.

The article quotes mouse giant Logitech’s CEO about a futuristic concept in which the mouse is a high-end accessory that you use forever “like a Rolex” with the benefit of periodic software updates. I’m not sure about the rest of you, but I’ve had my current desktop mouse for over a decade, which is just about an eternity in tech circles. I think I paid 40 bucks for it, so even if I had to buy two or three in a career, it’s going to be a hard sell to try to get me to purchase a premium product. Interestingly, the article notes that despite the CEO’s comments, a spokesperson for Logitech said that the so-called ‘forever mouse” is not actually on the product road map.

From Willie Nelson: “Waymo chaos. I couldn’t help but think of the lyrics to ‘On the Road Again’ after reading this piece about autonomous taxis going bonkers overnight in San Francisco.” The article describes a situation where Waymo’s driverless taxis converge on a parking lot, creating a situation for which their software isn’t optimized. The cars end up confused and begin honking while struggling to enter and exit parking spots. Residents of adjacent buildings note that it’s been happening repeatedly over the last few weeks, leading to sleep disruptions. A Waymo spokesperson is quoted as saying that they are “aware that in some scenarios our vehicles may briefly honk while navigating our parking lots. We have identified the cause and are in the process of implementing a fix.” Time will tell how proficient their coders are and how good their quality assurance process really is.

I was reminded the other day that if I am going to be doing contract IT work for the local health system in the coming months, I’ll need to show proof of influenza vaccination. They’ve had policies in place that address mandatory flu vaccines for more than 15 years, but I haven’t seen anything yet on what the policies will be for COVID vaccinations this season. It was particularly timely because I also saw this public health article today in JAMA Network Open that looked at how vaccine mandates impacted vaccine uptake among US healthcare workers. The authors looked at a sample of 31,000 healthcare workers across the US. Not surprisingly, they found that state vaccination mandates correlated with increased vaccine acceptance among healthcare workers.

We’re experiencing a COVID surge in our area, fueled partly by a contingent of individuals who attended a national youth rally on a college campus. The close quarters of tour buses, college dorms, packed arenas, and group breakout sessions created many exposure pathways, and according to those who attended, masking was nearly non-existent. I think we’ve been in a relative period of quiet with COVID and people have stopped thinking about it and their risks of exposure when they’re in large groups with crowded conditions, and it’s probably time to think about that again.

I’ve had several important work and family events lately that I don’t want to risk being sick for, so I’m typically one of the handful of people on planes who are masking. I just gave some N-95 respirators to a friend who was picking up two hospitalized elderly relatives at discharge, so it’s always good to have some supplies on hand and enough to share.

Has your institution announced COVID vaccination policies for the fall or are they sticking with only influenza requirements for now? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/12/24

I’ve spent my entire career in healthcare and healthcare IT. I have worked in a number of settings, from small private practices to large health systems, and from startup technology organizations to major EHR vendors. In every one of those settings, the need for teamwork has been emphasized. When you work in a patient care organization, you learn that there are dozens of teams that support patient care, whether directly or indirectly. There are the frontline clinicians, but there are also people in engineering, environmental / housekeeping, supply chain, finance, and more. When you’re working a clinical shift in the hospital, how those teams function can be highly variable.

Where I trained as an intern, we were assigned to teams that rotated the responsibilities for accepting admissions and working up patients who were newly admitted to the hospital. However, we really didn’t function as a team. Each intern was assigned individual patients to care for, and a supervising resident oversaw the activities of the interns on the team. We were only a team in as much as we had similar working schedules for the days we took call. The work was much more individual, even down to the fact that when one intern finished they could go home, while other interns might be knee deep caring for extremely ill patients. In hindsight, after going through formal education on team dynamics, it would have been more accurate to refer to us as an “on-call cohort” rather than an “on-call team.”

I’ve seen that cohort concept play out among nurses who are working a shift on the same unit, where one member of the “team” might be assigned a disproportionate share of the work for a variety of reasons. One of my favorite nurses texted recently about a shift where there was a need to pull nurses away from nursing tasks to serve as sitters for patients that had been identified as having a high risk of falls, disorientation, or self-injury. Instead of figuring out a way to divide the work throughout the 12-hour shift, one nurse was assigned all of the nursing patients for the entire shift, and other nurses were assigned to be sitters for the entirety of the shift.

Since being a sitter is perceived as being an easier job by many, there wasn’t any incentive for people to volunteer to divide the work any other way, such as creating two six-hour nursing blocks and two six-hour sitting blocks, so that the work could be more evenly distributed. It’s difficult to feel like you’re a member of a team when you also feel like you’re the one that has been left holding the proverbial bag for all the patients on the unit, all by yourself.

I experienced a lot of non-team “teamwork” during the height of the pandemic when working in emergency and urgent care settings. Sometimes it just happens because of the varying levels of acuity of patients as they come through the doors, and chance determines whether you wind up with a patient who is relatively straightforward or whether you wind up with one who is extremely ill. While some facilities have algorithms to try to even out those patient loads, others work on a strict rotation that determines who is responsible to pick up the next patient that arrives. The combination of different types of patients you are responsible for often determines whether a shift is perceived as easy or hard, as does the makeup of your support team. When you have a team that clicks, it can make things seem much more tolerable, and it’s that feeling of teamwork that can get you through.

Unfortunately, that feeling of teamwork was also exploited during the busiest parts of the pandemic, as workers were forced to work while sick and when they were at the point of exhaustion. They were pushed to their breaking points and felt like they had to keep going because there was no one else to take their place, and that’s not a situation that anyone wants to be placed in again. That negative application of teamwork – the pressure that you have to do something because “you can’t let the team down” – led to many of my colleagues leaving direct patient care roles as the pandemic’s demands began to decrease. Unfortunately, I continue to see people who are asked to work under poor conditions with “the good of the team” being cited as a reason.

I recently had the chance to observe a technology team where members were not only cross trained, but were intentionally grouped to ensure redundancy. In the event of illness or competing priorities, the team was resourced so that responsibilities could be shifted to multiple other team members, reducing the risk that any one member would feel that work was being dumped on them should someone need to step back due to illness or personal conflicts. Part of the need for redundancy was inherent in the kind of work being done, which involved life support for individuals working in a hazardous environment. But it got me thinking about why we don’t take more of that kind of approach in healthcare. Certainly our patients, who are someone’s mothers, brothers, sisters, fathers, or other loved ones, deserve to have care delivered via processes that don’t allow them to fall through the cracks.

Why do so many care delivery organizations still use what could be described as single-threaded staffing models? For example, one physician, or one nurse, or one patient care technician is assigned to a certain number of patients. What would it be like if we cared for patients in groups, with backup and redundancy? Would we benefit from having more immediate collaboration around how we approach a patient in front of us? You see this in academic centers, where you may have physicians at different levels caring for a patient, such as an intern, a resident, a fellow, and an attending physician. Sometimes one will see something that another didn’t, which can lead to better outcomes for the patient.

I know some organizations are trying to do this in the nursing realm, using new models such as virtual nursing to provide additional layers of support for nurses working on hospital inpatient units. Sometimes the virtual nursing model carves out certain care tasks — such as intake and discharge functions that can be appropriately delivered via virtual modalities — and sometimes it’s more of a virtual mentor model to provide an extra set of eyes for nurses who may have recently completed their training and orientation. Although these models were originally designed to help solve nursing shortages by tapping available nurses who might not be able to work in person, there are additional less tangible benefits, such as improved collaboration and a feeling of collegiality.

The same thing holds for technology teams. I know everyone is trying to run as lean as possible, but there’s a cost to doing so. Running an engineering team ragged because it’s not staffed appropriately generally does not lead to strong performance in the long term. It does, however, lead to resentment, lack of focus, lack of buy-in, and often to employee turnover. Cutting corners may lead to short term savings, but ultimately there are long-term consequences that will need to be addressed.

I never thought I’d reach a point in my career where I would be excited to see organizations that were admittedly playing the long game and that were unashamed about putting people over profits. These are certainly the exception in our industry rather than the norm, but I’ll be keeping my eye out for other examples and following them over the coming months.

Do you work at a place that is willing to pay more to ensure higher quality outcomes? Are they focused on balancing work so that everyone can succeed? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/8/24

I like to stay close to my family medicine roots, so was excited to provide some local locum tenens coverage for a friend who was taking a much-anticipated vacation. Her practice uses an EHR that I’ve used to deliver patient care in the past, so I was confident in my ability to step in without a lot of retraining. Since I’m a new user on this particular system, I expected it would be a bit slow, especially since I wouldn’t have any medication favorites built and wouldn’t be terribly familiar with documentation templates in her particular system.

What I didn’t expect, however, was finding a defect that was recently injected into the system as part of an upgrade. In the prescribing system, the pick list that would normally be used to select how many times per day a medication should be taken had been morphed into something virtually unusable.

For an ambulatory medical practice, one would expect all of the “by mouth” options to be at the top of the list for easy selection. Instead, I was greeted by all the intravenous selections, followed by rectal and other options. The list also wasn’t responding correctly to keyboard inputs if I tried to do a type-ahead search, which meant that I had to scroll (and scroll and scroll) to write prescriptions. Needless to say, it was less than optimal for patient care.

I mentioned it to the office manager and she gave me explanation of it being upgrade related, so I can only hazard a guess at how many thousands of users are having their time wasted by this bug. It doesn’t impact physicians who primarily prescribe using a favorites list, so I guess I know what I’ll be doing this evening to make tomorrow less painful. Many newly trained physicians enter practice in July and August, so I bet I’m not the only one.

I also had the opportunity to attend a continuing education webinar this week. I was particularly excited about the session because one of my former medical students was presenting on an important clinical topic. I’ve presented on hundreds of webinars over the last decade, hosted by major academic institutions, medical societies, technology vendors, state health departments, and volunteer organizations. The best ones conduct a practice session or at least distribute a set of ground rules to explain how presenters should interact with each other and with the audience. When organizations don’t do this, sometimes they get lucky and everything goes well. In this situation they didn’t get lucky, however, as one of my friend’s co-presenters apparently didn’t get the memo to turn her camera off when she was not presenting.

Since there were only three panelists, their camera feeds were front and center. I’m assuming that her co-presenter was multitasking and looking at something humorous based on her facial expressions. Unfortunately, those expressions were occurring at a particularly sensitive point in the discussion that made it appear that she was laughing while serious patient harms were being reviewed. I’d like to assume that this was just an oversight on her part, and that she didn’t mean to be disrespectful, but either way it’s bad form. I hope someone at her organization recommends that she review the recording so she can see how she was projecting herself to the world.

I wish I would have run across this article earlier in the Summer Olympics hype cycle. Some of the parents of competitors were outfitted with heart rate monitors to see how their anxiety manifested as their athletes competed. NBC displayed data from the father of one of the US gymnasts during one of her routines. One would think that it would be enough to just display the facial expressions of loved ones since you can see every second of anxiety or amazement broadcast to the world already. Commenters on the article felt that displaying heart rate data was a bad idea, using words such as invasive, creepy, and unsportsmanlike to describe the practice.

Another article that I ran across this week detailed a physician who is accused of behaving badly by making over $1.5 million in personal charges on his business-issued credit card. The physician pleaded not guilty to the charges, with his attorney stating that “the funds he used were not stolen funds.” The card was used for $115,000 in cash advances, $176,000 in pet care, $348,000 in personal travel, $109,000 in gym memberships and personal training, $52,000 in catering, and $46,000 in tuition payments for his family. A savvy commenter called out the fact that he spent more on pet care than he did on his children.

The amazing thing about the situation is that the charges occurred over a seven-year period before being caught in an audit. According to the article, his institution is the only state-run hospital in New York City. One would think that being a public institution would make for stronger accounting controls. The physician is scheduled to appear in court again at the end of September.

Speaking of September: I discovered this week that the spelling and grammar checks in Microsoft Word will not catch “September 31” as something you shouldn’t type. It’s something I’ll be manually watching for in the future.

I wrote earlier in the week about the evolution of language and how that might impact large language models. I was excited to see this article about the forces changing language on a daily basis and that teenage girls are a major driver. It should be noted that the article is from Australia, which has its own unique linguistic offerings. Some of the experts interviewed in the article note that young women drive changes faster than young men and that this isn’t a new phenomenon – it has been studied extensively, including reviews of letters written from the 1400s to the 1600s. The fact that social media connects people from different regions and countries is also driving rapid change. One expert encourages people to place themselves close to a group of teenage girls to listen to how they communicate as a representation of where language is headed. I’ll be looking at my interactions with various community youth groups differently moving forward.

What do you think about changes in language and how they might be driven by social media or other societal forces? Leave a comment or email me.

Email Dr. Jayne.