EPtalk by Dr. Jayne 4/6/23

As a clinical informaticist who has been around the block more than a couple of times, I know I have more knowledge than the average physician about how EHRs work. As an informaticist who has spent the majority of her career working with large health systems and healthcare delivery organizations, I also have a good knowledge base for all the ways organizations can be set up and how they manage their relationships with physicians in their communities and in affiliated academic institutions.

I’m a member of a couple of groups on social media that help physicians navigate issues with their EHRs. I enjoy helping people find solutions for their issues or at least helping them figure out who in their organization to approach for help. It’s kind of my way of giving back, since I didn’t have a lot of help when I started out in the EHR world and I remember how helpless I felt.

A number of large organizations have extended their EHRs to community partners, and nationwide organizations provide hosted versions of various EHRs to smaller practices. I’m working with someone who just joined a two-physician practice that is on one of these hosted systems, but has no idea how to get help. Part of the problem is that she joined an existing practice that expects her to just take things on faith, even when they’re not working correctly (like when she hasn’t seen financial reports since the 2022 year-end close). The situation is complicated by the fact that the organization has given cutesy names to various EHR initiatives and modules that don’t actually align with the names given by the EHR vendor or standard terminology like “practice management system.”

For a while, none of us could figure out what EHR she was on until the group got her to send a screenshot of her login screen. She doesn’t have access to any vendor resources or education outside of what is offered through her partner health system’s learning management system, which she mistakenly thought was actually offered by the EHR vendor. The office manager is stonewalling, saying that the physicians aren’t allowed to talk to the EHR liaison. 

Although I understand trying to have a local support structure in place to keep physicians from calling about things that could be handled by their office managers or super users, there seems to be a huge disconnect. Most of the large healthcare delivery organizations I’ve worked with that have these kinds of community offerings also have a designated physician liaison to work with the community physicians and make sure their needs are met, and that doesn’t seem to be happening here.

I’m hoping that we can help her figure out ways to learn how to work more efficiently in the EHR as well as ways to work with her practice leadership to make sure they’re not just taking advantage of a new physician fresh out of training who doesn’t yet know the right questions to ask. Unfortunately, most residency training programs don’t include any kind of education in the business of managing a medical practice or in trying to manage colleagues or navigate the minefields of hospital medical staff politics, so I’m hoping we can at least help her a little.

I critique the emails that I get from vendors prior to conferences, but I have to give full credit to Merative for their appropriately themed email promoting Merge Imaging solutions. The subject line was “It’s 106 Miles to Chicago…” and the email opened with “It’s HIMSS… and we’re wearing sunglasses. Hit it!” The Blues Brothers were iconic during my formative years and the musical numbers from the film are some of my favorites. Chicago isn’t my favorite location for conferences, but I always love a good Blues Brothers throwback, so thanks to the team at Merative for making a tired CMIO smile at the end of a long day.

I recently had to change my phone number and the process has caused chaos with some of my online accounts and loyalty programs. I was interested to see that Panera Bread is testing Amazon’s biometric technology at its bakery-cafes, specifically with palm scanning. Customers can scan not only to link their orders to the loyalty program, but to pay for them as well. The technology is already being used at Whole Foods locations along with some sports venues. Although some people are skeptical of giving up their biometric data, using facial recognition to unlock phones is commonplace so it’s hard to argue against palm scanning. Panera is resting at two locations in St. Louis and plans to expand use to up to 20 sites over the next few months.

It’s not about healthcare IT, but all of us are patients at some point in our lives. From a patient perspective, this research article in JAMA Internal Medicine caught my eye. The authors look at more than 200 new drugs approved in the US from 2017 to 2020 and how they were approved (or not approved) in other countries. More than 20% of the drugs weren’t approved in Australia, Canada, or the UK “due to unfavorable benefit-to-risk profiles, uncertain clinical benefit, or unacceptably high price.” Unsurprisingly, the median cost for these medications in the US was more than $115K per patient per year, with some being over $230K per patient per year. As the old saying goes, follow the money.

One of my favorite CMIOs sent me this MIT Technology Review article about how to break the cycle of being hooked on our devices. The highlight reel — screen time isn’t always bad, and sometimes we just need to do some mindless surfing. However, understanding how engaging with the digital world is making us feel can be valuable. Setting boundaries around digital time can be helpful, and developing new things to do when bored can help break the cycle of digital dependence.

I’m a big fan of that last piece of advice. I’ve always been a big reader and usually carry a book if I’m just around town or my Kindle if I’m on a plane. I’m a member of a couple of book clubs that have forced me to read some things that are outside my usual comfort zone. I’ve enjoyed it, plus it’s a good way to force yourself to disconnect. I still have the guilty pleasure of doing the Wordle every morning, but I don’t think that’s going to be too many people’s downfall.

What’s your favorite online time waster? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/3/23

I was glad to flip the calendar to April this weekend. Travel, conferences, and a couple of big projects have had me hopping.

Other than going to HIMSS, I get to stay close to home this month. In addition to work responsibilities, I’ve had a couple of big projects at home and was able to put one of them to rest this weekend. Of course, there are always more things to work on, but it was a good feeling to know that it was done and I could move on to something else. Unfortunately, the project I picked up next turned into a bit of a mess. I was hoping to have it done before next weekend, so I’ll be working double time in the evenings to try to get it done.

To the positive, I discovered that the book I’ve been hustling to finish in time for tomorrow’s book club isn’t actually due until the following month, so that was an unexpected bonus. The book, “Demon Copperhead” by Barbara Kingsolver, is one of the most challenging books I’ve read in a long time. It’s fiction, but a big part of the plot revolves around the growth in high-volume prescribing of opioid pain killers and the resulting devastation across parts of the US. The book features a broad cast of characters – the pharmaceutical representative who assures physicians that the medications aren’t addictive to patients with legitimate pain, the well-meaning country doctor who prescribes liberally, the drug dealers who take advantage of patients who have become addicted, and the family members who have to cope with the aftermath.

It’s also a scathing portrayal of the foster care system and those who abuse not only the process, but also the children in their care. Those sections were difficult to read and I’m sure they would be triggering to many. It’s also the story of a child in crisis who grows up to be a teen who encounters crisis after crisis, and just when it looks like he’ll make it out the other side, tragedy strikes. As a physician who has cared for patients in some of the situations portrayed, I can’t imagine what it would be like to be confronted with so many and in rapid succession. Although I feel a sense of accomplishment at having finished the book, I’m not sure I would have read it if it hadn’t been chosen by my book club.

From a healthcare IT perspective, it’s always a slow news time in the lead-up to HIMSS. Companies save up their news to release it at the beginning of or right before the conference, when there is always the potential that it will get lost among other “big” news stories.

I don’t have a sense of how large HIMSS will be this year. The organization is notoriously quiet about discussing its projected attendance and I haven’t even heard any rumors this year. Last year’s event was a shadow of itself, and after attending some of the competing conferences, I understand how they are more attractive to attendees than the granddaddy. At least this year I haven’t seen HIMSS promoting its less-than-useful Accelerate platform in the lead-up to the conference. In fact, I’m not sure I’ve heard anything about Accelerate at all in the last year.

Last Thursday was National Doctors’ Day in the United States. It dates back 90 years to its first celebration in Winder, Georgia. Although the day was designed to recognize physicians for their work with their patients, their communities, and society, it happens on March 30 as a commemoration of the date in 1842 when Dr. Crawford W. Long used ether anesthetic for the first time. It became a national holiday in 1991.

This year seemed different for many of my physician colleagues, with little recognition even after the difficult years of hard service during the pandemic. One of my emergency department friends found it ironic that her hospital distributed the Doctors’ Day snacks via a lounge that the ED physicians were unable to access because they didn’t have the right permissions on their keycards. That contrasted mightily with the week of celebration that one of our mutual friends experienced, with breakfast on Monday, lunch on Tuesday and Wednesday, a dessert buffet on Thursday, and gift baskets of Girl Scout cookies on Friday.

As far as tangible gifts are concerned, it seems like most of the people that received something physical received an item with the hospital name or logo on it, including umbrellas, backpack coolers, and some less than thoughtful items like stress balls. One colleague posted a picture of the elegant wooden cutting board she received from her hospital, which given its 12×17 inch size, seems like an interesting choice. Other celebratory options included chair massages, gift cards, aromatherapy supplies, and the always popular visit by the therapy dogs. Several of the physicians I talked to said they planned to pass on some of the gifts to their staff members, who don’t often get recognition if they’re not nurses or other professionals with designated recognition days.

My hospital solicited patients to give financial gifts in honor of their care teams, while giving the actual physicians zero recognition, not even an email. I realize that I’m a community physician and not employed by the hospital, but I thought it was tacky that I received the solicitation email (I’m also a patient) but not any other kind of greeting. Several of my residency colleagues reported having a similar experience, although two eventually did receive emails but they arrived well after 3 p.m., making them seem like an afterthought.

I was surprised that I didn’t receive emails from some of the big hitters that should be celebrating physicians in the US, like the American Medical Association or even my own specialty societies. In an informal poll in one of my physician-only Facebook groups, less than 30% received any recognition at all. That’s surprising given the number of physicians who are thinking about cutting back or leaving the workforce.

The bottom line is that it’s not about the gifts or the meals or the puppy petting zones. For many physicians, it’s about feeling like their hospital administration appreciates them and the work that they do for patients. Each person in the hospital – whether they’re in engineering, housekeeping, food services, supply chain, pharmacy, or any of the numerous other roles – has a critical role in helping patients and it’s important to make sure that everyone feels like their organization appreciates them, especially after the struggles of the last three years.

What would make you feel like your organization appreciated you? Leave a comment or email me.

Email Dr. Jayne.

ViVE and CHIME Wrap Up with Dr. Jayne 3/30/23

It was another busy couple of days at the conference. I had the opportunity to walk the show floor with a couple of friends yesterday and today as well as to hit a couple more sessions.

Overall, I liked the conference better than HLTH. It wasn’t as in your face trying to be cool as HLTH, but it was well organized. The exhibitor booths are all formatted the same way, depending on size and a couple of other factors, and I found it made for a less-distracting trip around the show floor. It’s less glitzy than you see at HIMSS, but it felt like it was easier to visually scan a booth. A vendor I spoke to said they like the setup because it helps level the playing field and also makes it easier to get the booth up and running compared to all the packing and unpacking at some other shows.

I’m still not a huge fan of having sessions on the show floor, but understand how it came to be. None of the panels I attended were jaw-dropping, but I had low expectations and wasn’t disappointed.

I thought the food service was better at HLTH, especially the grab and go options. At ViVE, the meal lines seemed long regardless of when I tried to eat during the scheduled blocks. On Monday, I ended up at the CHIME member luncheon that was held upstairs. It was a quieter venue to have a solid conversation with one of my colleagues about some healthcare IT problems I’m trying to solve.

CHIME provided several other networking opportunities, but my favorite was the CHIME League of Women luncheon on Tuesday. The program’s theme was “Mentorship in Action” and included a mentor-mentee pair among the speakers. The comments of panelist Kris Nessa from Innovative Insights really resonated with me. Kris was talking about the community of CIOs and other execs that has come together through CHIME and how the relationships and support have helped lift a lot of people up and encourage the development of the next generation of healthcare IT executives.

It made me think about the early days of my career, when our health system’s CIO was intent on crushing the IT project I was working on because it was being led by the operations group with IT support as opposed to being run by IT. He made it clear that he didn’t think clinical people should be working on IT projects and seemed particularly hostile to the women on the team, despite the fact that we were going live with some bleeding edge technology that ended up being the subject of numerous conference presentations. Thinking back, it’s likely he viewed innovation as a threat.

I’ve never had a non-clinical mentor. The conversation made me wonder what my career might have been like if someone from the technology side had taken me under their wing. I hope that in the current phase of my career I can be helpful to those working their way up the ladder or trying to break out of a mold that they might not have chosen.

Dr. Nick van Terheyden @drnic1 and I stopped by the Health 2047 booth to ask what it was all about, since “helping early-stage startups transform bold ideas into healthy returns” sounds interesting. It’s actually an initiative of the American Medical Association, and the year is tied to the anniversary of the founding of the AMA rather than the timing of any bold initiative.

Nomi Health’s booth reps were engaging. In addition to sharing the local favorite Goo Goo Cluster candies, we had a great conversation about the design of their booth and some of their ideas for enhancing it. I admire the knowledge or marketing folks. There’s so much more to color, graphics, and flow than most people appreciate.

CoverMyMeds was sponsoring haircuts, blowouts, and makeup applications. If you timed it right, you could get all fancied up then head over to the DrFirst booth for a complimentary headshot.

Speaking of DrFirst, their team did not disappoint, with matching shirts. Apparently they had matching shoes earlier in the week, but I missed those.

The Best Shirt award definitely goes to Perx Health’s VP of marketing. I think he said it was from Australia, and he was a great sport to pose.

The costumes at Teletalk reminded me of HIMSS of yore, when lots of exhibitors tried to be as catchy as possible. The boots were nice also.

The Best Shoe/Sock Combo was found at the Intelligent Medical Objects (IMO) booth. They’re always a strong contender in this category, and I can’t wait to see what they have in store for HIMSS. Since it’s local to their home base, folks might not even have to be choosy when they pack.

Hyro’s Whac-A-Task booth was a hit. I’ll have to use this pic to explain to some of my younger colleagues who never had the pleasure of playing the original Whac-A-Mole game.

Saving the best for last, Liberty Solutions hosted a bourbon tasting at their booth. They were giving solid advice on the characteristics of the different options, which makes sense given the fact that they’re a consulting firm.

The closing bash was a concert with the Black Crowes at the Wildhorse Saloon, although I preferred the opening group Chapel Hart. They were clearly having fun with their performance. The entire event was sponsored by Clearsense. From where I was standing on the second floor, I could see the decibel meter and it was interesting to see how it got louder as the night progressed.

I ducked out early but not before spotting the ultimate bedazzled ViVE jacket. Everyone seemed to have a good time, although threading my way through the crowds on Broadway as I headed back to the hotel seemed more like a contact sport than a walk.

On Wednesday, I had a little more downtime than planned at the Nashville airport and was glad to take advantage of some of the local food offerings that were better than the generic fare you find at most airports. Although the airport is undergoing construction, it didn’t feel chaotic. I decided to walk off some of the southern hospitality I’ve experienced this week with a lap through all the concourses. At the end of the A gates where some of the more commuter-type carriers arrive, I spotted some workers looking out the windows and acting generally giddy with excitement. It turns out that a Boeing 777 aircraft was diverted in from Atlanta last night and they were watching it being moved on the tarmac. Several of them couldn’t get over how large it was (towering over the other planes) or that a small tug was pulling it around the airport. Sometimes you just run across things that make you smile and I was glad to be part of that moment.

I wrangled the email beast and played catch up on the plane and was glad to see that the FDA has cleared the opioid overdose reversal drug Narcan for over-the-counter sales. Overdoses are a major problem across the US and we’re seeing lots of accidental ingestions by children as well. Hopefully removing the prescription hurdle will make a difference for people. I had to provide the date of my last COVID booster on a form I was completing, so I popped into my patient portal to confirm the dates. I was surprised to see a recommendation to schedule a flu shot. The flu season is long over in most of the US and I’m also current with a vaccine documented in the portal. It also recommended that I schedule my mammogram, and I’m current on that as well.

Alert fatigue is real and applies to patients as well as clinicians, and inappropriate reminders just encourage people to click through without reading. I’ll have to ask my IT friends at that institution what they’re trying to solve for with those reminders, which weren’t there a couple of weeks ago.

What aggravates you the most about your patient experience in patient portals? Leave a comment or email me.

Email Dr. Jayne.

From ViVE and CHIME with Dr. Jayne 3/27/23

This week I’m in Nashville to experience the combined event that is CHIME and ViVE. I didn’t attend ViVE last year, but I heard stories about it, although Miami might have provided a different vibe than Nashville. 

Speaking of, it’s been some time since I’ve visited. Nashville has undergone some dramatic transformation in the last decade. The downtown Broadway-adjacent areas are chock full of party buses, pedal pubs, and bachelorette parties, at least on a Saturday night. Fortunately, I had a local guide for the evening, and after tapas downtown, we were able to avoid the tourist traps in favor of more interesting neighborhoods with plenty of local color.

It’s amazing to see all the new construction being interspersed with cute bungalows and historic features. It seems to work better in some areas than others, although the real estate prices are pretty high for things that are going to be torn down anyway. Germantown was a neighborhood that caught my eye and we’ll have to plan for extra time there on my next trip. Saturday night was also a quest for the best Old Fashioned cocktail, with the barrel-aged version at the Black Rabbit winning hands down.

Sunday kicked off with registration at the Music City Center. It was a low-key process with no lines. Swag was fairly standard, with a conference bag, water bottle, and mints, with an optional hat. Among the goodies in the bag was a reusable drinking straw from Lirio. I’m a huge fan of reusable straws at home, but I’ve never used them when traveling. If I decide to do so, the little carry bag is a plus.

Then it was back across the street to check in with the CHIME side of the conference, which was even more laid back. I was able to connect with a colleague over breakfast and also make some new friends, so that was a plus. Today was a day for CHIME Foundation members to host focus groups, and there was quite a bit of traffic for the offerings. My first experience with the focus groups was last fall. I found them to be a valuable way to hear about some of the challenges that other organizations are facing and how they’re dealing with addressing them. After hearing some of the stories told in the groups, you feel like you’re not alone.

I attended a couple of focus groups today, and although they were great for networking, the sessions themselves were a bit of a mixed bag as far as content. The attendee evaluation sheets are supposed to include stated goals for the focus groups. One group I attended didn’t seem to have stated goals and the presenter nearly lost control of the group. The discussion veered way off topic, but that conversation still delivered some learning. Namely, that if you get a bunch of CIOs, CTOs, and CMIOs in a room, you never know quite what you’re going to get.

Another group that I attended used an audience polling tool, not only to gather information, but to make sure the participants were engaged. I liked that strategy. Because of the way the polls were constructed, it was clear that they had spent time pre-session to determine what they were trying to achieve with it and how to get the information they wanted. The way the meeting rooms were positioned brought in lot of street noise that was occasionally distracting.

I managed to get out in the afternoon to enjoy the sunshine. I enjoy looking at historic buildings and downtown Nashville doesn’t disappoint. Plenty of buildings have interesting details and there are lots of historic markers around town that I didn’t see when I was out last night.

There are plenty of sassy shoes and boots out on the streets of Nashville, but I wasn’t able to capture pictures without seeming like a creeper. I didn’t have a wing woman with me at the time to act like she was posing for me while I surreptitiously captured a pic of the shoes in question. If you didn’t bring your own boots, there are several boot shops close to the convention center, so there is still time to pick up a souvenir. From there, it was back to the room to do a spot of email, and then on to the CHIME welcome reception.

The reception was hopping, although there was a bit of a check-in process for those of us who didn’t have the right symbol on our badges to indicate that we were CHIME members rather than just ViVE attendees looking to score some appetizers. The crowd was a veritable Who’s Who of healthcare IT, but it was so dark I couldn’t be on the lookout for shoes. The accessory of choice was apparently the light=up cowboy hat that came in black, blue, pink, white, or yellow. One attendee was even spotted wearing one of each color, which seemed excessive, but hey, when in Nashville, you do you.

The lights came on at 7 p.m.and they started moving people out, which coincided with the start of the ViVE opening reception proper. The event was packed. I ended up peeling off for a dinner date, but from the reports I received, I didn’t miss anything earth shaking. If you were there and have something different to report, please let me know.

Because I’m often blogging on the road, I travel with two devices to ensure that there are no questions about inappropriate use of my employer’s resources. My trusty Surface Pro 4 has served me well for more than six years. It has  been nice to carry as my secondary device because it’s not only small, but has great resolution and all the features and functions of a laptop. It also has the Surface Pen, which is great for my drawing-intensive hobby.

Unfortunately, my Surface has started having some battery issues and runs a little hot. I decided to look at options for a replacement. If it gave up the ghost on a trip it wouldn’t be the end of the world since everything I do is backed up to a cloud solution, but when I have free time, I usually don’t think about spending it to shop for hardware. I got a popup on my device today about considering a trade in, and decided to walk through the process just for giggles. My trusty pal has served me well, but apparently it’s worth less than a tank of gas as a trade in. I’ll hang onto it until it fully dies because the value of having a backup device in case of emergency is worth much more than 40 bucks.

If you were replacing an aging Surface Pro, what would you buy? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/23/23

People are always asking me how I’m reacting to various things in the news. I was saddened last week to see that Pear Therapeutics is searching for ways to remain viable. They were one of my favorite finds at HIMSS22.

Unfortunately, I don’t think frontline physicians really understand what Prescription Digital Therapeutics (PDT) products are and how they differ from recommending that a patient just download an app. PDTs have to be approved by the US Food and Drug Administration before they can be marketed for patient use. Pear has treatments for substance abuse disorder, opioid use disorder, and insomnia that are clinically proven to provide benefit to patients.

For the technology to make it to patients, however, it has to be prescribed by a licensed clinician, and many clinicians are simply overwhelmed. It’s challenging to get them to learn about new drugs, let alone entirely new paradigms. If someone knows about PDTs, they have to identify appropriate patients, then prescribe the solution. A prescription transmission goes to the PDT company, which then has to fulfill it. In Pear’s case, by providing an access code that allows the patient to download it from Apple or Google Play.

Once the patient begins using the tool, the clinician receives notifications through a prescriber dashboard and can monitor patient progress. It’s not unlike prescribing a medication. The intervention still requires monitoring and follow up by the prescriber, and patient adherence can be an issue. I hope Pear Therapeutics finds what they’re looking for and can continue the good work that they are doing.

I also received some questions about the potential for telehealth use to mitigate the unfolding tragedy in pediatrics, namely, the increase in all-cause mortality for children in the US. A research article published in JAMA last week looked at the increase in child and teen deaths that began pre-pandemic but worsened during last few years. The largest increase in pediatric mortality in 50 years is being led by injuries, which include motor vehicle accidents, overdose, homicide, and suicide. All of them were on the rise prior to 2019, with suicide being on the rise as early as 2007. Even children from ages 1 to 9 had increases in death rates. Infants younger than 12 months were the only ones spared. The article summarizes some of the racial disparities that accompany the rise in mortality, with non-white children being the most impacted.

When talking with people about potential interventions or solutions, everyone says “telehealth” as if it’s a magic bullet. Although telehealth can reduce the burden on families who are trying to get their children help — through easier access, reduced driving, etc., — the reality is that there simply are not enough therapists to go around. Social workers and others who deliver telehealth therapy are leaving the field at an alarming rate. Policy makers need to go deeper and look at the causes of increased mortality. Nearly half of the increase in 2020 was related to firearms deaths, which were the leading cause for children aged 1 to 19 years.

The article points out that nearly all the gains that have been made in pediatric longevity over the past few decades are being erased by “bullets, drugs, and automobiles.” So much for improving outcomes with asthma, vaccine-preventable diseases, premature birth, and the like. I continue to come across parents who bury their heads in the sand about what is going on with their children and who seem shocked when the physicians caring for them suggest that they need to talk to their middle schoolers about sex, drugs, and guns. Frankly, by middle school, it’s a little late for a lot of that, depending on who your kids run with, but as family physicians and pediatricians, we’ll keep trying. We can throw some telehealth at it as well, but it’s a much bigger issue than the majority of people understand.

Several people have also asked for my reaction to “The Match,” which is the National Resident Matching Program. It’s the multi-month mating dance where medical students try to figure out where they will continue their training through internship and/or residency, and where training programs figure out who their workforce will be for the next several years. There were some huge shakeups in Match data this year, with emergency medicine taking a serious hit. It was bad enough that the American College of Emergency Physicians and other organizations issued a joint statement about the specialty’s prospects. It cites “workforce projections, increased clinical demands, emergency department (ED) boarding, economic challenges, the impact of the COVID-19 pandemic, and the corporatization of medicine, among many others” as reasons leading students to choose specialties other than emergency medicine.

I’m not an emergency medicine physician, but I’ve spent the last 17 years of my career practicing alongside EM physicians in the emergency department and high-acuity urgent care settings. The specialty has been absolutely dumped on during the last three years. If you don’t know what ED boarding is, that means that when there aren’t enough beds in the hospital to admit new patients (usually because of nursing or other staffing shortages), those patient stack up in the emergency department. Depending on the facility, often the emergency team has to care for them. Sometimes it’s bad enough that patients are even discharged from the hospital after a multi-day stay without ever going to a regular room.

That’s not what EM physicians signed up for, and it’s not their particular skillset. When primary care practices shut down due to COVID, everyone went to the ED and the urgent cares. Some physicians were seeing 80-100 patients each shift, while other physicians shut down. It was brutal, and the things we saw were horrific. The moral injury from having to ration care still haunts many of us. The sense of powerlessness that most of us felt for weeks grew to months and into years with little relief. Some of us are still coping with the symptoms of post-traumatic stress disorder, and a lot of us have left the profession.

For those frontline healthcare IT folks who have been trying to support the emergency department through all of this, you’ve seen it and understand why students don’t want to choose a career in the emergency medicine trenches. Thank you for your patience and compassion when we were frustrated day after day and the technology seemed like just one more thing causing torment. For those of you who haven’t seen this, or who haven’t been a patient lately, the downstream effects of this Match will ripple through our health systems for years to come. Ultimately patients will continue to bear the brunt of the mess that is the US healthcare system.

Would you encourage your child or loved one to pursue a career in medicine? What about healthcare technology? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/20/23

I was hanging out with one of my favorite computer science students over the weekend and ChatGPT was a hot topic. He has been working on a group project, and someone who didn’t have a partner asked if they could join the group by way of an email that was clearly AI generated. The first couple of sentences weren’t too bad, but then the email started laying it on thick with comments about how hard the new member planned to work and “rest assured I will do my best” type syntax which isn’t typical of the age group.

Since this student has access to better AI toys than I do, I decided to have some fun. A lot of people in my life know that I write for a blog but they don’t read it or really know what it’s about, so I wondered what generative AI thought about my alter ego: 

Tell me what you know about the writing style of Dr. Jayne HIStalk.

Dr. Jayne HIStalk is the pseudonym of a physician who writes a popular blog about healthcare information technology. Her writing style is characterized by a unique blend of humor, wit, and incisive analysis of industry trends.

Dr. Jayne often uses anecdotes and personal experiences to illustrate her points, and she is known for her ability to distill complex concepts into clear and accessible language. Her writing is often critical of the healthcare industry and its shortcomings, but she also offers practical suggestions for improving healthcare delivery and patient outcomes.

Dr. Jayne’s writing is also notable for its use of pop culture references, particularly to science fiction and fantasy, as well as her ability to inject humor into even the most serious topics. Her style has been described as irreverent, thought-provoking, and engaging.

Overall, Dr. Jayne HIStalk’s writing style is distinctive and engaging, and has helped to establish her as one of the most influential voices in healthcare information technology.

I felt like that write up would be useful for the back of a book, should I ever write one. I think it sums up what I’ve been up to for the last 13 years, although it seemed a little schmoozy with the compliments. Since physicians are starting to use ChatGPT to write everything from prior authorization forms that help patients get medications approved to school and work notes excusing absences, I decided to see if I could get it to do my work for me.

Write 500 words in the style of Dr. Jayne HIStalk about the value of telehealth.

Dr. Jayne here, and today I want to talk about the value of telehealth. With the rise of digital technology, telehealth has become an increasingly popular method of providing healthcare services. Telehealth, also known as telemedicine, is the delivery of healthcare services through digital communication technologies such as video conferencing, remote monitoring, and mobile health applications.

Telehealth has become especially important in recent times due to the COVID-19 pandemic. The pandemic has forced many healthcare providers to pivot to telehealth in order to continue providing care to their patients while minimizing the risk of transmission. This has led to a surge in telehealth usage, with patients and providers alike recognizing the many benefits of this approach.

One of the main benefits of telehealth is increased access to healthcare services. Telehealth allows patients to receive care from the comfort of their own homes, eliminating the need to travel to a healthcare facility. This is particularly beneficial for patients who live in rural or remote areas, where healthcare services may be limited. Telehealth also allows patients to receive care outside of traditional office hours, making it more convenient for busy individuals who may not have time to visit a healthcare facility during regular business hours.

Another benefit of telehealth is improved patient outcomes. Telehealth allows for more frequent monitoring and communication between patients and their healthcare providers, which can help identify potential health issues early on and prevent them from escalating. Telehealth can also improve patient education and self-management, empowering patients to take a more active role in their own healthcare.

Telehealth can also lead to cost savings for both patients and healthcare providers. By eliminating the need for in-person visits, telehealth can reduce healthcare costs associated with travel, parking, and time away from work. Telehealth can also reduce healthcare costs associated with hospital readmissions, as frequent monitoring and communication with patients can help prevent complications and ensure timely interventions.

Finally, telehealth can improve provider satisfaction by reducing administrative burdens and improving work-life balance. Telehealth can eliminate the need for providers to spend time on administrative tasks such as scheduling and paperwork, allowing them to focus more on patient care. Telehealth can also provide more flexibility in terms of scheduling, allowing providers to work from home or outside of traditional office hours.

In conclusion, telehealth is a valuable tool for providing healthcare services in today’s digital age. Telehealth offers many benefits, including increased access to care, improved patient outcomes, cost savings, and improved provider satisfaction. As telehealth continues to grow in popularity, it will be important for healthcare providers and policymakers to work together to ensure that telehealth services are accessible, affordable, and of high quality.

Although it’s an accurate essay, it doesn’t seem to incorporate anything specific from a stylistic standpoint that makes this feel like a sassy HIStalk blog versus a middle school essay. I decided to ask it about the pitfalls of telehealth to see if using a less positive topic would allow it to pull in some humor, pop culture references, or particular insight:

Write 500 words in the style of Dr. Jayne HIStalk about the pitfalls of telehealth.

Telehealth has become increasingly popular in recent years as a way to provide medical care remotely. While telehealth has many benefits, including increased accessibility to healthcare, reduced travel times, and greater flexibility for both patients and providers, there are also several pitfalls to consider.

One of the biggest challenges of telehealth is the lack of in-person interaction. While video conferencing and other forms of remote communication have come a long way in recent years, there is still a sense of distance that can make it difficult to establish a rapport between patient and provider. This can be particularly challenging for patients with complex medical needs or those who require a more personal touch.

Another challenge of telehealth is the potential for misdiagnosis or missed diagnoses. Without the ability to perform a physical examination, providers may miss important signs or symptoms that could indicate a more serious underlying condition. In addition, there may be technical issues that could impact the quality of the video or audio, making it difficult to accurately assess the patient’s condition.

Privacy and security are also major concerns with telehealth. While providers are required to follow certain guidelines and regulations to ensure patient confidentiality, there is always the potential for sensitive information to be intercepted or shared inadvertently. In addition, patients may be more hesitant to share personal information over a video call, which could impact the quality of care they receive.

Finally, there is the potential for telehealth to exacerbate existing health disparities. While telehealth has the potential to increase access to care for those who live in rural or underserved areas, there are still many barriers to accessing care, such as lack of reliable internet or computer access. In addition, some patients may not feel comfortable with the technology or may prefer in-person care, which could impact their willingness to seek care remotely.

Despite these challenges, telehealth has many potential benefits and can be a valuable tool for both patients and providers. To mitigate the risks associated with telehealth, it is important for providers to receive proper training and education on the use of telehealth technology, and to be aware of the potential pitfalls and limitations of remote care. Additionally, patients should be informed of the risks and benefits of telehealth and encouraged to ask questions and voice their concerns about the use of remote care. By working together, providers and patients can ensure that telehealth is used in a safe and effective manner, improving access to care and helping to bridge the gap between patients and providers.

I’m wondering if the fact that I used sequential prompts to ask the questions contributed to the fact that it didn’t include a reference to the author or a definition of telehealth. I think it did a good job pulling in some of the concerns that are often voiced about telehealth, but it still felt a bit like a school essay and not anything that readers would find engaging or otherwise different from the dozens of bland articles that pop up in healthcare IT publications. It’s certainly not to a level of sophistication where I can let it write for me, but it was a fun exercise and it was good to hear what someone from another generation and point of view thought about whether generative AI is ready for prime time or not.

I spent the rest of the weekend playing catch up and getting ready for the fact that I’ll be out next week for the ViVE and CHIME meetings. I’m headed to Nashville on Saturday so I can spend some quality time with one of my favorite shoe junkies and see what has happened to the town in the decade or so since I’ve last been there. I’ll be writing my next couple of posts from there, so if you’re in attendance and see any good shoes or wild conference behavior, be sure to send your thoughts my way.

What’s the best way to spend a cold dreary weekend, when ChatGPT isn’t as entertaining as you hoped? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/16/23

I’ve been carefully following the Silicon Valley Bank implosion, especially the stories about the electronic transactions that contributed to its death spiral. The most striking data point: customers were attempting to withdraw more than $42 billion within a 24-hour period, which works out to approximately $500,000 per second.

I admit that I’m one of those people who has grown used to being able to transfer money on a timeline of minutes to seconds, but the idea of that much money moving around is nearly unfathomable. The bank failure, along with concerns about other lenders, has led to the flow of more than $15 billion to Bank of America. Other large banks, such as Wells Fargo and Citigroup, have yet to comment on the amount of new money flowing in.

People frequently compare what we’re doing in healthcare IT to the digital revolutions that have occurred in other industries. I enjoyed this article about accounting firm PwC and its plans to use an AI chatbot to help its legal team boost efficiency. More than 4,000 workers will have access to an AI-enabled chatbot provided by Harvey with the expectations that it can assist with tasks such as due diligence and contract analysis. Harvey works with large language models in the legal space and uses OpenAI and ChatGPT technology.

Even though we’re several days past the Daylight Saving Time transition, several people I know are still struggling with sleep/wake cycles, especially where children and pets are involved. There’s plenty of push for making Daylight Saving Time permanent, but the medical establishment isn’t convinced. A recent article in JAMA notes that medical societies such as the American Academy of Sleep Medicine “overwhelmingly” support the continuation of Standard Time if we’re going to stop jumping back and forth. They note that during Daylight Saving Time, “the body’s internal circadian clock, which synchronizes to solar time, is out of step with the social clock, or local time.” This results in higher numbers of motor vehicle crashes, depression, and stroke, not only during the transition period, but throughout the summer. There’s not a ton of research on time changes, though, with the authors noting that only 159 articles have been published since 1962.

The reality is that there’s a finite amount of sunlight each day, and choosing one time paradigm over the other determines whether that extra light is in the morning to help us get going or whether it’s later in the day for after-work and after-school activities.

Interestingly, some of the most prominent research in the field stems from Russia, which instituted permanent Daylight Saving Time from 2011 to 2014 before moving to permanent standard time. In a retrospective study of adolescents and young adults, researchers found that ongoing Daylight Saving Time created a dissociation between social and biological clocks which “potentially exerts a negative influence on adolescents’ sleep habits, mood, and behavior.” People also forget that the US tried year-round DST in January of 1974, resulting in an extended period of dark mornings during the winter when children are headed to school. Standard time was restored by October of that year. There’s plenty of other great information in the article, so if you’re looking for a deep dive, I’d give it a read.

I was interested to learn about proposed legislation that would prevent companies from using health data for advertising and marketing purposes. US Senators Amy Klobuchar, Elizabeth Warren, and Mazie Hirono introduced the Upholding Protections for Health and Online Location Data (UPHOLD) Privacy Act, which would curtail the profits companies generate by using personally identifiable health data for advertising. Where HIPAA focuses on covered entities, this bill takes protections to the next level, allowing patients even more control over their health data when it resides with apps, tech companies, and other organizations. The bill would impact the numerous companies that harvest health information but aren’t regulated by HIPAA and would also ban the sale of location data.

From Igloo Fan: “Re: organ donation. Did you see this article about the donated liver that got stuck due to road closures for a marathon?” I hadn’t seen it, so I appreciate the share. Apparently the liver was stranded by the Philadelphia Half Marathon with 30,000 participants hitting the streets. Dr. Adam Bodzin ran into the field, traveling half a mile to where the van carrying the organ had reached a literal road block. Fortunately, police were able to transport him back to the hospital with his precious cargo. I had the privilege of working on my hospital’s transplant team during training and it was an unbelievable experience, if often surreal. Our team treated each organ procurement surgery with the reverence and awe it deserved and as a surgical subintern I was honored to be left behind to help return the donors to the best appearance possible for their families. Once those cases were complete, we caught up with the team performing the actual transplant procedures, and the sense of awe continued. There’s nothing like watching a donor organ start functioning. If you’re an organ donor, make sure your family knows your wishes. If you aren’t, please consider making it possible to give the gift of life should something unforeseen happen.

I love it when readers send me funny emails, even though I don’t always have time to reply to them. I’ve had some long-term back and forth correspondence with some readers to the point where I feel like I really know them. One of those readers and I have had an ongoing dialogue about virtual workplaces where you’re constantly expected to be on camera. It was the best laugh of the day when I opened a message to read this: “I’m on a Zoom and this woman is casually sipping a bottle of magnesium citrate.” I’m just hoping his co-worker was knowingly drinking a laxative and didn’t have it confused for some other beverage in the refrigerator. March is Colorectal Cancer Awareness Month, so perhaps she was getting ready for a recommended screening test.

What’s the wildest thing you’ve seen on a conference call? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/13/23

A recent article in JAMA Health Forum caught my eye with this title: “Association of Primary Care Visit Length With Potentially Inappropriate Prescribing.” The study’s goal was to answer the question, “Are primary care physicians more likely to prescribe potentially inappropriate medications during shorter visits?” in part as a proxy for seeing whether shorter visits resulted in lower-quality care.

The authors looked at visits from 4.3 million patients, noting that “those who were younger, publicly insured, Hispanic, or non-Hispanic Black had shorter primary care physician visits.” These visits were associated with higher rates of antibiotic use for inappropriate conditions, such as upper respiratory infections. They were also associated with prescriptions for both opioid analgesics and benzodiazepines in patients who presented with painful conditions. The authors concluded that shorter visits were associated with some measures of inappropriate prescribing, but not all.

It’s a difficult study to analyze, especially looking at the demographics included in the study. We know from other research that there can be racially and ethnically associated differences in care quality. We know that black women have higher maternal mortality and less prenatal care compared to white women, and there are plenty of other examples of racial disparities in care. It’s also difficult to understand from the write-up exactly what kind of EHR data was used in the study, which was conducted from March 2022 through January 2023.

The researchers pulled a dataset from multiple states across the US that encompassed both claims and EHR data from users of the Athenahealth platform. EHR timestamp data was used, including flags for check-in, patient intake, the clinician encounter, checkout, and signoff. In some clinics, these stamps can be a poor proxy for patient visit duration, especially when there’s a lot of waiting involved or when physicians don’t appropriately change the status of visits as they move through their schedules. I would be interested to see data on the concordance of those timestamps with actual visit durations as observed in the practice before using them as a proxy.

The visit time was variable between physicians, and although the median visit length was 18.9 minutes, the range was 14.1 minutes to 24.6 minutes. There was some data I didn’t expect when looking at visit length alone. Those visits that were scheduled for 30 minutes rather than 10 received more physician attention, as one would expect. However, the difference in time spent was only four minutes for the longer appointments. That might indicate that triage algorithms or human schedulers aren’t doing a great job predicting the correct appointment slot for a given patient.

Not surprisingly, visits that had five or more diagnoses were 9.1 minutes longer than those with only one recorded diagnosis. New patient visits were 4.1 minutes longer than those with established patients. The data supported previously proven conclusions, such as female patients having longer visits than male patients and older patients having longer visits than younger patients. It also showed that patients with commercial insurance had slightly longer visits than those with Medicaid or other payers.

The researchers found a correlation between longer visits and a decreased likelihood of inappropriate antibiotic use. On the flip side, longer visits had a positive association with potentially inappropriate prescribing among adult adults, which was an interesting finding. The authors note that “many of the prescriptions that we observed may have been refills; thus, it may have taken the physician less time to refill the medication than to engage in a discussion about de-prescribing.”

The authors end by stating that there are opportunities for additional research and operational interventions for visit scheduling and prescribing decisions in primary care. They also note that data showing that non-Hispanic black patients had shorter visits than non-Hispanic white patients seeing the same physician, which could result in accumulation of time disparities that can potentially contribute to racial disparities. They conclude that the data “should motivate organizations and policy makers to detect, interrogate, and address underlying systemic causes such as structural racism.”

It would be interesting to compare data pulled from Athenahealth users and that from users of other EHRs that may have varying levels of clinical decision support or guidelines content within the clinical workflows. In my community, the user base of the Athenahealth EHR tends more towards an independent primary care practice user base. Practices that are owned by or affiliated with the large health systems or academic institutions tend to use a different EHR, as they do across the US. Therefore, using data from one vendor alone might not be representative of primary care practices across the US.

It would also be interesting to control the data for owned versus independent practices, large versus small, and those who are participating in risk-based contracts versus those who aren’t. I’ve found that certain kinds of practices tend to have a more systems-based approach that can make short appointments more efficient than they might be elsewhere.

I work with physicians who practice in a face-to-face environment, those who practice entirely via telehealth, and those who either do a hybrid approach from within their practices or who practice at separate in-person and telehealth jobs. I’ve seen telehealth physicians held to standards that some of their in-person counterparts aren’t monitored for, because there’s a suspicion that somehow telehealth physicians are doing a worse job at following guidelines and standards than their in-person colleagues.

It would also be interesting to compare and contrast the data for telehealth visits done by third-party providers versus those delivered by the patient’s medical home. You would also have to look at hybridized care models such as a primary care office that uses an acute care telehealth pool that’s part of an overall health system, or primary care offices that allow third-party providers to work within their own EHR.

There’s not a tremendous body of literature looking at the length of telehealth visits compared to the outcomes of those visits, and maybe someday I can be part of the research into how telehealth can best be used for what kinds of care and what clinical decision tools work best to provide care in different environments. It’s been a long time since I was involved in research, but I enjoyed it. I’ve just entered a new Maintenance of Certification cycle with my specialty board and a practice improvement project is in order, so one never knows.

What do you think about the association with visit length and care quality? What have your experiences been from the patient side? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/9/23

I survived my trip to the ATA conference, but I can’t say I’m glad to be home. Leaving beautiful the warm and sunny environment of San Antonio for the rainy chill at home was definitely an adjustment. I’m glad I left my heavier coat in the car so I would have it when I got back.

Overall, it was an interesting conference, in that I met some great people and learned about some novel use cases for telehealth. From a logistics standpoint, though, I heard a fair amount of grumbling from attendees and exhibitors alike. The themes:

• Meal service hours were tightly controlled. Although beverages were laid out 25 minutes before lunch was to be served, the catering staff literally had guards in place blocking anyone from even getting water from the lunch service tables. On the other hand, meals were served throughout the show floor, so that made it easier to pop out and get something. There was no break service upstairs where the majority of sessions were held, however.
• Breakout rooms weren’t ideally sized for the attendees. Some were standing room only, where others seemed like vast caverns with presenters speaking into a dark void. I don’t recall having the option of indicating interest in a session in advance, which would have helped with room sizing if that’s something the event planners are interested in for the future.
• The Saturday through Monday scheduled really seemed to mess with people’s sense of time and date. Although they enjoyed being able to focus on sessions on Sunday without dealing with work email, most people still missed three days of work with Friday and Tuesday travel, plus lost their weekend.
• Exhibitors felt the event wasn’t as well attended as they expected. Exhibit hall hours were long, running from 10:40 a.m. to 6 p.m. On opening day, they let attendees in before it opened, which ruffled some feathers since people weren’t in their booths yet. On Sunday at 5 p.m., the aisles were a ghost town, and on Monday by 4:15, attendance was slim.

On Monday I attended a great Executive Deep Dive session and really enjoyed the first panel, which included veteran healthcare IT guru John Glaser. He’s been a voice of reason over the years and has good advice on how to run projects in a mindset that increases the changes of them being successful. I enjoyed his comments on the different ways that projects tend to turn out: 30% successful, with the rest being divided among options such as “trainwrecks” which are the spectacular failures, or “the great disappointments” which are ultimately worse.

His solid advice of keeping the transformation aspect at the forefront, as well as making sure everyone understands that transformation never ends, still rings true. Other advice such as making sure you have candor and openness on a project and making sure you aren’t trying to do too many things at once are sometimes overlooked but critical to successful initiatives. I also appreciated his advice to know how to pull the plug on an initiative when you see it’s not going to work out or drive value. One of my favorite takeaways from the panel was Glaser’s description of political support for transformation projects: “it’s like a slowly leaking balloon…. You have to re-inflate it every day.”

Monday night was the ATA social event, held at the Hard Rock Café as well as next door at the Howl at the Moon dueling piano bar. The Hard Rock scene was a little more chill, with people sitting and chatting while enjoying hors d’oeuvres and drinks. It was considerably less tame at the piano bar, where some of us retreated to the outdoor balcony in order to be able to have a conversation. I couldn’t help but wonder whether the apartments on the other side of the Riverwalk had soundproofed windows or how the residents otherwise coped with such noisy neighbors.

Still, it was a fun event to meet other attendees, learn what they’re doing in the industry, and to catch up with old friends. I’m at the point in my life where I can’t hang with the party crowd as well as I used to, so I headed back to the hotel while things were still in full swing in order to be ready for my early morning flight.

Wednesday was catch-up day. I’m privileged to have a great team who always has my back while I’m away, which is a big change from when I was doing interim CMIO work. The email volume was manageable and I caught up on some clinical reporting and other projects. The bright spot in my day was talking to one of my favorite graduating college students who is on the receiving end of some career recruiting by an EHR vendor. It was interesting to hear how the company portrays itself to potential applicants who are in non-healthcare fields and what they think of the recruiting pitch compared to other companies who are trying to catch their attention.

Since his major is highly specific and he’s got a very specific career in mind, he plans to look elsewhere, but it was an interesting conversation nonetheless. One of his close friends was also recruited and plans to pursue the opportunity, so I’m looking forward to hearing more about their journey.

I reached out to a couple of friends to ask about their HIMSS plans as I plan my Chicago travel. It sounds like even some of my die-hard attendee friends have opted not to attend this year. It’s a combination of working for companies that still have travel restrictions in place, not wanting to be away from family events given the later spring dates this year, and having limited conference budgets.

I’m not sure if large conferences will ever be what they once were in the pre-COVID era. From a HIMSS perspective, healthcare organizations are still recovering from the financial impacts of the pandemic, and if they have technology dollars to spend, they tend to be looking in focused areas. I’m not sure the large-format boat show of old is relevant to today’s buyers, but would be interested to hear from others with spending authority.

What’s the primary way you engage vendors for technology purposes? Are conferences and trade shows on their way out? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/6/23

Jayne Goes to ATA

I have arrived at the American Telemedicine Association meeting in San Antonio, escaping the freezing rain of the Midwest for the blindingly bright sun of Texas.

Since it’s been a number of years since I’ve been to the downtown area, I did my usual walkabout. I’m always stunned by how small the Alamo is and how surreal it is to be in the middle of downtown surrounded by tourist shops and a wax museum. Although the Riverwalk was bustling Friday night, the surface streets were more subdued. I saw police responding to two restaurants, one near the Alamo and the other on the Riverwalk, due to disorderly patrons. By 7 p.m., Alamo Plaza was all but deserted, but the Riverwalk was bustling.

Saturday morning, I got my four miles in along the Riverwalk before many tourists were up and about. Most people don’t realize that the touristy section of the San Antonio River is made possible by a dam, which can control the height of the pool in the Riverwalk section. I grew up along a major river and had many trips to the lock and dam complexes with my dad, so I’m more prone to notice these kinds of things than the average tourist.

San Antonio is definitely doing its part to keep the area clean, with ample service workers out hosing off sidewalks and picking up trash during the early morning hours. It’s a shame that people have to throw trash in the river in the first place, but maintenance workers were fishing it out nonetheless.

On the way to registration, I stumbled upon San Antonio’s own “love locks” bridge near one of the less traveled sections of the Riverwalk.

At the convention center, I found a street artist working on this piece using paint pens. It was fascinating to watch how they controlled the lift with one hand and painted with the other.

Registration was a breeze, and the friendly check-in agent even asked me about the marathon shirt I was wearing. The conference bags were minimalist in nature and I like that. This is the kind of bag I keep in my suitcase for grocery runs when I’m traveling. It contained the usual flyers and postcards, along with a COVID-19 test kit from sponsor EMed, which is a great thing to include in a conference bag since many people have decided COVID is “over” and I suspect that a lot of the allergies people are complaining about might just be COVID.

On the other end of the useful spectrum is this single sock from ProAssurance. Attendees have to go by the booth to get the other one. Although it seems clever, it has the potential to generate a significant amount of waste, and attendees are becoming more attuned to that. Given the pattern on the sock, I’ll probably go by to get the other one for my favorite MD/JD, however. There were a couple of flyers in the bag, along with a couple of white papers, but none of the random junk I’ve gotten at other conferences, which was much appreciated.

After a brief sojourn to my hotel room to catch up on some of the working hours I missed while traveling yesterday, it was time to head back to the conference for a “Deep Dive” session on the business aspects of telehealth. It was a great session with lots of detail and a ton of attendees, resulting in standing room only conditions and people sitting on the floor around the edges of the room. Topics included compliance, professional liability, cyber liability, and the new proposed DEA regulations on controlled substances within telehealth.

I liked the seating arrangements – large round tables in the front for those who prefer that configuration, and standard rows of chairs in the back. The audience seemed engaged, with few people leaving until the end. I found the event photographers distracting, though. They were constantly in the room and would move around to take a new round of photos every time new panelists took the stage, often blocking the view of the speakers. A couple of them were also using 360-degree flash units even when shooting photos from far away, and although I don’t think they did much to illuminate the subjects they did a great job of blinding the audience momentarily. I wasn’t super keen on them taking long slow video panoramas of the audience, but I guess that’s just the nature of the beast these days.

From there we were off to the opening session which included speakers from the ATA, Optum, Google, and Microsoft. Topics were far ranging and there was a lot of discussion about how telehealth should evolve and expand in the post-COVID era. The presenters were largely industry folk. I overheard some people talking afterwards that it would have been good to hear from some patients whose lives had been touched by telehealth or whose care was made better through the technology. It’s nice to understand how the work we do impacts people at the point of care, whether they are clinicians, patients, or their families. Maybe ATA will consider incorporating something like this next year.

After the opening session, there was a casino night-themed social event with food and beverage service, although based on the attendance, I think a lot of people ventured out for dinner. I’m not much of a gambler, but it was fun to watch people celebrating at the craps table and to catch up with people I don’t normally get to see in person.

I’ve got some sessions picked out for the next couple of days of the conference, including ones on health equity, telehealth reimbursement, policy and advocacy, interoperability, and usability. I’ll also be hitting the exhibit hall and checking out some potential vendors as well as meeting up with a couple of old friends.

Hopefully there will be some time to soak up a little bit of sun in between sessions because the weather is certainly nicer here than it is back home. My step count was off the charts for today, so it’s now time to put my feet up and settle in with a good book to ensure I’m ready for what looks to be a pretty long day.

What kinds of things do you most like to experience at conferences, and what do you like the least? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/2/23

The hot topic around the virtual water cooler this week was the National Labor Relations Board (NLRB) decision this week that employers can no longer use two specific strategies to silence laid-off employees. Employers are not permitted to include overly-broad confidentiality clauses as terms of a severance agreement. Additionally, they are not permitted to include broadly written non-disparagement clauses that prohibit discussion of previous employment with third parties.

The case involved hospital employees in Michigan who were furloughed when non-essential services were halted during the early days of the COVID-19 pandemic. The decision applies to all US employers with the exception of railroads and airlines. There’s always the chance of an appeal, but for now, the decision is in force. It’s 23 pages of dense reading if you are looking for a sleep aid at the end of a long day.

I’ve mentioned that I’m on the teaching staff for a leadership seminar for one of my volunteer organizations. The participants will be spending five days with us and we’ll be covering a variety of topics around project planning, team development, managing diverse people, and effective communication. I’ve been prepping for some of my sessions and have three presentations on communication, so I was excited to see the Grammarly State of Business Communication report hit my inbox. It was conducted by Harris Poll on behalf of Grammarly Business and surveyed 1,000 knowledge workers and 250 business leaders. The respondents were full-time workers at corporations with 150 employees or more and were across a mix of industries and job functions. Business leaders were at the director level or higher with decision-making authority over strategy, development, customer experience, budgeting, or hiring.

Findings that caught my attention:

• The time spent on written communication is up 18% from 2022, but the quality of written communication is waning. This aggregate of 21.4 hours per worker includes writing and responding to written communications, creating materials to be shared, reviewing and editing the work of others, revising materials, and other writing tasks.
• Effectiveness of written communication has declined 10% over the past year.
• Miscommunication is frequent, with 100% of respondents reporting miscommunication at least once per week, 66% reporting it once per day, and 48% reporting multiple instances per day. Miscommunication costs US businesses $12,506 per employee per year and comes with decreased productivity and increased worker-reported stress.
• One in five business leaders feel that inadequate communication has eroded brand reputation, with 19% reporting lost deals due to poor communication. Conversely, one in three leaders feel that effective communication has helped them gain new business.
• Confident writers are more likely feel confident in their work and engaged in their roles than non-confident writers. They also report higher mental well-being at work.
• Increases in asynchronous work creates greater urgency for projects aimed at improving the quality of written communication.
• More than one in five workers report that they have considered finding a new job due to poor communication.

There’s such a great push for many industries to bring workers back to the office that I think people sometimes lose sight of the benefits of asynchronous work. The majority of respondents felt asynchronous communication made their jobs more flexible. Additionally, a good percentage of workers in key demographics felt asynchronous work made them feel more included: 40% each for millennial and Latinx workers, and 39% for neurodivergent workers.

I was particularly interested in learning the details of people’s specific struggles with written communication. The majority of respondents (71%) struggle to choose words that don’t offend others and with finding the balance between formal and casual written speech. Additionally, 63% say they spend too much time trying to convey their message in the right way. There are additional challenges for workers with English as their second or less familiar language, who report higher levels of uncertainty than their primarily English-using colleagues on things like tone, word selection, communication length, jargon, and idioms.

The long and short of it is that communication is key, and I’m looking forward to being part of a leadership development experience that puts some useful skills and well-accepted methodologies in front of people who might not otherwise receive formal communication training. As a side bonus, this is an outdoor leadership program so I get to do all of my teaching in front of a picnic table rather than in front of a Zoom screen. There will also be some sleeping in a tent, which is fine by me, although I’m crossing my fingers for beautiful spring weather rather than the rain and hail I’ve had teaching previous outdoor leadership courses.

From Bianca Biller: “Re: March is Colorectal Cancer Awareness Month. Look what greeted me on a practice visit. Hopefully the patients will identify with it and get their tests scheduled. The practice had a whole ‘Patient Communication’ wall with at least 10 signs taped to it.” Bianca included a picture of that wall that I can’t run due to the practice letterhead being all over the documents. Some of them are laminated, and based on the photo, they range from knee height (diabetes) to about seven feet from the ground (Affordable Care Act and preventive visits). The fonts were pretty small and I can’t imagine anyone being able to actually read it all. Hopefully they are using other methods to communicate with patients such as their website, patient portal, email outreach, and chatbot campaigns.

The practice also uses a super fancy inventory management system for the exam rooms, placing the burden of managing inventory on the people who are in direct contact with patients and using the supplies in the rooms. I guess the days of having the staff clean and restock rooms at the end of each day have passed. I understand the “just in time” approach here, but I guess the idea of working at the top of your license might not be top of mind in this practice. Compared to regular checks by support staff, this also increases the risk that you could run out of something if you inadvertently let supplies get lower than the time it takes for someone to notice that the magnets have moved and to find the time to get an item and restock it.

At my last clinical location, there was a designated support staff member that started going through the office with a supply cart in the final hour before closing. Despite seeing up to 20 patients in each exam room each day, we never ran out of anything, we always had what we needed for patient care, and delays were nonexistent. It’s a brave new world, I guess.

As I get ready to head to the American Telemedicine Association’s 2023 Annual Conference & Expo in San Antonio for the first time, I have to reflect on the fact that it is the spammiest conference I’ve ever attended. There are only 220 exhibitors on the list and it feels like I’m getting emails from all of them. Some have a tone of increasing urgency, asking if I missed their previous email and pushing for a response. I understand the sales strategy here, but it’s annoying and actually makes me less likely to consider you as a vendor when you do this. I also loathe emails that address me as “Hey Jayne.” An email isn’t a formal letter and personally I don’t think it needs a salutation. I’d rather receive one with no salutation than one with the “Hey” at the top.

What’s your greatest pet peeve when it comes to email? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/27/23

I’m headed to several conferences over the next two months. I spent some time this weekend going through the agendas and looking at the details to identify specific sessions I’d like to attend.

Smaller conferences tend to have smaller agendas, so it was fairly easy to determine what I planned to attend at the first of the series, which is the American Telemedicine Association Annual Conference & Expo in San Antonio. Given the frigid weather across most of the US, I have to say I’m looking forward to the San Antonio weather as much as I’m looking forward to any of the sessions. The topics I’m excited about most include remote monitoring, legal issues, and health equity.

Regarding the latter, telehealth holds huge promise, but there is still significant concern that large groups of patients are being left behind due to technology and connectivity issues. My focus is more on health literacy and the barriers it creates as far as care delivery, so it will be interesting to see what the speakers have to say.

The agenda for the CHIME/ViVE mashup was a little more complicated to navigate since it has a lot of sessions that run concurrently across a half dozen different tracks, along with a number of CHIME-only sessions and events. I found a fair amount of overlap in the concepts behind the ViVE tracks and ended up having to really look at the session descriptions versus being able to use the tracks or titles to help thin out the options. I also looked at the speakers and will be making sure to hit sessions with speakers from organizations that are constantly in the news, such as Amazon Clinic and Teladoc.

I didn’t attend ViVE last year, but the way it’s set up seems similar to HLTH. Many of the sessions are focused around experts discussing their opinions. Although those can be interesting, for those of us who have been heavily into evidence-based medicine, we know that when assessing the strength of a recommendation based on a body of evidence, expert opinion is the weakest. When attending those kinds of sessions, I often find myself thinking, “that’s great, but the proof will be in the proverbial pudding,” so I anticipate having that feeling often during the conference.

If you’re going for talks that hit higher up the evidence-based scale, HIMSS is the place to be, at least as far as its concurrent education sessions are concerned. I’ve made fun of HIMSS in the past because the submission timeline for sessions is so far ahead of the conference that material can become stale. However, that significant lead time is useful when you’re performing an advance review of what is going to be presented and assessing it for things like level of evidence and commercial bias. For those sessions where continuing medical education or other credits will be offered, they must include designated learning objectives, along with disclosures of any financial relationships that might be related to the content of the presentations.

Although some of the HIMSS sessions I’ve been to have been dry, they’re usually well put together and the presenters are happy to correspond with you afterwards if you want to dig into their topics. Of course, several of the sessions I’d like to attend are on top of each other, which is a shame. In the past, I’ve found the recorded sessions to be variable in quality, and if I remember correctly, the lower-cost pass I bought for this year doesn’t include access to the recordings. 

Some of the presentations I’m looking forward to at HIMSS cover health equity, standards and interoperability, using automated care programs to improve clinical outcomes, and integrating virtual care with other healthcare delivery options. I’m doing some volunteer work with underserved populations, so I’m particularly interested in one of the sessions on street medicine and delivering care to the homeless. I’ve worked previously with one of the organizations that is presenting and I’m excited to see how their program has grown in the intervening years. It sounds like they’ve added a lot of technology tools to their approach while they still manage to maintain the focus on whole-person care.

It’s always fun to see where people have ended up in this industry, It feels like we were so green trying to do some of these technology initiatives back in the pre-Meaningful Use days. Some of my favorite clinical informaticists have crossed the 20-year mark in the business, so I’m looking forward to catching up with them in any downtime we can find.

Of course, one of the most fun parts of conference season for the HIStalk team is making the rounds at vendor events and reporting on the overall buzz. In the post-COVID era, those vendor events have been fewer in number and lower in key than when healthcare IT was in its more glamorous phases. That’s to be expected given the economy and the fact that marketing folks know that throwing a big bash with a lot of random attendees who don’t even have decision-making authority isn’t likely the best way to spend their cash. Still, if you’re throwing a blowout event where general attendees can register, feel free to send invites our way and we’ll consider anonymously dropping by.

As long as the weather holds, Chicago is one of my favorite cities for HIMSS because it’s easy to get around and has plenty of non-conference activities going on, unlike Orlando, where everything is mostly concentrated in that one section of International Drive. Unlike Las Vegas, you don’t have to walk through a smoky casino to get to where the action is, so that’s a plus.

Several people have told me that Nashville has turned into a fun conference location, although I haven’t been there since one meeting in 2008 that was held entirely at the Gaylord Opryland Resort. I’m looking forward to seeing what it has to offer and will be happy to have the opportunity to catch up with one of my favorite people in her hometown. It’s always good to have a friend who knows where the real fun is to be had and how to avoid the tourist traps and overhyped restaurants and bars.

If you’re taking part in upcoming conferences, what are you looking forward to the most? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/23/23

In the “not a major surprise, but it’s nice to see some data” category, a recent study published in the Journal Healthcare finds that scribes are linked to a 27% reduction in primary care burnout rates. The authors looked at using remote scribes to assist primary care physicians in an effort to boost physician wellness.

The research was performed at University of Wisconsin Health and included approximately 200 physicians in the specialties of family medicine, general internal medicine, general pediatrics, and adolescent medicine. Individual scribes were paired one-to-one with physicians. The intervention group included 37 physicians and the control group numbered 160. The scribes used an audio-only cellphone connection to listen to visits and create documentation in real time. Orders were entered and held in a pending status for physicians to execute. The final notes also underwent review, editing, and signature by the physicians.

Prior to the intervention, more than 70% of physicians reported burnout. Post-intervention, that number was down to 51%. Although that change is dramatic, it is accentuated by the fact that for those physicians who didn’t work with a scribe, their burnout rates rose from 50% to 60%. Additionally, those working with scribes were more likely to describe their workplace as “joyful” and “supportive.” Measures of EHR-related stress were lower than those clinicians who didn’t have scribes. Working with a scribe slashed up to 66 minutes of EHR time out of an eight-hour physician day, with half of that being outside the scheduled workday.

Interestingly, looking at the study design, those receiving scribes were self-selected and had to agree to not only participate in program evaluation efforts, but to see one additional patient per half-day clinic session in order to offset the costs of the scribe. Both of those factors may have had an influence on satisfaction.

The authors noted that four of the intervention group dropped out of the project within the first year, and it would be interesting to look at the reasons given. They also noted that the project began just prior to the COVID-19 pandemic, “which dramatically disrupted clinical operations and could have affected the post-intervention wellness and EHR measurements.” Still, they conclude that “the fact that a scribe program can be revenue-neutral with modest increases in productivity makes them an attractive intervention to help organizations improve the wellness of their physician workforce.”

I think that if primary care colleagues fully did the math, many of them would be willing to see one or two more patients per day in order to shave time off their after-hours documentation.

Working with scribes was critical to my survival in the early days of the pandemic, when my urgent care’s volumes spiked. It would have been impossible to see 80+ patients per day without a scribe. A good chunk of those visits were for COVID testing or COVID concerns without any symptoms, and my scribes were able to capture not on the patients’ stories, but all of my counseling and medical advice, before I left the room.

Unfortunately, many of our practice’s best scribes gained admittance to medical school in the summer of 2020, decimating the program. It wasn’t able to recover prior to the subsequent COVID peaks, and the lack of scribes was directly associated with a number of physicians leaving the organization in the first half of 2021. There is definitely some work effort involved in onboarding a scribe program, but if your organization is experiencing clinician burnout, it’s worth considering.

Senator Tammy Baldwin of Wisconsin is going after health system Ascension. In a letter to the health system’s CEO, she calls out the fact that “Ascension is required to provide charitable benefits to the community and operate solely to serve a public, rather than a private interest. Despite these requirements, Ascension has significant for-profit investment activities that dwarf what the system providers in annual charity care.” She goes on to state that “by operating like a private equity fund, Ascension is squeezing staff, closing facilities, and extracting cash from its member hospitals for dubious ‘management fees’ all to advance its investment activities and provide compensation to its executives.”

Baldwin also calls out the fact that at the recent J.P. Morgan Healthcare Conference, Ascension’s CEO talked up its $18 billion in cash and investments, noting “This number raises questions about why Ascension, a mission-driven health system with non-profit status, is not prioritizing reinvestment into serving vulnerable communities and its own operations – which should include increasing pay and improving working conditions for its burned out and overextended health care workforce.”

She cites data that Ascensions investment funds lost the system more than $200 million more than the organization provided toward charity care during the most recent financial quarter. She closes with a demand for data covering fiscal years 2015 through 2022 that describes investments, returns, charity spend, debt collection practices. She also asks for information on management fees charged to hospitals, how monies from the Provider Relief Fund were used to address hospital staffing, details on over $250 million in charitable care during the last three months, and a list of compensation packages for executives and board members.

I’ve worked for several health systems that sat on billions of dollars while the proverbial city burned. I’ve seen essential frontline workers struggle to maintain full-time status while managers are incentivized to turn them into part-time workers so they don’t have to pay benefits. I’ve seen these systems put the squeeze on primary care physicians while they build fancy non-clinical additions on their buildings. And we’ve all seen some of these organizations aggressively pursue patients for their portion of payments, while barely paying heed to their supposed charitable missions.

On my most recent patient-side visit to one of these systems, I experienced understaffing, scheduling issues, and dirty facilities. With cash in the double-digit billions, it feels like they shouldn’t have baseball-sized dust bunnies in the waiting room. They also shouldn’t be shifting patients away from established physician relationships to brand new mid-level providers because the physician panels are full and they “can’t afford to hire” additional physicians.

It will be interesting to see how this plays out with Ascension, and I’m sure other nonprofits will be following closely.

What do you think about so-called non-profit health systems who have billions in the bank? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/20/23

ChatGPT and similar tools continue to be some of the hottest topics around the virtual physician lounge. Plenty of clinicians are experimenting with using the tools to help respond to patient messages, and the bravest souls are even looking at using it to create visit documentation.

Although it’s tempting to think that we might be on the cusp of having reliable tools to help us with some of the most time-consuming parts of our jobs, the reality is that the technology is not yet ready for prime time as far as using it in clinical scenarios. Unfortunately, many frontline physicians may not understand the limitations of the system and are wading into some pretty deep water where it comes to patient care.

Some of my non-medical friends have been using it as well and have a lot to say about the fact that its output can sound completely convincing, but is factually incorrect. There are some examples going around, such as where it lists the peregrine falcon as the fastest marine mammal. The computer science folks note that in order for models like ChatGPT to be useful in healthcare, constraints need to be placed on their predictive capabilities.

For example, if you were using the tool to summarize a patient’s chart, you don’t want to allow it to predict procedures or treatments that didn’t happen. My friends seem to think that the easy answer in healthcare is to just have the physician review everything to make sure it’s accurate. However, those of us who practiced back in the days of heavy use of medical transcription know that’s easier said than done. The number of transcriptions that went out the door without proofreading or corrections was staggering, and led to outcomes running the spectrum from laugh-provoking to malpractice.

There’s also the not so small matter of HIPAA and the risks of feeding large quantities of patient information into the dataset used by the tool. Additionally, trying to leverage AI-based technologies for healthcare isn’t cheap. I’ve seen several startups that try to pass their solutions off as “AI-enabled” when all they really have is a bunch of sophisticated decision trees. There’s a certain threshold of money that has to be raised in order to be able to afford the work needed to truly move into the AI space, and understanding whether a company even has the resources to realistically do AI work should be one of the first steps in determining if they’re blowing smoke.

In related topics, some of my colleagues were discussing a recent editorial in JAMA Health Forum titled “Garbage in, Garbage out – Words of Caution on Big Data and Machine Learning in Medical Practice.” The piece opens with a quote from Alan Turing: “A computer would deserve to be called intelligent of it could deceive a human into believing that it was human.” It goes on to talk about machine learning and the use of data to predict clinical outcomes, such as adverse events related to medications. We know all too well the risks of using data sets that aren’t representative of the population in question or that don’t have all the information needed to generate a reliable prediction. The article uses the example of an opioid prediction rule that didn’t included data on cancer diagnoses or enrollment of hospice as a rule that isn’t ready for prime time.

Especially in the primary care trenches, physicians are often so busy just trying to get the daily work done that they may not be digging in to understand exactly how predictive rules are generated or how valid they are. They have to rely on regulatory agencies and the editorial staff of medical journals to vet proposals. Although this can delay the time for new tools to get to the point of care, it can be a valuable step for protecting patient safety. The article notes that it’s also important to reevaluate rules on a periodic basis, since medical knowledge continues to evolve. It gives the evolution of an HIV diagnosis “from a death sentence to a manageable chronic illness” as an example. It’s good food for thought.

Around the administrative / non-clinical physician water cooler, one of hottest topics over the last couple of weeks was that of annual performance reviews. Making the jump from clinical practice to management requires more than just an interest in administrative topics. It also involves understanding how corporations work and some of the tactics that they use to manage their human capital.

A physician who is new to administrative work recently learned that he would have to perform stack ranking when analyzing his team’s performance. For those who may not have run across this, it requires managers to score workers against their peers rather than against goals and objectives. The first time I ran into this was when I worked for a large hospital system, and a management consultant that had been engaged to “trim the fat” forced our department to implement it.

To make matters even worse, annual merit raises were tied to the stack rankings. For managers with exceptionally talented teams who were all working at or beyond their potential and who were achieving great results, it’s agonizing to have to allocate more of a raise to some and less to others when they were all working extremely hard and crushing their goals. As a relatively new physician leader at the time, I hadn’t been exposed to anything like that. It’s not something you learn about in medical school and it certainly wasn’t covered in the couple of physician leadership intensives that I was sent to as the health system prepared me for greater administrative roles. Fortunately, I’ve spent the better part of the last decade working in environments where this methodology isn’t used, and I felt more than a little disbelief at the fact that it seems to be becoming popular again.

I’m a firm believer that if an employee isn’t meeting expectations, that needs to be addressed early and often through individual conversations with their manager and potentially a performance improvement plan if needed. It shouldn’t be left until the annual performance review. On high-performing teams, members should be able to work without fear that they’re going to be unfairly compared to co-workers just because of a methodology. Stack ranking is hard on managers as well as employees, and contributes to an overall toxic workplace culture. The fact that it’s still out there despite the literature about its consequences says a lot about companies that continue to use it.

The last hot topic of the week was a recent study that looked at whether the board members at the nation’s top hospitals have healthcare backgrounds. Published earlier this month in the Journal of General Internal Medicine, it found that less than 15% of board members had a healthcare background versus finance or business services. Other interesting findings: of those with a finance background, 80% had experience with private equity funds, wealth management, or banking. The rest were in real estate or insurance. Of those with healthcare experience, 13% were physicians and less than 1% were nurses. The authors only looked at top hospitals and there were challenges in finding publicly available information about boards. This could be even more challenging when looking at smaller institutions.

These topics are just a sampling of those that are on the collective minds of physicians who are often just trying to put one foot in front of the other as they slog through caring for patients.

What do you hear when you’re working with clinicians? Are there any particularly hot topics? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/16/23

As we approach the end of the declared emergency surrounding the COVID pandemic, it will be important to assess how shifts in healthcare policies including those involving payment, access, and prescription medications will impact health outcomes.

A recent article in the American Journal of Obstetrics and Gynecology Maternal-Fetal Medicine looked at hos telehealth care impacted racial disparities in visit attendance during the pandemic. As background, the US has a terrible track record for maternal care, with maternal mortality rates that are significantly higher than other high-income countries. Additionally, in the US black woman are more likely to die during pregnancy and childbirth. During my time in the emergency department, the number of women I cared for who had no prenatal care was simply stunning given our time and place in history.

Researchers at Penn Medicine performed a retrospective cohort study looking at the issue by comparing data from 2020 to the same time period in 2019. Self-identified patient demographic breakdown included 63% black, 26% white, and 1% Latinx individuals. Prior to the addition of telehealth, black patients were less likely than others to attend a postpartum visit. They were also less likely to receive a postpartum depression screening or to breastfeed their infants.

After telehealth implementation, postpartum depression screening rates were equivalent, although black patients remained less likely to breastfeed. The authors concluded that “telehealth implementation for postpartum care during the COVID-19 pandemic was associated with decreased racial disparities in postpartum visit attendance” in a way that was statistically significant.

Numerous studies are demonstrating that telehealth can improve patient outcomes in the right situations. Especially for patient populations that may be marginalized, telehealth options can open the door to care that patients might not otherwise receive. Benefit can be derived from both video and audio-only telehealth visits, assuming the right protocols and safeguards are in place. In the short term, there are just some things that can’t be done without a face-to-face interaction, but as technology improves those gaps are narrowing.

I had dinner with some of my favorite smart women tonight and telehealth was a key topic, as were other non-traditional care delivery opportunities including school-based health clinics, mobile care units, and more. There are so many dedicated people in the healthcare arena who want to make sure patients get the care they need. Now it’s just a question of aligning the right priorities and incentives to make it happen. There are more than enough dollars being spent on healthcare, from insurance premiums to facility and provider bills, that we should be able to do better. We should be able to be better. The next few years will be interesting, indeed.

As someone who has been officially classified as a remote worker for more than 12 years, articles that talk about how remote work will be the death of business tend to catch my eye. The most recent one featured investor Marc Andreessen and his warnings that remote work isn’t good for younger people in the workforce. I got a kick out of the quotes where he called the office a “continuation of a college campus experience” and where he hinted that remote work has prevented not only the development of workplace relationships, but has stifled office romances. For any of us who has had to manage a team where romance may be in the air, I think we could do without the latter.

He also alleged that remote workers don’t have a sense of connection to their co-workers and that they don’t even know who their neighbors are. I’ve been with a fully-remote team for more than a year now, and I have to say that my relationships with some of my coworkers are as strong, if not stronger, than those with people who live in the same ZIP code.

In my experience, it’s more about putting the time in to understand who people really are and how they work best than it is about seeing them in person every day. It’s about setting shared goals and supporting each other, whether you’re 10 feet away or a thousand miles away. My co-workers are engaged outside the workplace whether they are younger, older, married, or single; whether they have families nearby, or whether they don’t. They take non-career-related classes to broaden their horizons, volunteer with various organizations, and travel. They find their sense of community through a mix of virtual and in-person interactions.

As someone who is older and I hope wiser in the workplace, I personally think that it’s healthy to shift the culture away from the idea that the workplace should be our social center. Wanting to have a life outside of work is a significant reason why many want to embrace remote work situations, where they can live where they like and have less time commuting and more time for other pursuits whether they be solitary or with others. I think some of us have forgotten the things that happened with in-office work that made people uncomfortable and that were difficult to get away from due to close quarters. We’ve all dealt with generally boorish behavior, people trashing the lunch room, unwanted smells, unwanted noise, and HR-worthy happenings at company parties and functions.

Although bad behavior can still happen in a remote environment, somehow it seems easier to tune out. If it gets to the point of needing to file a formal complaint, it’s more likely to be documented through email, chat logs, recorded meetings, and other media. Those “your word against mine” situations may look entirely different in a distributed workplace. I know I’m significantly more productive not working in an office, and that includes both work and non-work tasks. Given my penchant for throwing a delightful loaf of Three Cheese Semolina bread in the oven and timing it to be done just in time for dinner, I’m not sure I’d ever want to be in an office full time again.

What are your thoughts on remote work? Will it be the death of us, or should we not believe the hype? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/13/23

I went to a birthday party Sunday night, which of course overlapped with the Super Bowl, turning it into an impromptu Super Bowl party. It has been years since I’ve actually seen the game played since usually I volunteered to work Super Bowl Sunday because it’s a historically mellow day in the emergency department and urgent care arenas. People would typically only come in if they were truly sick, which meant a fair amount of downtime, the deployment of numerous Crock Pots, food that you could cook in a microwave or toaster oven, and plenty of camaraderie.

The worst place I ever worked on Super Bowl Sunday was labor and delivery. That is primarily because no one came in during the pre-game or the game itself, but waited at home as long as humanly possible before coming in. Once the final scores were tallied, people started arriving in droves and every bed was full, with babies arriving quickly. One year we even had to deploy a team to the parking lot to assist a patient who didn’t quite make it.

It was nice to be able to hang out with family and friends, although I did have to manage a patient callback in the middle of it due to some pharmacy-related shenanigans. The after-hours exchange was flustered and I wasn’t sure about waiting for the usual process to work, but I was happy to give them a ring. My family hasn’t seen me on call in years, so they were wondering what could possibly be going on.

The planned menu was all about the birthday person. By halftime, I was wishing that I had some taco dip, smoked queso, or Buffalo chicken wings. Certain foods just go with football, at least from my past, so maybe I’ll have to make up for it with this week’s meal planning.

I haven’t seen some of my extended family in some time, and it’s always interesting to try to explain to them what exactly it is that I do as a CMIO and how I can still be a physician if I’m no longer working in the emergency department. Usually I explain that I help manage all the clinical systems behind the scenes, including the patient portal and the software that the physicians use when they write their notes, order labs and tests, or send medications to the pharmacy.

Even with advanced age, many family members are used to communicating with their physicians through a patient portal or following their lab results on their phones. It has been fun to watch some of them become more active participants in their healthcare, although there is always the one relative that takes everything they hear from their doctor as gospel and refuses to question anything, even when the only doctor in the family says they might want to ask some questions based on some concerning prescribing patterns.

Some days are more difficult than others, such as when you have to explain to clinicians that although they have great ideas about workflows, they are not always possible. Especially when you are using a certified EHR, certain things, including workflows that are deeply connected to coding, billing, and other regulatory requirements, just can’t be changed. I’m a fan of giving my users choices, though. If you’re not happy with your current state, here are two potential future states that we can actually accommodate based on the EHR and regulatory guidance, so  which do you prefer? Often they end up preferring the current state, especially when it has been designed by board-certified clinical informaticists who have observed thousands of patient care encounters and who have worked in numerous EHR and documentation systems. 

Other difficult days happen when end users are raging against third-party requirements, but blaming it on the EHR. Sometimes these third parties have created the requirements because they are good for patient safety, and I’m not likely to budge on those. For example, when a physician doesn’t believe that they should have to associated a diagnosis with a prescription. I can certainly empathize with those two extra clicks, but as a primary care physician, I think it’s important that patients know what condition they are taking a medication to treat.

Additionally, when you work for a healthcare organization that has decided that this is a good thing and has created a policy and procedure around it, there’s not much I can do for you as an informaticist other than teach you the most efficient workflows and show you how you can use your clinical support staff to help you make some of these associations as they prep patients for their visits.

I’m always shocked by physicians who don’t know where their grievances should be directed. For example, if they don’t like the clinical policy and procedure, they need to take that up with their department chair or the chief medical officer, not the CMIO or a member of the clinical informatics team. I think sometimes we wind up at the tip of the proverbial spear because we are actually in the clinics interacting with people on a regular basis, which might not be the case with a CMO or a department chair, especially in a geographically diverse organization.

The best days are when someone proactively reaches out to you to let you know that they think a feature that you have recently deployed is cool. I remember vividly the technology that I deployed that generated the first non-hate email from a physician. That was more than a decade ago, and those emails are few and far between.

At my current institution, we were recently early adopters of a solution that I think is pretty darned revolutionary, and most of my physicians don’t have any idea how cool it really is compared to other commercially available options. It’s leaps and bounds better for our patients, has multilingual support, and uses data already in the EHR to drive a better user experience. However, because it has a purpose that some of our providers don’t think is necessary, it’s not getting the love it deserves. We’ll see if more users start to engage with it as they develop a greater understanding of what it can do, and I’ll still hold out at least a little hope that some clinician eventually says thank you.

Valentine’s Day is coming up on Tuesday, so consider showing a little love to your favorite clinical informaticist. If you don’t want to impress them with a witty card, conversation hearts, or an edible treat, consider thanking them for trying to make your user experience the best that their budget and staffing allows.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/9/23

Mr. H’s current poll asks about the methods used by patients to send medical information to clinicians in the past year. I wasn’t surprised to see that patient portal messages are leading the way, followed by phone calls and electronic forms. Mailed paper forms and faxes are at the bottom of the list, as expected.

It would be interesting to see a poll around the topic of “In which ways have you had productive communication and/or a positive outcome” when looking at electronic communication and portal messages. I recently tried to use the online scheduling feature offered by my dermatologist, with whom I am well established. There were no spots available until June, so I used the feature located on the online scheduling page called “request an appointment.” I mentioned that the request was to be seen for a suspicious and changing mole that had already been seen by my PCP, who recommended I see dermatology. I listed my preferred days and times, but basically said that due to the nature of the issue, I was willing to take any open appointment.

Four days later, I received a portal message back that “we are not currently offering online appointment requests” and was directed to call the academic medical center’s access center. If you’re not offering online appointment requests, I might recommend disabling that feature so that patients can’t use it. I’ve used the access center before to request an appointment with this dermatologist and it’s a centralized scheduling nightmare. For urgent issues, they take a message and route it to the office who hopefully calls you, and then if you’re like me and tied up on calls and in meetings all day, you play phone tag, which is exactly what the online requests are supposed to prevent.

I mentally said, “forget it” and made an appointment with a new dermatologist who was happy to get me in within 48 hours given the history and PCP referral. Since my clinical issue was resolved, we will see if my original dermatologist ever follows up, who now has a concerning message documented in my chart. We are going on six weeks so I’m not holding my breath, but for a patient who isn’t as persistent in getting care, it could be tragic.

From Jimmy the Greek: “Re: chatter about using ChatGPT in healthcare. It might amount to the scene out of ‘A Charlie Brown Christmas’ where Lucy is listing off phobias and asking Charlie Brown if he has them.” I’ve certainly seen some interesting applications, or should I say attempted applications, of ChatGPT recently. Today brought an email from a colleague that was most likely produced by some sort of bot since the syntax didn’t sound anything like her usual written patterns. I found it pretty annoying since what she sent was a reply to a pretty straightforward question that could have been answered in five words or fewer. It’s fine if you want to play around with it, and since we are both informaticists, it could have been “hey, check out what ChatGPT created as a reply,” but since there had to be a few more back-and-forths to get the original question answered, it wasn’t much of a time saver.

Everyone is trying to figure out how to streamline workflows in ambulatory medical practices. Solutions being implemented for pre-visit flows include patient portal-based check-in that can be completed at home up to a few days prior to the visit; chatbot-based flows that can be completed either at home or upon arrival; and self-check-in kiosks. A recent article in the Annals of Family Medicine looked at a “self-rooming” process implemented in primary care clinics from October through December 2020. Researchers found that most patients preferred self-rooming, although some felt less welcomed, more lost or confused, more frustrated, or more isolated compared to escorted rooming.

Based on the overall positive response, the organization decided to roll out the process to all remaining primary care clinics, and it will become a permanent change for the institution. The process design included some decidedly low-tech features, such a laminated wayfinding card that was used by the patient to reach their exam room. Once the visit was over and the room had been cleaned and prepared for the next patient, the card was returned to the front desk so that another patient could be directed to the newly prepared room.

I recently learned that my residency training program is celebrating its 50th anniversary and will be holding a gala in honor of the milestone. Unfortunately, they didn’t start promoting the event until 60 days out, which isn’t nearly enough lead time when you consider that most of us open our clinic schedules up to a year in advance and on-call schedules are done at least 90 days in advance. I circulated the information to my class and the residents in the years above and below mine, but it looks like only the handful of folks who can travel without taking off work are likely to attend.

I had no idea the program had reached such a major milestone and it really seems like a missed opportunity to bring people together. Other organizations I’m part of that have had similar events have sent cards anywhere from six months to a year in advance telling people to save the date, which is key if you want to try to get a couple hundred physicians together in the same place at the same time.

It’s technology upgrade time at the House of Jayne and I’m very happy about my first purchase, which was a Kindle Paperwhite. I’ve been using the Kindle app to read on a decade-old iPad and decided I wanted something smaller and lighter for travel. Amazon was offering a deal on the high-end version as long as you didn’t mind buying it in Agave Green. I’m thrilled with the purchase and have already burned through two books. I’m still getting to know all the features, but it’s a significant step up from my previous reading situation.

I also had to break down and replace one of my monitors, which started having some issues with static electricity. Every time I touched my keyboard tray after walking on the carpet and accumulating a charge, the monitor would suffer a blue screen of death that required a reboot to bring it back to life. Tomorrow is unboxing and installation day, so wish me luck as I crawl around and under the desk to get things hooked up. Still on the to-do list after that is a new phone, but that’s a much larger project, especially since I want a full featured Android device that’s on the smaller side.

What’s your favorite piece of new technology? What’s the one thing you’d recommend everyone consider getting? Leave a comment or email me.

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