EPtalk by Dr. Jayne 7/11/24

It’s a milestone week at HIStalk as this edition of EPtalk marks my 1,400th post. I was struggling with ideas on what to write about, but a veritable treasure trove of topics came my way.

First is the health system that hasn’t updated its content in several years. I won’t name it to avoid unnecessary shame being heaped upon the good people who work there, but someone in a leadership position needs to allocate some resources to remove outdated banners from several clinical modules. The eyebrow-raising content included a strongly worded reminder that I shouldn’t be treating COVID-19 with unapproved medications such as ivermectin or hydroxychloroquine. The year 2021 called and it wants its alert back, folks.

From IT Guy: “Re: my company’s return to office policy. I’m not thrilled about it, so I was intrigued by a headhunting email. On a whim, I decided to check out the company. Check out their leadership page.” Employees apparently get a custom bobblehead figurine after they’ve worked there a certain number of years, and that’s how key company figures are represented on the website. Two of the three founders are depicted without shirts. Although I appreciate the detailed artistry of the washboard abs on the bobbleheads, I’m not sure what this representation says about workplace culture.

From Lady Go-Live: “Re: my implementation project. I had a strange encounter with a physician today. We are literally days to go-live and have been conducting dress rehearsals in critical areas of the hospital to make sure that nothing is missed. During today’s walk-through, I was berated for using a checklist to make sure that everything was covered. The physician told me that if our system was so easy to use, I should have been able to run the checklist from memory. The reason it was so strange? He was a surgeon.” It’s funny how resistant certain people can be to checklists, even ones that have been proven to avoid serious patient harm. Pilots and other critical workforce members had been using them for years before they were introduced to healthcare, and still people balked. Atul Gawande’s bestseller “The Checklist Manifesto” was released in 2009, but some people act like it’s still a brand new concept. Maybe if checklists were run by AI, people would get on board, because after all AI makes everything better.

I’ve written before about the stresses that early discharges and hospital at home can place on family members. This week the Journal of the American Medical Association published a research letter that addresses caregiver burden and hospital at home programs. The authors surveyed a representative sample of US residents about their willingness to perform care in the home. The survey was distributed from August to October 2023 and included nine questions that followed a description of hospital at home. The survey had a 92% cooperation rate and 47% of respondents reported acceptability of the idea, with 36% being neutral and 16% saying it was unacceptable. Interestingly, the percentages didn’t vary significantly across characteristics such as health insurance coverage, health status, or sociodemographic factors. The authors acknowledge that they didn’t measure some factors, including the respondent being part of a multigenerational home, and also acknowledged the challenges of working with self-reported data. It would be interesting to construct a longitudinal study of attitudes at baseline, after a recommendation for home-based care for a loved one, during that care, and at the end of the episode of care. Researchers, get cracking.

I’m spending some quality time out of the office this week, experiencing some of the finest humidity the continental US has to offer. As I was trying to figure out a nice way to have my auto-responder message say “Look, I told you I would be completely off the grid, please for the love of all things respect my need for a little time off.” However, that’s not good business etiquette, and even if there was a socially appropriate way to word that message, it wouldn’t be acceptable in working environments where managers expect people to be available 24×7. Just because nearly all of us carry smartphones doesn’t mean we need to check our work email, but I’m betting more of us do than we admit. Some people do it so that they can delete items in real time so they don’t come back to an overstuffed inbox. Others do it almost as a compulsion, especially if they’re better at being busy bees than they are at taking a break.

I reflected a bit on some of the most memorable out-of-office messages I’ve seen. One former co-worker decided to go bold and announced that she was out of the office to travel to see Taylor Swift, with no apologies for taking time off to do something that was clearly important to her. On the flip side, I once had a co-worker document that he would be out of the office from 10 a.m. to 2 p.m. for a medical appointment and to please text him during that time. If he truly had something urgent going on at work as well as from a medical standpoint, I feel bad that his employer left him so completely without coverage that he felt the need to post that message. I’ve been in work situations with that kind of pressure, but having also had people’s lives literally in my hands, I decided that non-clinical needs would just have to wait until my return.

It also gave me the opportunity to reflect on some of the best supervisory relationships I’ve had over the years. One of my favorite leaders was highly intentional about time off. She not only made sure that her direct reports took all of their allotted time off, but made sure we carried the practice forward into our teams. She would remove people from email threads when she knew they were out of office and provided gentle reminders if someone tried to add an absent colleague back to the discussion. Because of behaviors like that, we knew that not only did we not need to check our email when we were out, but that we most certainly shouldn’t respond to anything unless we wanted to reveal the fact that we were disregarding her instructions to “enjoy the time away and don’t worry about work, because we’ve got you.”

What is the most memorable out of office message you’ve seen? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/8/24

I enjoyed having some time off around the recent Independence Day holiday. Costco’s holiday cake did not disappoint, although I’m not entirely sure why it had 61 stars. Kudos to the cake decorator who managed to fit them all on there, even though there were a few spares. I hope everyone had a safe holiday and is heading back to their respective work weeks without any injuries that were caused by heat or fireworks.

Since I had some downtime, I worked through some training assignments for a new clinical employer. It’s always interesting to start at a new company and find out how they handle all the mandatory training sessions for providers. It’s not just HIPAA, but also Medicare-related fraud, waste, and abuse training, controlled substance training, and more.

The organization that I’m contracted with also includes cultural competency sessions as well as those on diversity and inclusion, rolling those up under a larger curriculum on being an effective clinician. One would hope that we learned these things during our training, but I understand their need to cover all their bases and make sure that everyone in the organization is operating under the same expectations.

Along with many of my colleagues who work in emergency and urgent care settings, sometimes we aren’t employed by the facility where we’ll be working. Many of us work for staffing companies or third-party medical groups that have contracted with the facilities to provide physicians. In addition to doing the training required by the organization that is actually paying us, we also have to do the mandatory trainings for the facilities where we’ll be working, even though the content is often similar. There’s no reciprocity for these trainings, sometimes not even within the same health system, and it can be mind-numbing to sit through so many duplicate sessions of the same content published under the auspices of different medical staff offices.

Depending on the situation, many physicians, especially those who are working for large, privately held telehealth providers, are considered independent contractors. The contracts are often heavily one-sided and physicians aren’t paid for the time spent in training, which is a bit of a double-edged sword as far as balancing attentiveness with the financial bottom line. I think most people would be more likely to pay attention if they’re being paid a fair rate for attending classes. However, when they’re asked to go through nearly a full day of training sessions without compensation, it seems like a recipe for people to multitask or otherwise not take the training seriously.

The training I completed this weekend had the added pain of misrepresenting the length of various modules, making it challenging to fit it into my allocated time frame. For example, a module that was advertised as “10 minutes” actually involved reading a densely formatted 40- page document, then attesting to having read and understood its contents. I’m no expert in reading comprehension, but I think that expecting someone to digest a full page of text in 15 seconds is unrealistic.

Even more concerning, that large document contained numerous links to other policies and procedures that we were also expected to attest to understanding, which is just ridiculous. I’m sure a good number of people just click through it and check the box, which isn’t going to serve them well if something bad happens. A couple of the links were broken, so I had to email the physician liaison team to get copies of the policies that I’m expected to read. I wonder how many of us are actually asking for the documents versus just going through the motions. Maybe asking for the documents from the broken links is a test to see if we actually read the pages.

Some of the other training sessions were sloppily constructed. For example, a 60-minute course contained three, 30-minute sessions. It feels like someone updated the training and threw something else into the course but didn’t update the learning management system with the correct information. The modules themselves had clearly been edited over time, and not with particular skill. Audio levels within a single recording ranged from virtually inaudible to painfully loud. 

Some of the written materials were pretty humorous. You have to wonder when a slide spells out “E-H-R” with intervening hyphens if it’s because they really don’t know that it’s simply “EHR” or whether they haven’t figured out how to adjust their slideware’s dictionary to keep it from autocorrecting to “HER.” There were also a couple of places where the voiceover incorrectly pronounced common medical words, which didn’t’ give me a lot of confidence.

The next piece of the onboarding that raised concerns was the organization’s demand for adherence to its conflict of interest policy, which basically says I can’t practice medicine anywhere else but at this facility. That conflicts with the whole ideal of being an independent contractor, and the idea certainly wasn’t included in any of the initial contracting documents that I signed.

Asking someone to sign a restrictive agreement after you’ve already contracted them is sneaky, to say the least. Other words that come to mind are “deceitful” and “unethical.” Another email was fired off, because I’m definitely not signing it. I only wish I had come across that little nugget sooner, because I wouldn’t have sat through several hours of unpaid training if that piece had been at the front.

I’m also wondering if there’s a whistleblower opportunity here, because if they are blocking the ability for independent contractors to have other employment, that sure sounds like a problem to me.

It’s sad when you feel burned out before you even start. I’m questioning whether I want to work for these people at all, even if we can resolve the various issues. If you can’t get the basics right, I have little confidence in your ability to support me through unwarranted patient complaints or a nuisance lawsuit.

I haven’t even made it to the EHR part of the training yet, which I was actually looking forward to because it’s always nice to see how someone else has their system configured and whether there are any tips and tricks that you didn’t already know. I’ll certainly chime in if I make it to the EHR training and strike gold.

What’s the most disappointing onboarding experience you’ve had? How does your current organization do better? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/1/24

This weekend was all about me fighting technology in its various incarnations and being philosophical about whether we are actually better off with all the bells and whistles that we have come to use in our daily lives.

My first struggle was prompted by the fact that I’m over a certain age and my vision prefers a large monitor compared to my laptop. I have a monitor connected via a docking station, so I really only use the laptop for its camera capabilities, along with being a separate screen for third-party messaging apps and other windows that I don’t want to inadvertently share while on a web meeting. Most of my clients prefer online meetings without video, so that wasn’t really an issue. However, I recently started collaborating with someone on a book (which is an interesting experience in itself) and she prefers on-camera interactions, so I decided to get a separate webcam to put on my primary monitor so I wasn’t always looking sideways on our calls.

After doing my usual comparison shopping and polling friends about their experiences, I narrowed it down to a couple of options that were available locally. One of the three was on sale at a shop a mile from my house, so I jogged over and had it in hand in short order. Everything I read indicated that I should be able to just plug it in to the docking station, tweak a setting or two on the laptop, and be on my way.

This was easier said than done. I struggled to get the camera to mount securely because my monitor has a curved housing on the back. It was downhill from there as I couldn’t get it to work using the docking station regardless of how many settings I tweaked. I resorted to connecting it directly to the laptop, which although functional, created a wiring mess that I was trying to avoid.

From there, I had a battle with some permissions on a client-provided laptop. The agent at the other end of the call was clearly following a script and didn’t fully understand what she was advising. She recommended that I “press and hold the power button for 60 seconds.” I attempted to clarify that she was asking me to restart the computer, therefore I would need to finish some work and get back to her. She advised that no, the computer was not going to restart, we were just “rebooting the power.”

I let her know that I would need to call back at another time and went about my business. I restarted after finishing my work and the problem was resolved so I didn’t need to call back, but it just emphasizes the importance of having people in your call center who actually understand the advice that they are giving and who aren’t just reading from a script.

The issues really hit the proverbial fan when my power had a momentary blip, knocking the internet offline close to midnight. I was half asleep reading a book anyway (“Project Hail Mary” in case you’re interested), so I manually turned off the lamp rather than having Alexa do it, and figured I would address it in the morning. My internet gateway rebooted without a hitch and my hardwired devices were back up, but the wi-fi had renamed itself and reset the password. That required tracking down the magical website where I should have been able to rename the network and change the password back, but I couldn’t figure out how to make my changes save. I’m stuck, in the short term at least, with a goofy 30-character password and a different network name.

Now I need to visit all my internet-enabled devices and get them reconnected, including my thermostat, a couple of Alexa devices, phones, a thermostat, and my smart TV so I can figure out how “Bridgerton” is going to continue to unfold without having to sit at my desk. I didn’t have time for that budgeted on my schedule today, so getting the phone connected was the best I could do for now.

With all that, I was more frustrated by my labor-saving devices than anything, and it was in that mood that I read Mr. H’s mention of the Sunrise EHR error in Australia that incorrectly calculated more than 1,000 pregnancy due dates. Regulators are investigating whether patients were harmed by the incorrect dates, which could have led to premature inductions of labor or mismanagement of patients who spontaneously entered labor well before their due date.

For example, when you’re concerned that a pre-term birth is imminent, there are treatments you administer to try to improve fetal lung function. Those are only indicated between very specific dates as far as fetal age. The issue affected public birthing hospitals in South Australia during the six months prior to June 5. SA Health is performing its own medical records review in parallel to the independent investigation. Approximately 100 patients have yet to deliver, so hopefully their dates are being appropriately updated. Patients have not yet been informed of the issue. 

Details on the incident are slim, with the article noting that due date fields in maternity notes were overridden by a calculation that was based on the last menstrual period. I haven’t used Sunrise since the late 1990s, but I’m guessing the system has a hierarchy for how it populates due dates, which might be determined from a last period, ultrasounds, other medical records such as assisted reproductive technology notes, patient-reported date of conception, or a combination of data available. However it manages those different data points, something went awry.

Back when I was delivering babies as part of full-scope family medicine, we would note all of those data points on this magical fold-out paper form and then document our final estimated date of delivery in a specific place on the form. It wasn’t sexy, but it was accurate, and the only way for it to be overridden involved a strike through and someone’s initials.

My question as a clinical informaticist is this: what happened six months prior to June 5 that caused it to be inaccurate? Was there an upgrade, an update, or some change to a template? What processes were in place (such as two sets of eyes checking on changes to critical patient care content) to prevent such an issue, and what went wrong?

If it is determined that patients were harmed by the issue, I certainly feel for them and for their families, because issues during pregnancy care can lead to a lifetime of “what if” questions that haunt parents. My experience transitioning obstetricians from the paper folding forms to EHR was that they planned to hold onto the paper until the last possible minute because it was a system that just worked. It would be interesting to see whether the benefits of electronic maternity documentation have been shown to provide improved clinical outcomes compared to paper documentation, but I doubt that study has been performed.

I could search for it, but instead I’ll be using my spare time to try to fix my household so that Alexa can once again turn on my bedside lamp.

What’s the technology you miss the most when it stops working? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/27/24

From Jaded CMIO: “Re your recent comments about the Medication Access and Training Expansion Act (MATE) and its 8-hour DEA education requirement being a time waster. I’m in the same boat – I don’t even see patients, but my institution forces me to maintain a DEA regardless. Did you see this commentary on Medscape?” The op-ed from Melissa Walton-Shirley, MD is subtitled “8 Hours of My Life I’d Like Back.” The author calls for reform of DEA regulation, including waiving the requirement for physicians who don’t issue prescriptions for outpatient narcotics (such as intensivists who might be giving controlled substances in the ICU) and issuing a nationwide DEA number instead of forcing providers to have separate ones for individual states. The piece has over 140 comments already and some of them are pretty entertaining. My favorite: “We should get 0.5 hrs just for reading this informative dragging of MATE. And Pharma should be forced to fund the DEA, not provider licensing fees – since when does the taxi driver pay your fare?”

US Surgeon General Vivek Murthy penned a guest essay for the New York Times this week, calling for a “surgeon general’s warning label” on social media platforms and advising users that “social media is associated with significant mental health harms for adolescents.” This would require an act of Congress that I doubt we’ll see anything about soon, however. Murthy issued an advisory last year with specific recommendations to make social media safer, and although there have been some interesting congressional hearings, I haven’t seen a lot of change. I’ve seen in my own community the level of peer pressure for young children to be on social media. I wish we could lure kids and their parents to consciously choose the outdoors and other activities rather than focusing on screens.

From Informatics Doc: “Re: patient portals. I just went to my mom’s Epic portal to see what meds she was currently on since there was some question about whether any of them were making her more confused and sluggish. When she first got her portal, I was impressed that it did a better job than the Cerner portal in terms of usability. It also had an option to print out a wallet card with an easy to read medication list, allergies, and problem list. Fast forward to today. Every option that I tried for getting a medication list showed the same cluttered view in which the info on each drug and its dose and times was interspersed with the pharmacy name, the prescribing doctor, the start date, and a refill button. Hitting the print button gave you the same thing in a PDF with slightly better layout. To get a medication list to send to my siblings meant taking an added 15 minutes to cut and paste into Word and clean out all the extras. Do the EHR vendors have something against a nice clear condensed med list? (I know Joint Commission contributed to the poor med list formats within the EHR by their dislike of Latin abbreviations, but have they caused this problem in the portals as well?)” I test drove this with a couple of organizations and it appears that it might be a setup issue rather than a vendor issue, but I’m not entirely sure. At the first system I logged into, the “current medications” page was cluttered up by information telling me how to request an amendment to my medical records for two of the system’s physician groups. The print version was a little better, but the entire first page was taken up by an inch and a half worth of text about the amendments, pushing the medications to another page. Only the first page had a patient identifier on it, which makes it a little less useful as something that you might take with you to a visit with a physician who uses a different EHR. The second system wasn’t displaying any of my meds, which is definitely unusual.

I’m not ready to blame the EHR vendor because I’ve seen enough client-inflicted setup issues in my career. One of the institutions in question clearly has a setup issue in another part of the system. My recent pathology results had a blank diagnosis (which to me should be a required field before they’re finalized) and also had a tagline at the top of my results that stated “EPIC results best viewed via link to PDF,” which I thought was odd since I had to scroll three times to find the link to the scanned document and it didn’t say anything about it being a PDF. I’m sure there are patients who might not know what they’re looking for or who might not have scrolled. My report was also missing important clinical information that I provided at the time of care (documented as “not provided,” which is simply not true). Sloppiness all around, but not necessarily the vendor’s fault. I think that a concise med list is important for patients to be able to put in a wallet, so if that’s an option, I hope our expert readers will weigh in.

The clinical informatics job market has been a hot topic in recent conversations with colleagues. I have several friends who are highly capable and genuinely nice people, but who have been impacted by sweeping layoffs at their organizations. Most have school-aged children, elderly parents, or both, so they are reluctant to relocate for a new position, which might get cut in a year or two just as easily as their previous one was. In a recent chat, one mentioned that they had made it through multiple interviews, but the companies in question had gone radio silent for a matter of weeks. That’s not only disheartening, but unprofessional. It takes a few seconds of a recruiter’s time to type an email saying, “Thank you for your time, but we will be moving in a different direction” or something similar. Another countered that although that experiencing is depressing, it can be a blessing in disguise when you figure out that the organizational was dysfunctional before joining it.

My favorite quote of the conversation says it all as my colleague described some of the organizational personalities he’s encountered in his job hunt process: “I feel like some of us spend so much time and thought honing our skills and presenting ourselves professionally and some others just Mr. Magoo their way from one executive role to another.” I think most of us have encountered leaders like that in our travels, bouncing from one unsuspecting organization to another. I’m grateful to have had at least a few experiences where I’ve worked with exceptional leaders, but that’s not the case everywhere.

How do you think the hiring process has changed over the last five years? Have things improved or are they only getting worse? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/24/24

I’ve spent the last couple of months mentoring a medical student who wants to include clinical informatics in their future practice. She’s doing an elective where she spends time with various physicians who hold informatics roles. She asked me to review a paper that she wrote about her experiences.

As part of the rotation, she worked with an optimization team that works with medical practices that are being acquired by the health system that is affiliated with the medical school. Her paper was about those experiences and how clinical informatics principles might be applied to scenarios that she witnessed during site visits.

First, I was impressed at her level of thoroughness. Despite not having a lot of formal experience in process improvement, she was able to document and categorize workflows and make suggestions about how they might be modified before the practice joins the larger system. She correctly identified that there will be a fairly steep learning curve, not just due to the EHR transition, but also due to operational processes that are outside what we would consider best practices. Some of the items she witnessed can make a big difference in a practice’s success.

Although I was surprised by some elements, others fell into the “no surprises here” category.

One of the first things she called attention to in her write-up were regulatory citations that were made by staff that didn’t actually align with the regulations in questions. These included telling patients they couldn’t give family members access to their records “due to HIPAA” even when patients were making HIPAA-compliant requests for information sharing. The office was also engaged in information blocking, telling patients they couldn’t see their own records. That will need to change, because I’m sure the health system doesn’t want the liability of someone creating a situation that results in a fine due to noncompliance.

Misinterpretation of the rules happens often, and the student listed the health system’s standardized annual training as a potential strategy for mitigation. I recommended that she also confirm that the optimization team planned to circle back after that training to make sure that any regulatory myths were fully debunked during the course of the training.

Another thing she noticed was physicians and other clinicians using EHR note templates, but not editing them to match the patients, such as including a bilateral lower extremity exam on a patient who had undergone a lower limb amputation. The clinicians claimed that they didn’t know how to modify the template, but the student was able to give some on-the-spot training.

She was shocked to see some physicians signing their notes without even reading them, and I hated to tell her that in some organizations, that is the rule rather than the exception. She was even more shocked to hear about the notes that I’ve seen where people add phrases like “Dictated but not read, signed to expedite communication,” which we both agreed is absurd as well as being a medicolegal risk.

She noticed that the practice was taking complete vital signs on all patients regardless of the reason for visit, and provided a nice discussion of why that might not be necessary. It turns out that the EHR was configured so that all vital sign fields were required, which is undoubtedly a huge time-waster for the practice as well as an inconvenience to patients. Examples provided included a patient having full vital signs documented for a suture removal, when really all that was needed was documentation of the procedure that was performed and the status of the wound in question. Knowing the EHR they will be converting to soon and how it is configured, this is a problem that will be easier to remedy once they’ve made their transition.

I chuckled as I read the portion of her report that dealt with prescribing habits. The physicians in the practice who complained the most about refill request volumes were, unsurprisingly, the ones who refused to follow processes that have been best practices for more than two decades, such as writing a patient’s prescriptions to cover the maximum duration allowable by law. For a compliant patient who is stable on medications, there is no reason not to write their prescriptions for 12 months if it’s legal. Not only do shorter refill periods require more work on the part of office staff as they process requests,they are also a risk to patients who might not take their medications as directed if there are delays in the refill process. She actually overheard one of the physicians tell a patient to “just call the office when you need a refill” despite the practice’s policy that refills should be requested through the pharmacy since the office receives electronic refill requests.

She had a question for me about how her paper should address the issue of physicians who are unproductive in the office yet blame the EHR even though they were doing a significant amount of non-work activities during office hours. She actually had observational data on how much time physicians were spending on Instagram, Snapchat, Facebook, and other social media during times that they could have been documenting patient visits, addressing lab or diagnostic results, or managing the inbox. For one physician who the team shadowed, the number of personal phone calls made during the office day was quite high. It’s hard to avoid so-called “pajama time” documenting at home when you’re not making the most of the time available to you at work. I asked her to work with the optimization team to find out how they address these issues with the organization’s physicians and staff, and to provide a similar treatment in her final paper.

We had a good discussion about what life was like in the time before smartphones and how the constant connectivity to information and communication tools has changed how many people work, both inside and outside of healthcare. During a recent trip to the airport, I watched a member of the housekeeping staff hold their phone watching videos with their left hand while mopping with their right hand. If that’s not an example of the addictive properties of certain technologies, I’m not sure what is. We had some good conversations about work-life balance and how the habits she’ll be forming in residency will influence her later actions, so I’m hoping she’ll take a mindful approach to how she is managing her own time and activities.

Due to the nature of the shadowing experience, she wasn’t able to get into much EHR optimization, but I’m glad she had the opportunity to do a little teaching about templates. In a recent conversation with some other clinical informaticists, one asked if we thought our roles were becoming obsolete. As long as there are EHR (and other solution) features that aren’t being trained to end users or that aren’t being used to their fullest, there will always be room for informaticists to help improve the daily work experience.

What are the small improvements you help your users with on a daily basis? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/20/24

The team at Geeks for Geeks has published its list of the 50 most common passwords, as identified through security incidents. I’m not surprised by entries such as 123456, password, admin, or 111111, but I was surprised to see these: monkey, dragon, princess, whatever, starwars, and startrek. My favorite from the list is trustno1.

At my most recent visit with a physician who I see annually, the office didn’t have her schedule template built for the coming year. They promised to send me a postcard when they open her schedule, but could not give an estimate of when that might happen. I don’t have a lot of faith in mailed reminders and my schedule is chaotic, so I put an appointment on my own calendar to follow up. I would rather receive a patient portal message that would alert me to the ability to schedule, as well as the ability to just schedule it myself.

A recent healthcare consumer preference survey showed that while nearly 40% of patients would like to schedule appointments online, 22% reported that their provider doesn’t offer that option. The report also addresses why patients are choosing urgent care over primary care, which is good food for thought for those who are trying to figure out the best ways to deliver care in their communities.

Miami Today reports that after 16 years, Miami-Dade County has agreed to sell naming rights to a transit station. The Civic Center Metrorail Station has been purchased by the University of Miami Health System for $2.9 million over 20 years. Starting in July, the station will be known as UHealth Jackson Station. Proceeds of the sale will go to the county for transit-related projects. Jackson Health System, which is owned by the county, was part of the initiative to gain the county commission’s approval. In additional to the ongoing fee, UHealth will pay for updated signage with the new name at the station and at other locations across the Metrorail system. The agreement also allows installation of digital displays to share branded materials.

MIT Technology Review ran an article last week about a new safety tool for operating rooms.AI-enabled “black box” devices are intended to capture information about surgeries. The idea comes from the black boxes that are found in aircraft, which allow investigators to review captured data following crashes or significant flight events. For operating rooms, data capture happens through audio/video as well as data from anesthesia monitors. Several medical device companies are working in this space, but a Stanford University surgery professor is looking at the entire operating room environment, not just the procedure itself.

This approach raises questions about patient and staff privacy, as well as legal issues. Surgeons have refused to work where systems are present, and devices have reportedly been sabotaged. The data that is captured can be compared against surgical safety checklists and other standardized measures of surgical proficiency. To train the models, surgeons or highly-trained technicians label items and actions so that the system can learn.

I reached out to a couple of surgical colleagues for their opinions. One feels that the technology would have been better received a decade ago, because physicians have increasingly come to feel like they “have a target on their back” for any perceived irregularities in the hospital, from their tone of voice to their leadership style in the operating room.

Speaking of workers worried that they are being monitored, Wells Fargo recently terminated more than a dozen workers after concerns of “simulation of keyboard activity creating impression of active work.” I bought my first “mouse jiggler” more than a decade ago to prevent my laptop from going to sleep while I was seeing patients. My health system had a lockout if the unit was idle for more than 90 seconds, and no one in IT would listen to a family doc who tried to explain that most physical exams take more than that brief time. Also, that it was ridiculous to lock out the laptop when it was sitting in the exam room in my direct line of sight. I’ve had corporate laptops where the USB ports were disabled, so I’m a bit surprised if a USB device was the approach that was used by the employees versus something more exotic. Wells Fargo has zero tolerance for “unethical behavior,” according to a statement, and the employees in question worked in financial management units, resulting in the situation being disclosed in a filing with the Financial Industry Regulatory Authority.

Pharmacy Practice News recently ran a piece on hospitals using smart speakers such as the Amazon Echo Dot in patient rooms. One installation allowed patients to ask questions about their medications while allowing the pharmacy team to communicate quickly with patients. Patient questions that are beyond the system’s standardized content can be converted to EHR messages that are delivered to pharmacy staff. The system is designed to accept various drug pronunciations that patients might use, which is great since there is often confusion around medication names.

In a deployment at Houston Methodist Hospital System, the system can also be used to help pharmacists quickly respond to orders for drugs used to reverse bleeding. The pharmacy-side device announces an urgent order and its notification ring flashes. Teams at the facility are looking into other uses for the device, including capture of patient-provider discussions.

I was a guest lecturer at a local residency program this week and enjoyed chatting with young physicians who were about to mark another year of training complete. The educational year traditionally runs from July 1 through June 30, and a couple of the attendees have precious few days left before they’ll be expected to work on their own. My presentation was on topics related to the business of managing a practice. Most questions were related to the role of private equity in healthcare. I wish my lecture had been scheduled a few days later, because when I arrived home, I found an email about the newly introduced Corporate Crimes Against Health Care Act of 2024. The bill was introduced in the US Senate and specifically addresses abuses that have occurred under private equity ownership of nursing homes, medical practices, hospitals, and other healthcare organizations.

The Act provides for increased transparency around changes in ownership such as mergers and acquisitions; criminal penalties for executives when abuses lead to the death of a patient; the ability of state attorneys general and the Justice Department to “claw back all compensation, including salaries, that is paid to private equity and portfolio company executives within a 10-year period before or after an acquired healthcare firm experiences serious, avoidable financial difficulties” due to “looting” by those executives. A press release from the bill’s co-sponsor, Senator Elizabeth Warren, specifically addresses the “private equity greed and mismanagement” that pushed Steward Health Care into bankruptcy.

What are your thoughts on reining in the role of private equity in healthcare? Will this bill become law? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/17/24

We are deep into the summer doldrums portion of the healthcare IT hype cycle. Companies that have big news to share are saving it up for the fall conferences. Some are making announcements that seem to be recycling old content and hoping no one notices.

I’ve worked with a number of provider organizations and it always seemed like summer was slow there as well. With employees taking vacations, the appetite for major go-lives or launches of new initiatives was typically low. I’m working on roughly a dozen smaller projects right now, which sounds like it could be chaotic but actually is going well.

Earlier this week, I worked on a project to help an organization get ahead of the game on their influenza vaccine campaigns. Review of their most recent data on flu-related hospitalizations revealed an upward trend, so they’re planning to mobilize in the community well in advance of vaccine availability. They are in the prep stages, but it is exciting to work with someone who is thinking ahead versus the usual last-minute crunches that come my way. I’ve drafted all their clinical messaging and created timelines for the different phases of the campaign, now it’s off to their various committees for any requested modifications and approval.

I also spent the better part of a day writing demo scripts for a solution vendor that has limited physician support. They are relatively new to the market and don’t have any physicians on staff other than an extremely fractional chief medical officer. Before connecting with me, they were letting their sales reps construct their own demo scripts. Based on some of the scenarios I was presented with, I suspect that AI may have had a hand in their creation. They were technically correct, but the scripts were stilted and didn’t flow they way they needed to in order to resonate with a clinical decision maker.

People ask what makes a good demo. I have a short list of things that I think about as I create scripts. First, you have to understand the audience. Is this a high-level demo to put on a website or to make generally available? Or is it for a specific group of clinical decision makers?

If it’s for clinicians, we need to understand the practice setting (inpatient, ambulatory, or something else) and the clinical roles that are involved, as well as the spectrum of patient demographics. Although you can make decent high-level demos that have broad appeal, when you are showing your product in front of potential end users, the devil can be in the details. Content for a community health clinic demo that will resonate with the audience may look quite different than that for a private practice in an affluent area.

When you get into the details of a clinical demo, it’s important to make sure that the scenarios are typical and appropriate. For example, going in front of frazzled family physicians with a demo that only includes patients with sinus infections and urinary tract infections is superficial at best and may make them think that you don’t understand what they do all day. However, rolling in with scenarios where patients have three or four chronic conditions and suboptimal insurance coverage will be a bit more impressive.

It’s also important that the team that presents it uses the right vernacular for the audience, and especially that they pronounce medical words correctly. Know where abbreviations are typical and how to say them. For example, talking about a coronary artery bypass graft (CABG) as a “cabbage” is OK. Calling it a “see-aye-bee-gee” is less than ideal.

Using obscure Latin names for anatomical structures is a no-no, especially if clinicians are used to using lay terminology for those parts. “Second toe” is just as good as “digitus secondus,” when you’re talking to a family medicine physician. You don’t want me thinking “what is he talking about?” when I’m supposed to be focusing on your product.

The scripts went back to the vendor for review and we will meet later this week to discuss them. I’ll be crossing the phalanges of my second and third upper extremity digits that they accept the recommendations largely as recommended.

I spent a big chunk of hours working on continuing medical education requirements that need to be complete before I can renew my DEA number in the fall. As a telehealth physician, given my state’s laws and my clinical employer’s rules, I don’t prescribe controlled substances. However, that employer requires me to keep a current DEA number as a proxy for proving that I haven’t violated any rules with the DEA. As of last summer, federal legislation requires everyone who is renewing their DEA registrations to attest to completion of eight hours of education on the prevention and treatment of opioid use disorder and other substance use disorders.

I had initially started an educational module from a well-known continuing education provider. However, it was light on the educational content and heavy on questions that aren’t germane to the practice of many physicians. For example, the first module was all about orthopedic patients presenting to the emergency department who might require pain management. There were several “which of the following is the BEST option to treat this patient” type questions. Those are always infuriating because there may be several options that are technically correct but the authors are hoping you read the one specific study that says a specific option is best. Not to mention, the reality of “best” often revolves around the patient’s insurance coverage, whether they can get someone to take a prescription to the pharmacy for them, and other factors that are independent of an isolated clinical scenario. That module wouldn’t have been useful at all for a gynecological surgeon, who has a need to prescribe controlled substances but who probably last saw an orthopedic patient in the emergency department during their residency training.

I powered through to at least get an hour’s worth of credit, but then spent a bit of time trying to find a continuing education provider whose content better matched my own needs. Surprisingly, the American Medical Association was the winner with a 50+ hour curriculum from which I could choose my remaining seven hours in a way that meets my needs. 

None of this addresses the fact that my clinical employer is making their physicians cumulatively spend tens of thousands of dollars each year to demonstrate that they’re not bad guys because they hold a valid DEA number. It’s just another hoop that each of us has to just jump through, unfortunately.

I also spent some time working on a residency lecture that I’ll be giving later in the summer, and that was actually fun. I always look for good visuals and a friend sent me a recent presentation from a gastroenterologist as an example. All of the graphics were GIFs that tied back to the show “Schitt’s Creek,” which was great given stool-focused theme of the lecture.

All in all, it’s another week in the life of a clinical informaticist. It can occasionally be dull, but usually isn’t that way for long.

What part of the year is the slowest for your team or organization? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/13/24

I get a lot of emails advertising webinars and educational opportunities. I don’t usually take advantage of them because my schedule is busy and the invites don’t arrive with enough notice to allow me to attend. However, a recent email from one of our local HIMSS chapter sponsors caught my eye.

It met all the criteria. I received it several weeks in advance, the topic was interesting, and it was advertised specifically as an educational session. I blocked my calendar and registered. I logged in well in advance, only to find a blank screen and no indication that I was receiving the audio or video feed. I appreciate a moderator who addresses attendees with some kind of “Thank you for joining, the session will begin in three minutes” kind of welcome so that you know you’re in the right place and everything is working.

It was well after the top of the hour and the webinar hadn’t popped up yet, so I refreshed the window and discovered that it had already started and I had missed the intros. It also was less of a formal education session than talking heads, with no agenda or educational objectives. I had yet to hear anything about healthcare IT in the first 20 minutes (although I did hear a lot about AI being used to predict the likelihood of a criminal reoffending and about autonomous vehicles), so I gave up.

If you’re putting on a webinar, here are my recommendations. Advertise your offering accurately. If it’s not going to be a formal educational session, don’t make it sound like one. Words like “chat” or “roundtable” indicate a less-formal presentation. Also, know how your platform works. If it won’t automatically refresh for early-arriving attendees, add a chat message to advise them to refresh the screen regularly so they don’t miss anything.

Anyone who has ever been in a clinical role in a hospital is used to hearing “The Joint Commission requires it” about policies that may or may not be subject to Joint Commission review. The Joint Commission recently released an update that clarifies its position on using secure texting for patient information and orders. Organizations can use that modality for orders as long as the information is secure, encrypted, and captured in the EHR with timestamps and author information. This brings The Joint Commission into line with CMS policies, although having providers enter orders directly into the EHR remains the best practice for order entry.

A friend clued me in to Spacetop, an augmented reality laptop that is under development and is available for reservation. Along with “the first spatial OS designed for productivity,” the G1 model is priced at $1,900 and will start shipping in October. Prescription lenses for the retro-looking glasses are included, although I would be more impressed if it included technology where the user could input the details of their eyeglasses prescription and have the system adjust the visuals automatically. It advertises a 100-inch visual canvas with a form factor that “fits a standard laptop bag with the glasses safely stored in hardcover.” The glasses include speakers and microphone for use during online meetings, although unless I’m interacting with a bunch of users with the same device, I think that would seem a little strange. If the company is looking for beta testers, I know a sassy CMIO who would love to give feedback.

From LaSalle Gal: “Re: MyChart. My health system sent me an email recommending that I turn on all the notification settings. Although it had technical instructions for toggling the notifications on, it seemed like a missed opportunity to educate patients on what it means to receive notifications, especially for patients who may not want to see test results before they receive a communication from their physician.” I reviewed the original email and I agree. It would have been easy to insert a sentence or two about how the organization releases results along with instructions for suppressing notifications that you don’t want to receive. I also thought this section was funny: “Even if a toggle is already green, you might not have all notifications turned on. To make sure all notifications are enabled, just switch each toggle off and then back on.” That doesn’t instill confidence to this user that the settings are accurate and functional. I’d be curious to see data about how many patients may have accessed the communication preferences settings in the weeks after this communication was sent.

Based on my comments about certain clinicians struggling with handwritten orders during downtime events, another reader sent this piece from NPR’s “Shots” blog that addresses the benefits of writing by hand. It summarizes some of the benefits of handwritten work, including better letter recognition in children and better conceptual understanding of material when adults take notes by hand. I own a set of amazing medical student notebooks from the 1920s (thanks, eBay!). It’s interesting to imagine the student sitting there, jotting his thoughts about the fact that “we are really just starting to understand the mysteries of the thyroid.”

Pet peeve of the week: the phrase “building an organizational muscle.” At best, it makes me think of bodybuilders oiled for competition, and at worst it reminds me of an old drug company ad for a diabetes medication that anthropomorphic characters such as Hungry Muscle, Burned-Out Pancreas, and Upset Stomach. (Side note: in trying to remember what the drug was, I discovered that you can buy the Hungry Muscle plushies online, so I know I didn’t imagine it. I also learned that there is a thing called the Medical Advertising Hall of Fame.) Whether you’re building an organizational muscle for change, for quality, or some other buzzword, there are better terms: “a culture of change” or “a commitment to quality” come to mind.

I spent part of the morning being a patient at my local health system. For the most part, the information I provided during the online check-in process was used, including an update to my health history and a review of systems. They required a new scan of my insurance card, however, even though I’ve had another appointment within the last 30 days and the card was scanned then. The receptionist also asked me the standardized COVID exposure questions that were appropriate several years ago, including whether I had any international travel within the last year or the last 30 days. I’m not aware of any recommendations for travel screenings in healthcare environments, so it felt like an organization that just isn’t staying current. It made me wonder how often the organization is reviewing its patient experience, as well as its ability to keep current with infectious disease recommendations.

How often do you reassess your patient registration and check-in processes? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/10/24

I have a lot of friends who work in the healthcare technology vendor space, and they are always curious to know my thoughts about health system priorities. A lot of them are on the sales side of their respective organizations and are trying to meet quotas, figuring out how they can get a hook with the health system executives that make purchasing decisions.

Of course, when they ask my opinion, they get just that. I can only comment based on the health systems that I know and the conversations that I’ve had. Priorities can vary based on community and regional factors, as well as based on specific challenges that a given organization has faced in recent months, such as cybersecurity incidents, labor challenges, and natural disasters.

McKinsey & Company recently released a report that looked at the investment priorities of health systems. AI always makes the list as something that organizations think will help in their transformation efforts, but it is unclear how much individual systems are investing in those technologies. McKinsey cites a 2023 working paper from the National Bureau of Economic Research as stating that machine learning could result in reductions of healthcare spending of up to $360 billion. However, McKinsey notes that while the majority of respondents to its survey say they are making digital transformation a priority, they also report challenges in resource allocation and planning.

In looking at data on already implemented capabilities, top priority areas include virtual health, revenue cycle management, digital front door, acute care throughput, and ambulatory care efforts. Leaders who were surveyed reported that those areas that might have the biggest impact include AI at the top, followed by virtual health and digital front door.

It’s interesting to see that the most impactful area fell lower on the spectrum of implemented technologies and roughly middle-of-the-road in being ranked as “unplanned” by leaders. From my discussions with leaders, it sometimes feels like AI isn’t being planned for in the same way as other technologies because of overall uncertainty in how to approach it.

The McKinsey survey gathered data on barriers to executing digital and AI transformation in the next two years. The item most commonly earning a number one ranking was “budget or capital limitations,” followed by “legacy systems are difficult to upgrade.” I was surprised that “unaware of the right digital solutions available” scored so low, with only six of 200 respondents ranking it as number one. That makes me wonder if those surveyed really believe that or if they’re just not admitting how challenging it is to find the right answers to some of the sticky situations that they are facing.

The report goes on to recommend five ways that health systems can evolve, including embracing the cloud, building partnerships, cautiously moving to AI, looking beyond off-the-shelf solutions, and changing up how they operate. For the latter two, they offer advice that I’ve been giving healthcare organizations for two decades now. Their example for looking beyond available solutions involves optimizing workflows “to enable more appropriate delegation” in order to save on nursing costs.

Process improvement advocates have been pushing the idea of delegation for years, yet I still regularly encounter physician offices that don’t have delegation policies for medication refills or scheduling overrides. I continue to see organizations that refuse to use proven strategies, such as data-driven float pools for staffing. Maybe now with the idea of technical enablement for delegation, as mentioned in the piece, people will get on board since adding technology often makes things appear more exciting.

As far as the recommendation to operate differently, the article calls for structures with “flatter, empowered, cross-functional teams,” which management consultants have been pushing for as long as I’ve been in the industry. In thinking across my career, I’ve probably only worked on three truly empowered teams the entire time. Too often, I see teams that are withering due to micromanagement and barriers they can’t seem to remove, such as absent organizational support, questionable corporate values, and lack of funding for key resources.

I asked a friend who is a health system administrator to weigh in on the recommendations. She agreed that many organizations need to get back to basics and to focusing their efforts on initiatives that might not seem sexy but that are needed to help build a strong base after the challenges of COVID. These include things like making employees feel valued, providing adequate resources for training and onboarding, and having a dedicated focus on removing the barriers that keep teams from meeting their objectives.

She told me a story about an operating room utilization project that another part of her organization worked on for months, crunching data about supplies, staffing, and room turnover rates. Despite recommendations from their on-the-ground process improvement staff, leaders wouldn’t negotiate with other departments to make frontline operating room staff available for interviews or workflow mapping activities.

It’s hard to fully understand a problem when you’re just looking at data and not talking to the people who do the job day in and day out. And if you’re not talking to the stakeholders, you definitely can’t get their buy-in or their support for your proposed changes.

The process improvement team was frustrated by the leadership barriers and their inability to make progress. They ultimately spent six months and who knows how much money designing a solution that made people feel disenfranchised, which automatically reduced its chances of success from the moment it was announced. After a failed pilot, the organization reopened the project and figured out a way to remove the barriers, with the team performing a significant amount of rework as they were able to get the input of those with the greatest knowledge of the process.

What would the outcome have been if the team had been empowered to do the job they were trained to do in the first place? In addition to providing process improvements six months sooner, they would have had the satisfaction of knowing that their expertise was respected and that they were treated as valuable members of the organization. I wouldn’t be surprised if the members of that team are a retention risk over the coming months, and anyone who has had to crunch staffing numbers knows that it’s always more expensive to replace someone then to use resources that you already have in place.

What do you think about the McKinsey survey and report on organizational investment priorities? Do their findings match what is happening where you are? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/6/24

ONC is seeking feedback on a recent white paper that highlights its vision for Health Equity by Design. The organization is formulating strategies to reduce healthcare disparities by including health equity throughout the creation and implementation of health IT policies, programs, and workflows. The approach aids in identifying gaps and disparities and creates an environment where “technology itself anticipates, avoids, and reduces, not exacerbates, health disparities.” Additional outcome goals include mitigating systemic inequities and improving person-centered decision-making, implementing population health interventions, and strengthening public health. Comments can be provided through June 10 at 11:59 p.m. ET.

Having worked in emergency and urgent care settings for the majority of my career, I’ve seen how the lack of easily accessible mental health services adds to overcrowded waiting rooms and delays patients from receiving appropriate care. A recent initiative in Oklahoma equips police officers and Certified Community Behavioral Health Clinics with IPads for telehealth visits, helping reduce the number of emergency visits and hospitalizations for mental health issues. More than 30,000 devices have been deployed to the field, allowing faster patient interventions in a less resource-intensive manner.

Police officers no longer have to wait with patients at the emergency department, and patients have a shorter wait time for lower-acuity care that better matches their needs. The statistics are impressive – a 93% reduction in inpatient hospitalizations for mental health crisis over a six-year period, and $62 million in savings. The program has expanded to provide IPads directly to behavioral health patients, further reducing the need for costly interventions. I hope other states, counties, and cities take note of this program and consider implementing it in their own areas.

A project for one of my clients led me to dig into the new final rule from the Office for Civil Rights (OCR) and CMS that is designed to prohibit discrimination in AI based on data points such as age, gender, race, and ethnicity. It’s great to have regulations, and this one in particular brings 558 pages of PDF joy, but it’s unclear how this will be enforced. AI bias can be difficult to detect, and when identified, there’s a chance that organizations will be subject to their own biases in determining how to address it. The presence of a formal rule opens the door for whistleblowers and reports of problems from end users, which should help keep the industry honest.

One of the important elements in the rule is the definition of the term “patient care decision support tool” as “any automated or non-automated tool, mechanism, method, technology, or combination thereof used by a covered entity to support clinical decision-making in its health programs or activities.” That definition encompasses everything from EHR-embedded AI clinical decision support to paper checklists found at the bedside, and everything in between. Hopefully this will serve as a catalyst for organizations to ask some questions about tools they have in place or are considering, including reviewing the data being used to trail the model or validate the tool, making the tool’s decision-making process transparent, identifying how people will be involved in the implementation and monitoring of tools, and describe the steps that will be taken if there is a suspicion that harm has occurred.

With that in mind, it’s timely that Epic Systems has released a new “AI Trust and Assurance Suite” that is designed to help clients test and monitor their AI models. According to announcements from Epic, the software is designed to automate data collection and mapping and to ensure consistency. Since one can’t really see Epic’s documentation unless one is an Epic customer (or someone violates all kinds of rules by slipping one a copy,) it’s unclear how this tool will work for the numerous Epic clients who have custom fields and their own unique ways of using data.

Epic says it will release the tool’s monitoring templates and data dictionaries as open-source software this summer, which should help clients who have custom AI models or who are using tools from third parties. Still, that’s a significant burden on clients who will have to analyze the tool and its functions carefully. I doubt many organizations have analysts budgeted to address it, so we’ll have to see what the speed of uptake looks like.

I’ve been mentoring a resident physician who is considering a fellowship in clinical informatics. One of our recent conversations was around the role of generative AI in academic pursuits. Most organizations I have encountered have come to the conclusion that they can’t prevent students from using the latest and greatest digital tools, but that guardrails need to be in place to preserve academic integrity. Oregon Health & Science University Professor William Hersh, MD has a clear policy for the “Introduction to Biomedical & Health Informatics” course that provides guidance to students. Key points include that generative AI systems can be useful tools but should not be used to substitute one’s own knowledge; and students can ask generative AI systems for content, but final responses — including those in discussions, quizzes, tests, and term papers — should reflect the student’s “own thinking, judgment, and language.” It is also noted that students shouldn’t shortchange their learning by relying on generative AI, and that the need for a fundamental core of knowledge and understanding is needed by practitioners in the field.

Pediatric dermatology researchers are celebrating their victory over ChatGPT as detailed in a recent study that looked at accuracy rates on board-type questions. They tested ChatGPT versions 3.5 and 4.0 using questions from the American Board of Dermatology as well as “Photoquiz” questions from the journal Pediatric Dermatology. Although ChatGPT 4.0 gave human pediatric dermatologists a run for their money in some areas, the humans outperformed both versions overall. Researchers call on clinicians to understand the tools and how they might be helpful in practice.

The Institute for Safe Medication Practices has released additional guidance on actions needed to prevent drug name selection errors when facilities are using automated medication dispensing cabinets. Although vendors have taken steps to improve their products, some features require a customer to opt in to the newer safety features through manual configuration or software updates. The Institute is calling on vendors to support dynamic search functions and standardized medication names, and for care delivery organizations to educate staff, analyze workflows, and require indications for certain overrides.

I spent some time this week helping teach CPR to a local youth group. Attendees were amazed at how much easier it looks in movies and television. Some of the participants were smaller physically and couldn’t generate the force needed to do effective compressions, but they were great at recognizing the signs that CPR is needed and demonstrating how to take charge of a scene. If you’re not certified in CPR and use of the AED (automated external defibrillator), consider taking a class. At minimum, consider learning about hands-only CPR from our friends at the American Heart Association and identifying where AEDs might be kept in your daily travels. Bystanders recently initiated CPR at my local Costco. Will you be ready if the time comes?

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/3/24

I use HIStalk as a primary source for healthcare IT news as much as the next person, so I was interested to see the recent Morning Headlines call-out about Google’s AI Overviews. I had seen them pop up in searches, but didn’t think too much about them since the last couple of weeks have been a whirlwind of meetings and deadlines with travel to a conference sandwiched in the middle.

I had a little bit of downtime this weekend and was planning to use it to complete my mandatory Maintenance of Certification questions that I have to do every quarter to maintain status with my specialty board. The online quarterly questions are open book and you’re allowed to use online resources. Normally I use well-trusted sites such as the United States Preventive Services Task Force, various professional journals, and UpToDate to research the answers if I don’t know them outright. This time, I decided to use Google to see what it would come up with.

Due to the honor code involved with the quarterly questions, I can’t share the exact queries that I did during the project, but I’ll share the results of some questions that recently came up related to continuing medical education quizzes and conversations with colleagues.

Asking Google how much calcium I should be taking in each day resulted in the AI overview that displayed the same data that appears on the website of the National Institutes of Health’s Office of Dietary Supplements. It showed values by age range and sex, since Google wouldn’t necessarily know how to define “I” in the query. However, asking it for tips on selecting the best blood pressure intervention for a female patient with a blood pressure of 200/90 didn’t provide an AI Overview. (UpToDate won that one, hands down, with multiple articles addressing the topic.)

The recommendations for breast cancer screening in the US recently changed. I asked Google for the current mammogram guidelines and was greeted with four sponsored results and then a result with a link to the US Preventive Services Task Force site, so that was a plus since it was a direct link to the primary source material. Of the sponsored links, the one from Mercy wasn’t even about mammograms, but rather a promotion for its multi-cancer-screening blood test. Another one of the sponsored links, from a local fitness organization, was last updated in 2020 and provided incorrect information. As a clinician, I was pleased to find that the search for “are COVID vaccines bad” returned two websites from the Centers for Disease Control and Prevention followed by one from Johns Hopkins Medicine.

I then turned to more routine primary care questions, such as “do I need penicillin for sore throat” and was pleased with the information the AI overview provided, including that “antibiotics only help with bacterial infections, not viral infections” and “most sore throats are caused by viruses , such as the common cold, and will go away on their own within a week without treatment.” It went on to suggest reputable home remedies including rest and gargling with salt water as well as links to appropriate articles from UpToDate, GoodRx, and the National Library of Medicine.

I also asked, “what is a sinus infection” and although the information that returned was appropriate, I was thrown by the weird punctuation and capitalization that came with it: “Sinus infections can be caused by a number of things, including: An inflammatory reaction, Allergies, A code that doesn’t get better or gets worse after 7 to 10 days, and Smoking.” Even my Microsoft Word editor function caught that one and didn’t want me to send it along to Mr. H. I was pleased that it got the Oxford comma right, however. The AI Overview blurb also included some solid home remedies, such as reducing stuffiness by drinking lots of fluids, using nasal saline spray, and putting warm wet washcloths on the face.

By this point, I was fairly enthusiastic about some of the responses, since they included basic self-care items that a lot of the patients who come to see me in emergency and urgent care settings don’t seem to know. I see too many patients who present for care without having tried any kind of remedies at home, so I asked a tricky one: “Should I treat my child’s fever?” I see a fair number of parents who don’t give their children any fever-reducing medications when they are sick, under the pretense that they didn’t want to treat it because they “wanted the doctor to see how high it was.” Speaking generally for the physicians in my generation, unless your child is an infant or has one of a few chronic health conditions, we trust your use of a thermometer and want you to give your child some acetaminophen when they have a fever because it will help them feel less miserable.

The AI overview was spot on, advising caregivers to treat a fever “if it’s making them uncomfortable or preventing them from drinking fluids.” It also advised that treatment might not be needed for toddlers and children who are eating, drinking, playing, and sleeping normally. Sometimes I see children who are running fevers, but zooming around the exam room eating Cheerios and drinking apple juice, so this kind of information might have saved parents a $50 or $100 co-pay as well as prevented a couple hundred dollars in overall costs to the healthcare ecosystem. The overview was followed by links to content from UC Davis Health, Stanford Medicine, and Cleveland Clinic, so I felt good about the overall results of the search.

From there, I asked Google for symptoms of abdominal aortic aneurysms, and received an AI Overview. The second item on the list of symptoms, a pulsing sensation in the abdomen, can also be completely normal. The overview then recommended that anyone with the symptoms listed “should see your doctor as soon as possible.” In reality, if someone is having symptoms from this condition, they need to be in the nearest emergency department because it can be a life-threatening emergency requiring immediate medical management and the potential for emergency surgery. I’d give that particular response a D-minus if not an F since the potential for catastrophic consequences is high.

I asked the question again in a different way: “Do I have an aortic aneurysm?” and was told that “many people with aortic aneurysms don’t have symptoms until the aneurysm ruptures” and had to scroll off the screen to see any kind of recommendations for evaluation or care, so on the overall topic of aneurysms I would give Google an F.

In summary, I thought the technology did decently well for basic questions that I deal with every day, although it bobbled a little on the aneurysm question. Given the lack of basic health education in many communities, including how to treat minor illnesses and injuries, Google’s AI Overviews might be a nice step towards improved health literacy. It certainly makes the “finding” health information component easier, especially for patients and caregivers who might not know how to access the website of a local health system or other respected health information organization. It also did pretty well on the board certification questions, although some of them were more specific and therefore didn’t generate an AI overview. I’ll give the tool a solid B-plus as today’s grade but will keep an eye on it to see how it does in the future.

Happy Birthday, HIStalk! Congratulations on officially being old enough to buy a round of drinks. As is fitting for a publication created by anonymous people across the country, I celebrated with pastry for one. Healthcare IT has evolved in ways that I never dreamed it would, and I’m happy to have been along for the ride with HIStalk.

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EPtalk by Dr. Jayne 5/30/24

I was talking to a colleague this week. We had a stroll down memory lane about the changes that have happened in the healthcare technology sphere during our tenures in the industry. I had made a comment about “doing electronic healthcare records since before Meaningful Use was a thing” and the conversation just spiraled from there.

We’ve seen practices opt out and take the penalties for non-participation, and we’ve seen practices overhaul themselves trying to get the most out of the bonuses. We’ve also seen a lot of organizations in the middle of that spectrum that just seem perpetually lost because they struggle to keep up with everything that’s going on in the regulatory world.

For those organizations in the swirl, the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) registration is open for the 2024 practice year. Organizations that plan to report an MVP can register through December 2, 2024 at 8 p.m. ET. That seems a bit of an arbitrary choice on the time and date to close out registrations, but I’m far from being the clock or calendar police. Organizations that plan to register should identify the MVP they plan to report, whether they’re going to use the Consumer Assessment of Healthcare providers and Systems (CAHPS) for MIPS Survey, and the population health measure they would like to be evaluated on. There are several other decision points, such as participating as an individual versus group versus subgroup, so if you’re not familiar with all of that, it might be time to do some reading.

I haven’t heard much about data being used in this way, but Vanderbilt University Medical Center is using data to identify outlier clinicians who are receiving a high number of patient complaints. Once the physicians are identified, trained physician peers review the data and provide feedback that is targeted towards behavioral modification. The program has lowered malpractice claim costs for the identified physicians by 83%. Although the work at Vanderbilt was only done in orthopedic surgery, it would be interesting to see how similar initiatives might pan out in other specialties. I’m curious how other organizations might be using patient complaint data – it’s not something I hear much about in the informatics community.

Speaking of data, I can’t wait to see some actual research on this new solution. Crescent Regional Hospital in Lancaster, TX has deployed a solution that creates life-size holograms of physicians in patient care areas, “creating an immersive, engaging, interactive experience.” It sounds exciting and all, especially when the hospital CEO uses the word “teleport” to describe what is going on, but other than being in 3D and requiring specialized equipment, it’s a very fancy video visit. It is being described as a “non-touch” visit rather than a virtual visit or video visit. I’d love to see a head to head study comparing this type of solution with in-person care and non-hologram virtual visits. I suspect it will score similarly to the latter, although there’s a potential for it to score worse if there are technical issues. I wholeheartedly support the use of video / virtual care, especially in areas where it’s challenging to recruit clinicians, but I can’t help but remember something else that creates an “immersive, engaging, interactive” environment – live physicians.

Depending on the specialty, some departments have been slow to integrate virtual care into everyday practice. A recent submission in JAMA Pediatrics looks at the incorporation of clinician-to-clinician e-consults within pediatric care organizations. Ideally, it would allow primary care physicians to collaborate with subspecialists about the care of a particular patient. However, researchers found rates for the under-18 population that were significantly lower than other patient groups. The authors note key areas that need to be addressed in order to expand the use of the modality: specific payment mechanisms, EHR interoperability, operational processes, consent, privacy, and patient engagement. It will be interesting to look back at this topic in a few years and see if advances have been made.

As I was wrapping up my recent trip, the idea of innovation labs was a hot topic. Apparently Atrium Health is building a 20-acre “innovation district” in Charlotte, NC that includes research buildings, a residential tower, retail shops, and a hotel. It will surround the medical school that is planned for the area.

Plenty of large health systems have innovation centers or programs. I’ve heard of them ranging from high-performing units that can create and commercialize solutions to buzzword-friendly boondoggles. One of my drinking buddies shared a feature from The Hustle that suggests that the innovation lab concept has lost its sparkle. Examples of non-healthcare innovation labs that were cited in the piece include Estee Lauder and Microsoft “to infuse AI into your beauty routine (whatever that means)” along with Major League Soccer, Mars (home of M&Ms and Snickers), Sephora, and Visa.

That particular edition of The Hustle also included a blurb about a startup (BrainBridge) that wants to transplant a human head onto a donor body within eight years. They plan to use high-speed robotic surgeons and AI algorithms to make it all work (of course there is AI!) The blurb links out to an article in the New York Post, so that’s something right there. I’d love to hear what actual neuroscientists think about the potential for this.

My buddy also shared that the edition mentioned that Firefox recently resolved a software defect that was opened in March 2000 for the Netscape Navigator product. I had a 15-year relationship with a software company once, but generally gave up on defect fixes once the requests hit the five-year mark. Kudos to the team for closing the loop on this one.

I’m back in the cicada zone this week, and I’d be lying if said I wasn’t eager for them to finish their life cycle and have the next generation burrow back into the ground. They are projected to decrease in my area in mid-June, but work travel will take me to places where they might continue well into July. I try to dodge them when I’m out for a walk or a run, but it’s amazing how loud it can be when one of them hits your windshield at high speed. Good luck, little critters, we’ll see you again in 13 years.

What is your cicada-palooza experience? Are you fascinated by it or ready to be done with it? Or tired of hearing the Eastern half of the US talk about it? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/23/24

I’m reporting this week from the AMIA Clinical Informatics Conference in beautiful downtown Minneapolis. Although I usually prefer to be in the great outdoors, I must say I’ve enjoyed being in the city and having zero cicadas flying in my face compared to what I’m used to at home. AMIA wins the best badge ribbons title hands down and has something to meet everyone’s needs for pop culture references.

The conference has been filled with great sessions and plenty of networking opportunities. It’s been nice to see people who I rarely see in person and to make new contacts. Of all the AMIA meetings, this one focuses the most on applied informatics. I’ve already jotted down several pages of helpful tips for upcoming projects. 

Speaking of jotting notes, I’m glad that the included AMIA pen writes smoothly, because it’s been a long time since I’ve taken notes by hand. I appreciate the workshop sessions that have had table setups because it makes it much easier to manage your notes or laptop as well as any snacks or drinks you might have with you.

I also heard some great quotes that were worth making note of. One of my favorites so far is, “People who are into tech aren’t always into communication.” This resonates with anyone who has encountered detailed instructions for electronic devices that don’t take into account the fact that end users aren’t necessarily engineers. Another quote in the patient safety realm was, “Pharmacists don’t break rules, so if they’re doing it, you know you’ve run off the rails.” I was also excited to hear two people at the poster session and reception discussing something they had read about in HIStalk, which always makes my day.

One conversation between sessions included anecdotal reports about what is going on inside Ascension hospitals during their ransomware-inflicted downtime. Someone with inside knowledge mentioned a situation where younger members of the staff were unable to read the cursive handwriting used by some clinicians. My local public schools stopped teaching cursive around 2008 or so, causing some entertaining moments at family birthday parties as the youngsters try to read their grandparents’ handwriting in greeting cards. Cursive or not, physician handwriting has been the butt of jokes for decades, and poor penmanship can result in significant medical errors. Something for hospital and healthcare delivery organization leaders to consider as they’re reviewing and revising their downtime plans.

Back to Ascension, the organization is providing updates on a state-specific basis. I noted these nuggets from the Wisconsin section: Ascension retail pharmacies remain unable to fill prescriptions and patients have been asked to “bring notes on symptoms and a list of current medications, including prescription numbers or bottles.”

Lawsuits related to potential HIPAA violations have been filed on behalf of Ascension patients in the US District Courts of the Northern District of Illinois, Western District of Texas, and Eastern District of Missouri. I couldn’t find information on the other two, but the one from Texas appears to be a class action. Buckle up, Ascension, it’s going to be a wild ride.

As far as cyberattacks and downtime are concerned, the Workgroup for Electronic Data Interchange (WEDI) sent an eight-page letter to the Department of Health and Human Services highlighting the vulnerability of the US healthcare system and the need for greater oversight and improved business continuity planning. It asks for a new Office of National Cybersecurity Policy led by a “Cyber Policy Czar” and a National Health Care Cyber Fire Drill Week. Regarding the latter, organizations would be charged to work not only with internal systems, but with “critical trading partners” to test systems and define contingency plans. I’m happy to dust off my high-visibility Incident Command vest for the occasion, I just need to find some snappy shoes to go with it.

From Hybrid Curmudgeon: “Re: Dell flagging employees that aren’t coming back to the office as much as they’re expected to. How degrading.” Apparently, Dell is aggregating the data from VPN usage and in-person badge swipes to assign color codes for employees to make it clear how much they are working in the office versus from a remote location. Workers are expected to be in-person for 39 days each quarter. Starting this month, workers will receive weekly updates via the company’s HR platform and will be assigned a color (green, yellow, or red) based on respective time in the office (regular, some, limited). Top performers with a consistent presence in the office will be flagged in blue. I’ve worked in organizations where a variety of indicators are used to identify employees to be placed on the block for the next round of cuts, and this is just one more piece of data to add to those matrices. Nine box talent grids, anyone?

Speaking of talent, one of the hot topics among CMIO types this week was the challenge of retaining talented clinical informatics staffers when they’re partnered with physicians who need to move across the country either for training or for improved job prospects. Allowing staff to work remotely would be an easy fix, but I understand the reluctance of health systems to want to deal with multi-state employment law and payroll regulations. I still find it humorous that these same systems will outsource their IT departments, sometimes outside the US, but won’t make accommodations to retain successful team members.

I also heard some discussion about the number of burned-out physicians who are trying to cross into clinical informatics as a “way out” and the political implications of having them appear in the hiring process. It sounds like some are claiming that they’re “in clinical informatics” because they’ve used an EHR in their career, despite the lack of deeper knowledge of healthcare information systems or the processes and governance needed to sustain them.

My outbound flight for the conference had a mechanical issue which led to a delay of about an hour. Although passengers weren’t thrilled, I didn’t hear a lot of people voicing concern about connections, so that’s a good thing. At least it wasn’t an issue like the one that occurred recently when a United flight from Zurich to Chicago had to divert when a passenger’s laptop was swallowed up by a business class seat. The crew was unable to retrieve it, and due to the risk of fire with lithium-ion batteries, the flight landed in Ireland. The ensuing chain of events, including the inability to access the laptop from anywhere but through the cargo hold, led to a crew time out and an overnight stay for passengers.

What’s the strangest maintenance delay you’ve experienced on a flight? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/20/24

We’ve all heard about so-called “quiet quitting” and other strategies that employees are using to try to cope with less than ideal workplaces. There is plenty of literature out there on organizational culture and time management, so I thought I would share a couple of the most intriguing things I’ve come across in the last few weeks.

One concept has been referred to as “intentional inflexibility,” which seems to be a fancier way of saying that you protect the time you need to get your work done and to perform your best. This could mean that you decline meeting requests if they are for your most productive times of the day, or that you refuse to be constantly accessible via email, messaging, app, or text. Maybe it’s letting emails sit for a couple of hours until someone else replies to them, or maybe it’s only checking your email twice a day and hoping that churn has already occurred before it gets to you (viewing your emails as a conversation is particularly effective for this approach).

One has to be careful of company culture when applying this approach, however, because an employee “having good boundaries” might be interpreted as not being a team player.

A related article was about having a sense of false urgency at work. I’ve been in situations where people text you to find out why you haven’t responded to their Slack message, when the overarching reason is that you’ve been on three hours of back-to-back calls dealing with acute issues. I was once hounded by a member of the marketing team about “what is your favorite movie” since that was part of a project around getting to know the executive team. He had sent it on a Saturday, I hadn’t responded by Monday afternoon, and he was on a deadline. Expecting turnaround on an item like that in under one business day definitely falls under the banner of false urgency.

As a member of senior leadership, I was happy to have a conversation with the marketing leader about realistic deadlines and the need to coach the team about how to interact with other members of the C-suite. Of course, this kind of issue could also have been avoided by having a communication policy that addressed how to identify urgent requests versus non-urgent requests and how to know what an appropriate turnaround time is for different types of interactions. One company I worked for had a policy that if you needed an answer within 24 hours, you had to call the person with your request. It made people think twice about how urgent a request might actually be before making their move.

Another idea I’ve been reading about is that of organizational drag, which is when teams lose productivity due to policies and processes, whether formal or informal, that waste effort and decrease output. This includes being required to attend meetings that should have been emails and spending time reading emails that shouldn’t have been sent in the first place. It can also refer to wasteful processes, such as time and attendance tracking that could be completed in more simplified ways.

I’ll never forget when one organization I worked with migrated to a well-known project management and time tracking platform. The build was so much more complicated than it needed to be and added hours each week to the tracking requirements for consultants. Consultants make money when they’re billing clients and not when they’re manually keying extraneous data. Despite the immediate negative impacts, it took over a year to get the system optimized.

I’m also re-reading “Out of Office: Unlocking the Power and Potential of Hybrid Work.” I know I’ve mentioned this one before, but after working a couple of consulting gigs in in health systems across the US, some of the content is resonating differently than when I first read it. In one of the early chapters, the book addresses how “just in time” staffing became the norm in organizations today, even though in reality it means relative understaffing, since you don’t have any surplus capacity if you’re taking that approach. When you’re understaffed, people are reluctant to take time off or to use their time off to its maximum, especially when they fear that teammates will have extra work dumped on them, or that they’ll have to do a mammoth clean-up effort when they return to the office.

Having managed large teams during my career and especially having managed teams whose time is billable, it’s important to understand what overhead goes into just being an employee. These are the nonproductive parts of a job and may include items like corporate compliance training (HIPAA and fraud, waste, and abuse anyone?), maintaining proficiency and certification on different software platforms, managing professional licensure, and learning the tools that are needed to perform your job, especially when your employer decides to rip and replace those tools while you’re still expected to be productive.

Particularly in organizations that are trying to be intentional about company culture, you have to bake that time into capacity management as well. If you’re having multiple monthly all-hands meetings, socials, and mixers that you expect people to attend, you need to account for those. All too often, I still see management teams overlooking how initiatives like this directly impact workers, especially if they are on teams that are hanging on by a thread.

I worked on one team where the manager planned to have a holiday party with the theme of decorating miniature Christmas trees. First off, there was no recognition of the fact that not all employees celebrated that particular holiday, and that even if they did, that decorating trees was part of their tradition. Then there was the fact that this gathering was set for an entire half day during the end-of-year push that many healthcare organizations feel if their fiscal year follows the calendar year.

There was a lot of grumbling about the event and the organizer was frustrated by the low level of RSVPs. Several of us staged an intervention and convinced her to call off the event and instead to have a post-holiday party to blow off steam after the year-end close was done. Rather than a gift exchange, employees were invited to bring a ridiculous item to swap, either something that they received as a gift or just had around the house and didn’t need or want, with any leftover items being taken to a charity drop-off site.

We all got a laugh out of the unlikely items, especially when someone actually wanted them, and people who wanted to de-clutter were thrilled to get rid of things. Did it end up 180 degrees from where it started? Yes, but it was exponentially more well received.

What trends are you seeing as far as how employees are trying to navigate ever-changing workplace conditions? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/16/24

I was back in the patient role this week, visiting a different hospital for my annual MRI. I was glad that the high-risk clinic at Big Academic Medical Center offered me the option to have it done at a branch hospital, which shaved 30 miles off my travel.

The hospital is relatively new. Each person coming in is greeted personally and their appointment is searched in the system to make sure that accurate wayfinding directions are provided. When I arrived at the radiology waiting room, there was a check-in line backed up due to a patient who was confused about whether he could go home or not.

Once the line cleared and I made it to the desk, I noticed that there was a sign inviting people to check in via the kiosk, but unfortunately the sign had been completely blocked by the long line of waiting patients. Additionally, looking at the situation with a process improvement eye, I noticed that the kiosks were on the back wall of the waiting room – functionally behind you as you came in – so you weren’t likely to see them.

Part of my check-in involved a paper MRI screening form on a clipboard, so I’m not sure the kiosk would have helped anyway. I haven’t gotten a pacemaker, deep brain stimulator, or other implants since yesterday when I completed my online check-in, so I’m not sure why those questions couldn’t have been formulated into a patient questionnaire that I could have completed while in my pajamas.

The study went smoothly and I slept through a big part of it, which is a plus considering how noisy an MRI can be. The noises were a little different than I’m used to because it’s a different machine, and the last sequence sounded a bit like the cicadas that have descended on my area.

When the technician returned to the room to free me from the scanner, she said she noticed on my chart that I’m a physician and asked where I practiced. I talked about my work in virtual healthcare, and that I work from home for the most part. She said she thought that was cool, but when I mentioned that it probably wasn’t applicable to working in radiology, she said I would be surprised.

She mentioned that since the scanner manufacturer is based in Germany. The process for scanning patients there has more physician involvement. They actually have protocols for remote scanning, where the physicians operating the machines work from either a control center or from their homes. This facility recently piloted it, and although results were good, it relied heavily on having a certain level of support staff at the bedside that doesn’t match up with how roles are defined in the US. Additionally, the hospital felt that there was too much liability for it to be successful in our current environment, so the pilot concluded with a determination that more investigation is needed.

I always enjoy having a serendipitous moment like this and learning something new. But as far as other opportunities discovered on this visit, if you’re a radiology director, you might want to visit your waiting rooms and assess the positioning of signage and kiosks. 

HIMSS has opened its call for proposals for the 2025 conference, encouraging potential presenters via email to “lead conversations and make waves.” One could have some marketing fun with the “make waves” idea if the conference were held somewhere near a large body of water, such as San Diego or New Orleans, which would be welcome additions to the venue rotation in my opinion. Instead, next year’s event is in the desert, which doesn’t really apply.

Regardless, the email prompted me to go ahead and make my hotel reservation since Las Vegas hotels are often disgustingly expensive. I usually stay at The Palazzo and was sad to discover that even 10 months in advance, not a single standard suite was available on the Wednesday of the conference. I tried different occupancy types to confirm and had no luck. It just seemed weird. Maybe they are saving all of those for exhibitors rather than attendees? Nonetheless, if you’d like to submit a presentation, you can do so through June 10 at 5 p.m. Central time. In the mean time, I’ll stick with the two queen beds and see if any of my friends want to cost share since the room wasn’t cheap.

I’m always on the lookout for practical applications of AI technology that cut through the hype that currently swirls everywhere. This write-up from Missouri S&T caught my attention, especially a photo caption that had an electrical engineering graduate student looking through a dermatoscope to learn more about skin cancer since his team was working on solutions to improve detection. Joe Stanley, PhD is a professor in computer engineering and recently received a $440,000 grant from the National Institutes of Health on a project that will tag existing skin photographs then employ machine learning to expand the usefulness of existing data.

Given the fact that the solution will be used by physicians, it’s critically important that those developing it understand what goes on in a medical office and how physicians use data and tools to care for patients. There are far too many solution development teams out there that don’t take this vital step, so kudos to this one for helping researchers better understand the field they’re trying to improve.

Another headline that caught my attention this week was about a hospital getting rid of passwords for nurses. Unfortunately, it was a mindless blurb about transitioning from passwords to a badge reader system on an innovation unit. I’m not sure how innovative or newsworthy that really was since we had that at my primary hospital sometime in the neighborhood of 2016 and I’m sure it was at other places before that. Must have been a slow news day at Becker’s, or maybe just a diligent placement effort by a solid marketing team.

I heard from a reader this week who has been forced to participate in his company’s Return to Office program despite the fact that none of his team works in the local office. Apparently the company is trying to promote “new, exciting offerings in the cafeteria” to reduce the sting of coming to the office three days each week. The day’s offering was heavy on salami, onions, and other aromatics that I’m sure would make people prefer to be on a video call afterwards than in an in-person meeting. The office also issued guidance on how employees should communicate with family when they’re stuck at work at the end of the day, encouraging them to just say that they are delayed without hinting that meetings are running late or that anything is less than perfect at the company. That’s just about the worst micromanagement I’ve seen, and I’ve seen a lot.

What’s the worst micromanaging tactic that you’ve experienced from an employer? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/13/24

I have friends who work for Ascension. The concerns coming out of their facilities, which are offline due to a ransomware attack, are quite serious. It sounds like they haven’t done adequate downtime preparation, let alone preparation for a multi-day incident that has taken nearly all of its systems out of commission.

Mr. H reported in the Monday Morning Update about a patient who left one facility because it had been two days and he still hadn’t been seen by a physician. This is completely unconscionable. I hope regulators step in immediately.

Any hospital leaders in any organizations who are not aware of the current ransomware and cyberattack landscape should be removed from their positions of authority immediately. Hospitals need to be drilling for the eventuality on a regular basis. Not annually, but monthly.

I’ve written about this before, but one of the most serious near-misses of my career, which to me will always be a full miss, occurred during an EHR downtime, when the environment in my facility can only be described as chaos. No one knew where the downtime forms were. They were reluctant to engage downtime procedures due to a misplaced fear of “having to fill out a bunch of paperwork” that is required when they formally call a downtime.

I was working in what was essentially a freestanding emergency department at the time, although it was licensed as an urgent care. Due to that licensing, we could have easily stopped taking new patients while we got things sorted. However, the fear of repercussions from management was too great. They continued to bring patients into the exam rooms, leaving the clinical teams scrambling.

Once I found out what was going on and that we were still taking new patients, I called the downtime and demanded we stop bringing in new patients. There’s no need to worry about diversion, EMTALA violations, or turning people away when you’re not licensed as an emergency facility. I’ve been around long enough and practiced in enough challenging environments, including in a tent and out in the field with no support, to know that sometimes you just have to take charge.

Shame on these facilities that are putting patients at risk through lack of planning, lack of leadership, and focusing on the bottom line instead of focusing on the patients who are in front of them. I hope they’re providing counseling for the clinical team members who are experiencing profound moral injury as they are expected to continue to just do their jobs in an untenable situation. One person who reached out to me described it as a “battlefield” situation.

For those of you who are in administrative positions, I urge you to walk to the front lines in various clinical departments in your facility and start asking questions about downtime. It’s not enough to simply trust the reports that are coming out of planning committees and safety assessment committees. My free consulting advice: you need to put your proverbial boots on the ground to find out whether people know what to do or not. It’s not enough to perform phishing tests and to look at the reports that show that people are becoming less likely to click on sketchy links or to visit dodgy websites. People have gotten really good at watching those cybersecurity videos and picking the correct answer on a bland, five-question test.

What you need to know, though, is that when push comes to shove and someone has taken control of your infrastructure, do your employees know how to see patients? Kind of like when you’re drilling for an inspection by The Joint Commission and you expect everyone to be able to explain the PASS acronym for how to use a fire extinguisher (Pull, Aim, Squeeze, and Sweep for those of you who might not be in the know) you need to ensure that everyone knows how to successfully execute a downtime.

Back to PASS, though. Knowing the acronym isn’t enough. Does your team even know where the fire extinguishers are? If a random person came up to them during a time when there was no inspection, could they verbalize where to find them? A downtime is no different. All staff should be able to articulate what are the conditions that require that a downtime be called, how to initiate a downtime, the various roles of the team during downtime, how to find the “downtime box” or whatever supplies they need to use, what the downtime communication plan is, and how to manage critical patient care tasks in the near-term while the entire downtime procedure is put into place. 

Every single healthcare facility needs to know how it will handle a multi-week downtime. News flash: no one is immune to this, and anyone who thinks otherwise needs to seriously reevaluate their leadership readiness. Our facilities need staffing plans to help workers cope with prolonged downtime, including adequate double-checks and safety procedures to account for the loss of systems we’ve all grown to rely on, such as bar code medication administration (BCMA), allergy and interaction checking, and electronic time-out checklists.

At this point, and especially after the Change Healthcare debacle, no one has any excuse for keeping their heads in the sand and thinking, “It couldn’t happen to me.”

This weekend marked the opportunity to cross something off my bucket list without having to leave my home state to do it. The raging Level 5 geomagnetic storms are the first to hit Earth since October 2003, which was a time when I was knee-deep in building my practice and didn’t know a solar cycle from the citric acid cycle. Being involved in amateur radio for the last several years has taught me quite a bit about the former, and every day that I move farther from medical school has allowed me to forget more details about metabolic cycles than I care to admit.

As a “science person,” I’m happy to see this month’s expanded Northern Lights phenomenon capture the attention of so many people. I personally learned that the aurora comes in all different colors besides the most-often featured green. I hope there are children being inspired by it and considering future careers that involve exploring our universe and all the fantastic phenomena around us. Kudos to my favorite college student for capturing this amazing pic.

Were you able to see the aurora, or do you still have a trip to the northern latitudes on your bucket list? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/9/24

The American Medical Informatics Association is working with the Patient ID Now Coalition to persuade members of Congress to reject language in Section 510 of a 2025 appropriations bill that continues to ban the US Department of Health and Human Services from investing money towards a national unique patient identifier.

Organizations are still using a hodgepodge of matching algorithms that often work, but sometimes don’t. There are particular challenges with pediatric patients when organizations include phone numbers in the algorithm. Infants who might not yet have a Social Security number are also at risk. I’ve seen EHR conversions that inadvertently combined a pair of infant twins due to inadequate matching algorithms, so I would very much like to see a unique patient identifier even if it’s voluntary and patients have to opt in. The risks to patient safety remain great and I want my care teams to have access to all of my data.

Also in Congress, the House Ways and Means Committee is entertaining a two-year extension of Medicare telehealth rules that have improved reimbursement since the COVID-19 pandemic. There are multiple bills under consideration, including the CONNECT for Health Act and the Telehealth Modernization Act. Without an extension, the rules will expire at the end of this year. Primary care docs are leaving my state’s rural areas in droves, and increased coverage would allow patients to have visits with physicians in other areas of the state without driving for multiple hours.

I’m so used to working in high-reliability organizations that it shocks me when I encounter an organization that probably should be more high-reliability than it is. I was at a large regional post office this morning, and apparently they had experienced a power outage and the electricity had just come back on. There was one customer at the counter and two in line, so the postal employee announced what had happened and asked for our patience as they rebooted the systems. It took a few minutes for her station to come back up, and when the customer was ready to check out, apparently the credit card machine didn’t work. She was sending several registered mail items, so went out to her car to rummage for cash or a checkbook.

The employee suspended her transaction and called me to the window, making an announcement to the dozen or so people that had accumulated in line that the credit/debit machine was down and that they could only take cash or check. Everyone behind me turned and left, and I was grateful that I had my friend Andrew Jackson in my wallet, although I haven’t carried a checkbook in decades. One would think that the US Postal Service would be critical infrastructure and have at least some level of UPS backup (uninterruptible power supply of course, not the competition) with generator backup. They can deliver despite rain, heat, and gloom of night, but a power outage is going to put a dent in things.

I’ve been a panelist for several Women in STEM events and am always on the lookout for ways to increase the number of girls interested in healthcare and technology careers. During a recent talk, one of my co-panelists talked about “The Scully Effect,”  which shows that women who watched “The X-Files” were more likely to pursue careers in STEM-related fields. According to 2017 data, 63% of study respondents who were familiar with the Dana Scully character admitted an increased their beliefs in the importance of STEM.

Many of the young women I work with weren’t alive when Gillian Anderson began playing Dana Scully in 1993, so it will be interesting to see who will be STEM role models for newer generations. Media popularity now seems to be centered on TikTok and various social media influencers, many of whom share unscientific and downright dangerous content. I’d love to see a campaign to raise awareness about the roles available to women in healthcare IT, since I’ve run across multiple medical students who didn’t have a clue that it was a career path.

Federal regulators in the US are taking a greater interest in the issue of organizational consolidation in healthcare. They’ve opened comments looking to understand “the effects of transactions involving health care providers (including providers of home- and community-based services for people with disabilities), facilities, or ancillary products or services, conducted by private equity funds or alternative asset managers, health systems, or private payers.” You can browse the submitted comments (1,400 so far) and see how frustrated patients, physicians, and other providers are with our healthcare non-system. Hot topics in the comments I screened include lack of competition, greed, hospitals requiring pre-operative labs to be done in-house at a higher cost than competitive labs, the negative effects of companies like CVS expanding their scope of business, and compromised patient care. All the talking heads in healthcare should have to understand comments like this one from Lindy:

I am a retired home health caregiver, as well as an American citizen who lives below the poverty line financially. It has been a lifelong struggle for me to access good healthcare, and it is only getting worse. Corporations are by design intended to maximize profit, and in the health care field, this translates into sacrificing the good of a human being for the profits of a corporation. Every human being should be prioritized over profit, failing that is to put money over humanity which degrades us all. How can it be that dollars are more important than a mother, a father, a child who is suffering and in need? It is cruel, heartless, and inhumane on every level. It is time to put the genie back in the bottle, prioritize human beings over dollar signs, and prevent moneychangers from having the ability to dictate who lives or who dies because of money. America must be better than that, and corporations must be kept in line with humanitarian priorities.

It’s National Nurses Week, so here’s a shout-out to all the nurses out there who are caring for patients day in and day out. Special props to my nurse informaticist colleagues, who have taught me so much about thinking about systems from different points of view.

Of course, there are still hospital executives behaving badly as they attempt to show gratitude to the people that make their facilities run. One example of a tone deaf gift choice was sent to me by a nurse in the Midwest. The hospital gave nurses lunch boxes, which felt particularly insulting to night shift workers since the facility removed all hot food service for them. They also require workers to use self-checkout for prepackaged items on the night shift. The only overnight worker is a cook who is doing prep work for daytime workers, who still have full food service, including salad bar.

It sounds like managers suspected that the gift wasn’t going to be well received and provided these adorable badge reels plus breakfast out of their own pockets.

What’s the most irritating thank you gift you’ve received from leadership? Leave a comment or email me.

Email Dr. Jayne.