Curbside Consult with Dr. Jayne 6/26/23

The clinical informatics community is buzzing with the news that ChatGPT was used to “pass” a simulated clinical informatics board exam. A recent article in the Journal of the American Medical Informatics Association describes the process used to evaluate the tool and goes further to question whether or not the general availability of AI tools is signaling the end of the “open book” maintenance of certification programs that many board certified physicians, including clinical informaticists, have come to enjoy.

Many of the medical specialty boards have moved to the ongoing maintenance of certification process, shifting away from the high-stakes exams that they used to require diplomates to take every seven to 10 years. My primary specialty board, the American Board of Family Medicine, began to pilot the maintenance of certification process in 2019. Since it had been a while since I practiced full-scope family medicine (which includes obstetrics), I was eager to try the new format, which delivered questions every quarter that could be answered using available resources such as textbooks, journal articles, or online references. This approach is a lot closer to how we actually practice medicine – which involves being able to investigate to find answers when we’re not able to pull the information from memory. High-stakes exams such as the ones we used to have aren’t reflective of our ability to deliver good care and such exams have been shown to negatively impact a variety of demographic groups.

The authors of the article tested ChatGPT 3.5 with more than 250 multiple choice questions drawn from a well-known clinical informatics board review book. ChatGPT correctly answered 74% of the questions, which leads to questions about whether or not it might be misused in the certification process. It was noted that ChatGPT performed differently across various areas within the clinical informatics curriculum, doing the best on fundamental knowledge, leadership and professionalism, and data governance. It did the worst on improving care delivery and outcomes, although statistical analysis didn’t find the differences across the categories to be statistically significant. The authors hypothesize that ChatGPT does better in areas where the questions are recall-based as opposed to those that emphasize application and reasoning.

They go on to propose that “since ChatGPT is able to answer multiple-choice questions accurately, permitting candidates to use artificial intelligence (AI) systems for exams will compromise the credibility and validity of at-home assessments and undermine public trust.” Based on some of the conversations I’ve had with patients over the last three years, I’m not sure patients are too impressed with the idea of board certification in the first place. It feels like some patients put more trust in what they see on TikTok and from various health influencers than in what I’ve learned over the last 25 years in family medicine. The phenomenon has definitely gotten worse since the COVID-19 pandemic turned healthcare delivery systems upside down.

The initial certification exams for specialties are still of the high-stakes format, and some specialties also require an oral examination. Those exams are proctored in order to ensure the integrity of the testing process. When I sat for the initial certification exam in Clinical Informatics nearly a decade ago, it was administered at a corporate testing center, and I took it alongside people taking the real estate licensing exam and other standardized tests. At least at the facility where I took it, I found the process to be nerve-wracking since there was a lot of waiting around and dealing with proctors who were trying to apply different standards to the different types of test takers. For example, my particular exam protocol required me to turn out my pockets and prove that there was nothing in them, but others didn’t have to go through the same steps. It created a feeling of overall uncertainty and was even worse when I needed a tissue due to a runny nose during the exam, when I was treated like I was trying to cheat somehow. Needless to say, I was happy when the maintenance of certification approach was brought to both of my specialty certifications.

One of my colleagues had asked why the use of ChatGPT was a problem since the process already allowed the use of external resources to answer the questions. (Examinees are prohibited from speaking with other people, however.) The authors addressed this in the article, noting that the current process requires examinees “to process and assimilate the information found online to determine the correct answer to the exam questions” where “when using LLMs like ChatGPT, exam takers can simply manually enter or automatically scrape the question into the freely available web interface and be given an instantaneous result. This transaction requires no prior knowledge of theory or application and eliminates the need for reflection, reasoning, and understanding but can still result in a passing score.”

The authors do note some limitations of their study, including the fact that they drew all the questions used from a single board review book. That approach may not be representative of the full range of questions used or content delivered on the actual board certification exam. Additionally, ChatGPT couldn’t be used to address questions that contained images. They go on to say that given the situation, certification bodies need “to explore new approaches to evaluating and measuring mastery.” They suggest that testing may need to include more complicated or novel question types, or may need to include images or graphics that can’t be easily interpreted by current AI technologies. They do suggest that “in some situations, there may be a need to consider reverting to proctored, in-person exams,” although I think there would be a general revolt of diplomates if the board actually considered this approach.

It should be noted that the maintenance of certification process currently includes an honor code attestation, where diplomates certify that they’re following the rules on the use of reference materials and that they aren’t consulting other people for help with the questions. It would be easy enough to broaden that statement and ask diplomates to agree to avoid using AI assistants or other similar technologies when completing their maintenance of certification processes. Personally, I’m glad to be at a point in my career where I might only have to recertify each of my specialty boards one more time. I don’t envy those in earlier phases of their careers who will have to tiptoe through the veritable minefields that new technologies are creating.

What do you think about ongoing proficiency exams, whether for physicians or other industry professionals? Are they useful for demonstrating competency and ability or just a way for certification bodies to generate cash? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/22/23

I continue to receive emails from multiple vendors addressing me as “Hey Jayne” and demanding that I schedule a call, or alternatively, respond to the email to tell the sender I’m not interested. I can guarantee I’m not going to respond to an email with that salutation, nor am I going to respond to bullying.

I keep trying to block the senders, but they’re somehow still getting through from at least two organizations. You might think that continued non-response would also be a ticket to be taken off of their marketing list. I’m also getting hit with solicitations for speaking engagements at dubious “conferences” that sound decidedly pay-to-play, but those seem to be a little easier to block.

In his recent Healthcare AI News roundup, Mr. H mentioned the inclusion of skin conditions in the Google Lens visual search tool. I decided to give it a whirl and ran three pictures of known dermatological findings through it. The tool scored zero out of three, so I think there’s still some opportunity for improvement. Granted, one of the conditions isn’t super common and it suggested a condition that is often confused with the actual diagnosis, but the other two submissions were very common, and I was surprised it didn’t do a better job with those.

When technology companies are marketing directly to consumers, it’s hard for primary care physicians and others who have the patient’s interests at heart to get ahead of the messaging and explain how these tools might or might not be used. It’s one more thing that overburdened clinicians need to add to their list of anticipatory guidance for upcoming patient visits.

AI continues to be a hot topic both within the US and around the globe. Various European consumer protection organizations are calling for investigation of AI systems in the interim before European Union regulations on the systems go into effect. Concerns range from the risks involved when AI generates content that mimics human work to the risk that AI could manipulate humans into doing things that will harm them. The European Union is creating rules for technology use, but they won’t go into effect for a couple of years.

Other countries are addressing the issue on a case-by-case basis, with Italy ordering OpenAI to stop processing user information during the investigation of a data incident. Nations such as France, Spain, and Canada are also looking into the technology. The next few months will be interesting as far as the continued discussion of AI and how it can best be used for the greater good.

I started doing some clinical work with a new organization and they’re eager to get my informaticist opinion on their EHR and how they might improve it. The first thing I recommended was some optimization to improve usability by putting the most commonly selected items on various menus in positions where they will be the easiest to select for the greatest number of patient visits. The EHR analyst couldn’t figure out how to do it, so he had to open a ticket with their vendor. It turns out that the EHR doesn’t allow this level of configuration, but rather forces items on the menu to be displayed in the order in which the menu items were built in the system’s back-end utility.

I remember seeing that kind of nonsense on a system I implemented back in 2009, but I thought that vendors had moved beyond that. It’s no wonder that physicians are complaining about scrolling since they are having to do more of it than they should.

Registration is open for the LOINC conference being held October 17-20 in Atlanta. Sessions will focus on health data interoperability issues. Attendees include providers, patients, laboratory organizations, government entities, software vendors, device manufacturers, researchers, and students. The first day will be “devoted to LOINC learning,” with educational sessions to support newer users of LOINC and grow expertise in advanced users. Subsequent days will include public meetings of the LOINC committee as well as presentations from the LOINC community. Proposals are still being accepted, and for those unable to attend in person, there is an option for online participation.

Speaking of conferences, one of my favorite readers is attending a meeting this week and sent some musings about his experiences. The meeting is the Multidisciplinary Association for Psychedelic Studies annual Psychedelic Science conference,  being held in Denver. Organizers estimated the potential attendance at 10,000 and continuing medical education credits are being offered. The conference agenda is fascinating, and my reporter has found it to be “wildly informative” and full of information about topics he had not previously been aware of.

Based on his reports, it feels like the event was pretty mellow and lower key than some other conferences. There was at least one EHR vendor was exhibiting although I didn’t catch which one it was. I imagine the vendor has to have either some highly specialized content, or alternatively, a fairly significant ability for clients to customize to meet their needs.

Other interesting offerings included sessions on the convergence of wearables, neuroscience, and psychedelics; a history of the discipline; discussion of rituals; practical techniques for prayer practice; the use of psychedelics in alcohol use disorder; and a stomp class.

The use of drugs like ketamine and psilocybin also features prominently in the agenda. I have worked with a handful of patients who have had life-changing experiences with ketamine treatment, so I hope people are open minded when considering some of these non-mainstream treatments. The website’s chatbot told me the conference was sold out except for single-day passes for Friday, so it sounds like plenty of people are interested in learning more.

I don’t have any conference travel planned for a while, so I’ll just have to live vicariously through my readers. If you’re attending a meeting we haven’t historically reported on, feel free to send your thoughts and observations. Or if you have ideas of meetings that you think HIStalk should be covering, please pass those along as well. As I put together my conference plan for the rest of 2023 and the first half of 2024, nothing is off the table.

Do you have any work-related travel that you’re looking forward to? What makes it unique or appealing? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/19/23

I mentioned a few weeks ago that I have been having issues with my health system’s online billing functions. I was receiving paper statements before I received the online bills and couldn’t figure out how to adjust it so that I didn’t get paper statements.

At a recent visit, I asked the staff to see if they could adjust it on their side, and they said they would try. Interestingly, they also refused to accept my co-pay at the time of service, which is a big negative as far as revenue cycle management, so I wasn’t hopeful that they’d be able to get my account set up in a best practice fashion.

It looks like the “turn off paper statements” piece worked because I received an online invoice today. It included the co-pay (no surprise there) but also an unexpected co-insurance amount that doesn’t match how my insurance works. I haven’t even received the Explanation of Benefits document yet, so I’m not about to pay it. We will have to see how this cycle continues to unfold.

We had some family adventures in healthcare this weekend, with an unexpected injury that required attention beyond what I could manage with my first aid kit. Of the urgent care facilities in the area, some had spots available for online check-in, but others didn’t. Since we wanted a minimal wait, we opted for the one that was displaying available capacity, which is also an organization that I know fairly well.

As expected, walking in with a bleeding injury of the head puts one at the front of the line whether you have an appointment or not. Unfortunately, the provider wasn’t a great communicator and was mentioning how busy she was and how many other patients she was tending to rather than making the patient feel at ease.

She tried to downplay the injury a little, but fortunately the patient followed my advice and advocated for the treatment that is actually standard of care – they only knew that because I had prompted them after evaluating the injury and referring them to in-person care. The alternative treatment offered is typically less time-intensive for the provider, but results in poorer outcomes for this specific patient scenario. Most patients don’t know the difference, and it’s sad when our healthcare system is repeatedly putting time pressures ahead of patients.

After resolving the situation, we headed out for some Father’s Day celebrations, and then I came home to catch up on some work. It was timely that Mr. H called out this New York Times story on the level of moral crisis that physicians in the US are facing. Not a day goes by that I don’t hear a story from a colleague about this issue.

I’ve worked for organizations whose relentless focus on profits led to inappropriate prescribing behaviors as well as excessive ordering of tests. In one urgent care position, management justified these actions by saying, “we’re still only one-sixth the cost of a visit to the emergency department” and regularly presented me with reports that illustrated how much of an outlier I was to my peers when looking at the sheer number of prescriptions ordered. It should be noted that this organization had its own in-house pharmacy for which it didn’t submit insurance claims, so all prescriptions generated revenue.

From a conscience standpoint, by the time I worked for this organization, my prescribing habits were well established. I didn’t fall into the trap of trying to keep up with my peers in a way that didn’t make sense for clinical quality. Due to my training and prior experience, I also tended to make more clinical diagnoses using decision support tools and algorithms rather than tests and imaging studies, so of course that was an issue as well.

Eventually the organization figured out that my clinical skills and procedural abilities allowed me to see patients at a pace and volume that still made them money, so they left me alone, and eventually, the reports stopped coming my way. At the same organization, I also had to deal with some occasional patient safety issues as they encouraged me to practice outside my comfort zone with certain procedures, forcing me to have difficult conversations about my refusal to treat patient care like the Wild West.

Once they transitioned from being physician-owned to being owned by non-clinical investors, I knew my time there was limited. Others saw the writing on the wall as well, and now the organization can’t even keep its locations staffed. Not because there’s a shortage of clinicians, but because there’s a shortage of those who want to work there.

The article details many of the issues I’ve run across while in practice or in talking with my colleagues. Physicians are reluctant to speak out when they find themselves in these situations, because it’s been reinforced that they need to be team players, or they have experienced that reporting their concerns can lead to retaliation.

Former physician peers have lied on exit interviews because they were afraid that what they said would make the rounds in the physician lounge and come to haunt them in their new positions. Even in large cities, the physician community can be small. Powerful physicians on a given hospital’s medical staff can make things difficult for physicians who are younger, newer, or who otherwise have less political clout.

When I initially entered practice, I was once called out by a senior physician who felt I wasn’t giving him enough referrals and demanded to know why. I’m not sure who I could have complained to about that since he was not only chair of his department, but president of the medical staff.

That situation is relatively mild compared to some of the pressures that physicians experience today, especially those who work in segments that are largely controlled by private equity organizations or who are under strict productivity models for their compensation. Many physician contracts have clauses that would be problematic for other classes of employees.

I was recently presented with a contract that specified compensation based on the concept of a 12-hour shift, with no extra pay for additional time spent. When I asked for the language to be changed, I was told no, that all the other physicians already working had agreed to it and they weren’t willing to alter it. Needless to say, I won’t be working for that organization. Whether they’re lying about what other physicians have agreed to or just being difficult, it’s a decent indicator that they don’t value their physicians’ time. I guarantee they wouldn’t offer that contract to a nurse.

When physicians don’t feel valued, it creates psychological challenges that make it difficult to deliver good patient care. Whether consciously or subconsciously, decisions are made in the heat of the moment that can impact patient care but are based on the provider’s current situation.

I suspect that’s what my family member experienced today, when they were offered two different but non-equivalent management plans with a comment that it was up to the patient to decide. The difference in the clinician’s time was about 10 minutes, but sometimes that 10 minutes is what keeps you from going to the bathroom, eating lunch, or taking care of two more patients waiting for care. It’s a sad commentary on what many of us are facing every single day with patients caught in the middle.

If you’re in a non-clinical role, do you consult clinical colleagues for advice prior to seeking care for yourself or a loved one? Have you had to advocate for yourself or someone else for medical care in the last year? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/15/23

I recently took a smaller version of The Great American Road Trip and made it a point to visit some historical roadside attractions. In the 1950s, it was all about seeing the USA in your Chevrolet (or equivalent) and families might have stopped at various quirky museums or points of interest.

One of the places I visited had a collection of antique cars. I was struck by the idea of this 1960s era Amphicar. In some ways it’s a solution in search of a problem, which is something we see often in the world of healthcare IT. I have so many vendor emails hit my box each week promising to solve problems that I didn’t even know I had that I can’t keep track of them all.

The Amphicar was innovative, but didn’t make it big, ceasing production only four years after it began. Sounds like a lot of the products I see out there.

A group of organizations including AstraZeneca, Elevance Health, Geisinger, and UCSF have come together to publish a framework for evaluating digital health products. The goal is for care delivery organizations, health insurers, and trade groups to use it to determine whether digital health products are evidence based. The authors examined 70 frameworks that were created to assess the evidence around digital health intervention, determining that the existing frameworks lacked the specificity needed by healthcare organizations.

Sometimes people forget that digital health interventions can be as important and useful to patients as medications and surgeries. For example, an appropriate intervention to help patients stop smoking can prevent lung cancer. Digital coaching to manage body weight can lead to reductions in heart disease and stroke. The authors identified certain requirements as being potentially non-negotiable for organizations depending on their needs: HIPAA compliance, FDA clearance, and ability to be understood by patients with a fifth-grade reading level were examples.

Organizations are instructed next to use existing evidence assessment frameworks that have been defined for non-digital interventions. Following that, they should apply the new framework’s 21-item supplementary checklist for considerations specific to digital health. These may include elements such as assessing an intervention for selection biases, looking at data gaps, or ensuring that underserved patients were included in the product’s clinical trials.

According to the article, there are 300,000 health apps and 300 wearables in the marketplace, so being able to determine quality of an intervention is key. I wonder how much traction this approach will get, especially when we’re already struggling to make use of evidence quality in non-digital interventions. One of the hottest topics among physicians in my area is the surge in providers offering non-evidence-based hydration and vitamin infusion services. Comments such as “the patients want it, and I don’t see the harm” win the day, along with the potential for revenue. I’ll be watching closely to see how the world of evidence for digital interventions plays out.

Mayo Clinic is planning a $1 billion expansion and its new clinical spaces will incorporate data from patient wearables. Clinicians will have the opportunity interact with patient data elements such as pulse, steps, and sleep. I got a chuckle out of the fact that the article specifically called out Mayo’s “marble-filled lobby” since so many hospitals are overly proud of their non-patient-care spaces while patients may struggle to have basic needs met.

I also found it interesting that it mentioned the tension between Mayo’s lobbyist and Governor Tim Walz over the potential for penalties against hospitals that have excessive cost growth. The project is part of Mayo’s plans to transform the city into an international medical hub. The system has pitched the state, county, and city for $500 million in public funding for campus-serving infrastructure improvements. The new expansion will impact several blocks in downtown Rochester and is intended to make the campus more streamlined and modern, eliminating wayfinding confusion and harmonizing the patient experience. Construction is slated to begin in 2024.

Northwell Direct has inked a deal with the US State Department to offer telehealth consultations to patients seeing Department of State medical professionals around the world. The offering will apply to US government employees and their families posted outside the US. Consultations will be available 24 hours a day, seven days a week and requests will be triaged for assignment to the appropriate Northwell provider staff in more than 100 specialties and subspecialties. Those providers will also provide medical clearance services before employees are sent outside the US, as well as clinical case reviews. Northwell Health also partners within the US with Teladoc for additional virtual care delivery services, so it’s not entirely clear how this will all fit together.

Speaking of government, the Surgeon General of the United States has issued an advisory about the impacts of social media on adolescent and child mental health. The report notes that social media use is nearly universal in those ages 13 to 17 with nearly two-thirds reporting daily social media use and one-third reporting use of platforms “almost constantly.” It goes on to conclude that “social media presents a meaningful risk of harm to youth” with those spending more than three hours daily facing double the risk of mental health problems as others who spend less time on social media.

The long and short of it is that “we cannot conclude social media is sufficiently safe for children and adolescents” and lists steps that can be taken to reduce the risk of harm in those groups. These include: reaching out for help for those negatively impacted by social media; creating boundaries to balance media use; being selective about what is posted and shared online; and addressing cyberbullying. A short summary is available or you can view the full advisory.

Many of my family physician colleagues are still trying to figure out how to balance their use of telehealth within the context of traditional primary care practice. A recent report from the University of Washington Center for Health and Workforce Studies showed that while there was limited data about how medical assistants participate in the telehealth setting, those staffers can transition to virtual roles following additional education and training. Unfortunately, I think a lot of organizations just try to throw people in a role without fully thinking it through. We saw this a decade ago, when practices decided they would just turn their medical assistants into scribes but didn’t think through how to create an appropriate training program or how that role transition might otherwise impact office dynamics.

More on the topic of transitioning historically in-person tasks to virtual caregivers. I was talking with some CMIOs earlier this week about whether they think virtual nursing is going to solve some of their staffing issues. Systems such as Washington-based Providence and Arkansas-based Mercy have already rolled out programs and labeled them as successful, preparing for expansion. Among the group, several were enthusiastic about the idea, and one said their system was in the process of rolling it out using internal resources. However, another said her system was about to sunset the concept because it hadn’t yielded the savings it anticipated. Although that organization’s efforts did dramatically reduce its dependence on travel nurses, those savings were countered by expenditures for hardware and third-party staff management.

Has your organization dipped its toes into the waters of virtual nursing? How is it going? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/12/23

I was intrigued by a recent study published in in JNCI Cancer Spectrum that looked at how capable ChatGPT is when asked questions about common cancer myths and misconceptions. The study, performed with the Huntsman Cancer Institute, compared ChatGPT output against social media.

I understand the premise. Many patients are getting their information from social media, friends, family, and people they know on a personal basis rather than being able to learn key information from their care teams. Sometimes this happens because people may be receiving cancer diagnoses via their patient portal accounts due to immediate-release results policies stemming from governmental regulations. Other times it happens because patients are unable to reach their care teams when they have questions or they don’t feel that their team is listening to them.

Cancer is also a condition that leads people to leave no stone unturned as far as investigating treatment options and potential outcomes. It’s one of the scariest diagnoses you can receive, and even as healthcare professionals, we are rarely prepared for it. There can be a lot of uncertainty about treatment plans and sometimes even about diagnoses, and patients often seek additional information or alternative treatments as a way of trying to maintain control of their own health and lives.

Generally, physicians appreciate working with engaged and involved patients who want to understand the pros and cons of various treatment options. But a number of industry forces create pressure on that scenario, including time pressures, insurance limitations of treatment options, and availability of options in a particular geographical area.

In fairness, the study was performed shortly after ChatGPT became widely available, so it may not be entirely applicable today. Researchers used a list of frequently asked questions that they sourced from the National Cancer Institute’s “Common Cancer Myths and Misconceptions” website. They found that 97% of the time, the answers from ChatGPT were in agreement with the responses provided by the National Cancer Institute.

In contrast, approximately one-third of social media articles contain misinformation. Distrust of medical institutions and medical professionals has grown exponentially since the beginning of the COVID pandemic, and patients may decide not to pursue standard treatments based on information they’ve heard from friends or family or might have found online. This can lead to negative outcomes for patients, who may expose themselves to increased mortality rates when selecting unproven treatments.

Even when considering medical professionals as a source of information, I’ve seen instances where misinformation can be spread. Sometimes patients consult neighbors or friends who might be physicians, but who are in specialties nowhere near the patient’s area of need. I’m not even an old timer, but I know that the treatments for various cancers have progressed exponentially since I last cared for patients with those diagnoses. I’m always careful to refer patients back to their oncologists, hematologists, or surgeons, but not everyone does that. I’m part of several Facebook groups that have exclusive physician membership, but we still see bad answers circulating when physicians who are patients themselves pose certain questions.

For physicians who are actively caring for cancer patients, knowing that patients might receive medical misinformation can increase their feeling of burden in delivering care. One of my colleagues feels she can never disconnect from managing patient portal messages because she feels that if she doesn’t answer the patient’s questions promptly, they will be more likely to go down the proverbial internet rabbit hole, leading to greater stress for the patients and their families. When we discussed having boundaries around these kinds of interactions so my colleague can have a break, she said she’s thought about it, but feels that correcting the misinformation later actually requires more work and emotional effort than just being continuously available to field questions. It’s a difficult spot for clinicians to be in when they feel called to serve their patients so broadly.

The study involved a blinded review of the answers to the questions, grading them not only for accuracy , but looking at word count and Flesch-Kincaid readability grade level factors. Answers from both sources were less readable than recommended by most health literacy advocates, but the responses from ChatGPT tended to use more words that led to a perception of hedging or uncertainty. The questions evaluated were striking, and included items such as:

• Is cancer a death sentence?
• Will eating sugar make my cancer worse?
• Do artificial sweeteners cause cancer?
• Is cancer contagious?
• Do cell phones cause cancer?
• Do power lines cause cancer?
• Are there herbal products that can cure cancer?
• Do antiperspirants or deodorants cause breast cancer?

I have to say that I have heard at least four of these questions from friends and family members in the last month or so,  and I am not surprised that they made the question set. The issue of antiperspirants and breast cancer risk comes up often in some of my social media channels, as to the questions about eating sugar and using herbal remedies.

Full documentation of both the National Cancer Institute answers and the ChatGPT answers are included in the article, in case you’re curious.

In addition to the question of accuracy, there’s also the question of specificity. Researchers noted that while the ChatGPT answers were accurate, they were also more vague than the comparison answers from the National Cancer Institute. This could lead to patients not thinking the answers were valid, or to them asking additional questions in clarification.

There was also concern about patients who might ask ChatGPT questions about cancer that are less commonly asked, and which might not have a large body of knowledge to form a training database. The study was also limited to the use of English, which has an impact on its applicability to broad swaths of the US and the world. As a patient and knowing what I know about the propensity for ChatGPT to hallucinate, I don’t think I’d want to go there for my medical information.

Given the newness of the technology when the study was performed, it would be interesting to see how newer versions would perform in the same circumstances. There are a couple of possibilities. It could become more accurate, or it could go completely off the rails as we’ve seen it do with some queries. Additionally, the content used for the models typically only runs through 2021, so current data might influence the results. I hope researchers continue to look at how ChatGPT might be useful as a healthcare adjunct, and where it might serve patients best.

What do you think about ChatGPT as a debunker of medical misinformation? Will it tell patients to inject bleach to kill viruses, or declare it to be an insane strategy? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/8/23

When I certified, one of the major components of the clinical informatics board exam curriculum was public health informatics. As a family physician, I understand the value of public health, and especially after the pandemic, most of us understand how underfunded it is in the US.

Various studies show that a dollar spent on public health has the power to reduce future healthcare spending by anywhere from $11 to $80 depending on the nature of the intervention, yet it’s still not where we prioritize our spending. The reality is that prevention isn’t sexy and doesn’t make money for the people who pay for lobbying, but a girl can hope that eventually policies will shift in a way that makes better funding a reality. A recent article in the American Journal of Public Health looked at the US life expectancy compared to that of other nations over the better part of the last century.

The author found that the US life expectancy began falling in the 1950s and continued to worsen over the last four decades. He also noted regional variation across different parts of the US, finding that the Midwest and south-central states fared worse than other regions. Almost a third of the US states have 60% or fewer of their children vaccinated, and that’s a basic public health intervention that is proven to save lives and reduce days missed at work and school. When people don’t see the value in that, it’s hard to get them on board with funding more “exotic” interventions like community gardens, food pantries, nutrition and cooking classes, and healthy environments for exercise and community activities.

As a clinician, it’s difficult to watch the decisions that health systems continue to make as they prioritize high-earning surgical subspecialties and cutting-edge interventions while they refuse to fund staff expansions in primary care. I’d love to see more research looking at the long-term cost savings and quality of life improvements when preventive care is prioritized.

I had that on my mind when I came across an article about how Regenstrief Institute is working with the National Association for Chronic Disease Directors on a project that will use EHR data to estimate chronic disease burdens at the national and local levels. I wasn’t aware that there was a project in the works for a Multi-State EHR-Based Network for Disease Surveillance (MENDS) or that local public health organizations will be able to tap into it.

The goal is for the EHR-derived data to replace more manual efforts, such as health department workers having to canvas at the community level. There are barriers to the data sharing, however, including the lack of a mandate for hospitals and provider organizations to share their data with public health agencies. Other potential issues include lack of accuracy in diagnosis coding and lack of staffing at public health agencies.

The Office of the National Coordinator for Health IT is looking for feedback on expanding the US Core Data for Interoperability classes and elements. The list of data elements was expanded to better reflect the clinical quality measures that are in use with Centers for Medicare & Medicaid Services quality reporting programs and also to incorporate greater use of FHIR-based reporting. The draft list of data elements for USCDI Version 4 will be open for public comment until June 30.

I had the chance to help a colleague out today when they were working on a specific formatting issue for a scholarly work. It’s been a long time since I’ve published anything, and as I was digging into the details, I was impressed by the number of resources available on the internet. Back in the day when I was a regular on the presentation circuit, you had to have a stack of reference manuals to make sure you got everything right before submitting your paper, which had to be sent in a box since it was typed, double spaced, and printed with multiple copies. As we think about standards in healthcare and standards in the digital universe, it’s intriguing to remember that some of the first usability standards were set for written scholarly works. When papers were all written with the same stylistic features, it made it easier to understand the content and less likely for the reader to have to wade through a confusing format. Usability principles have evolved over time, but still adhere to a common core of thinking, and it was nice to be pulled in as an “expert” on the topic.

I’ve been back on the road recently and summer travel is in full swing. Unfortunately, I started today’s leg of the trip at an airport that decided it would be good to shut down 50% of the women’s restrooms for maintenance at a time when they had 20 arrivals and departures in the hour surrounding my flight. Needless to say, it created some bottlenecks.

I always wonder if people exhibit the behaviors that I see in the airport during their “regular” lives. At least where I live, I never see people ordering hard liquor with their breakfast, but you see it a lot at the airport. In the boarding line today, I had two guys behind me chugging beers after they had been told they couldn’t take them down the jetway. There was also a group of high schoolers, the majority of whom had full-size bed blankets for their trip and were juggling all their gear while trying to figure out how to repack to try to get it all on board. I felt bad for their chaperone, who had largely lost control of the group. I’ve chaperoned groups of teens before and we always had strict rules about what they could bring or not bring so that we could avoid issues at the gate like I saw today.

On the plane, one of the students in front of me spent the majority of the flight kneeling backwards in her seat, talking to the person in the row next to me. Their chaperone, who was in the same row, just ignored it. Although it was annoying, I remember what it was like to be a teenager, so I decided to just tune it out. There have been so many changes to the typical US teen experience during the last couple of years that this might the only trip these kids have taken (or might ever take), and it’s good to see schools who are encouraging their students to see the world. I also learned today that you can’t take a bowling ball through the TSA checkpoint at this particular airport even though the TSA app says it’s permitted.

What’s the most interesting thing you’ve seen during travel this year? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/5/23

I spent the weekend largely unplugged, catching up on some household projects and indulging my need for quality time in the kitchen. My last-minute run for pickling and baking supplies created an interesting assortment of items at the grocery checkout, but when you like to do things old school, sometimes you really do need three kinds of vinegar and a jar of bay leaves.

My pickling efforts were slightly more successful than the baking one, which resulted in the first time I’ve ever had to admit that it’s possible to have too much sugar in a cake. When I finally reconnected this weekend, my inbox seemed to be forming a theme around the topic of healthcare IT gone bad.

First, there was the story of the National Eating Disorder Association chatbot being decommissioned after it recommended harmful behaviors, including dieting and calorie restriction. The organization at least owned the problem, stating that the advice being given was “against our policies and core beliefs.” Apparently the chatbot, called Tessa, was created around proven cognitive behavioral tools that have been shown to reduce eating disorders. However, it appears that programmers may have tried to make it work more like ChatGPT and ended up running off the rails. The original tool used pre-programmed responses and was not intended to be adaptive or to use AI features.

It’s been interesting to watch chatbots evolve over the last couple of years. Quite a few vendors claim to have created AI-enabled chatbots, but when you look behind the scenes, they end up being sophisticated (or sometimes not so sophisticated) decision trees. I’ve seen some alleged healthcare chatbots that are constructed by teams that don’t even have clinicians on them, which is truly worrisome. It’s always surprising to see the logos of organizations who have bought into the hype and probably never asked to speak to the clinical person behind the proverbial curtain.

When ChatGPT came to the forefront in recent months, I saw several companies try to leapfrog good design and development principles in an effort to be able to say that their product was using the technology. I’ve worked with enough technology organizations and on enough different projects to know that trying to cut steps out of the software development lifecycle is never a good idea.

The steps that organizations typically try to cut are the ones that are the most critical in my book: planning, analysis, and testing. They forget that the whole point of the process is to be efficient from both time and cost perspectives. When you rush to market, you usually end up paying for it on the back end with broken functionality and unhappy users. The piece that it feels like people forget though is that when you’re in healthcare IT, that can translate to patient harm. Developers always need to remember that regardless of whether you call them users, consumers, or patients, the person on the other side of the code is someone’s parent, child, friend, or loved one.

The next story wasn’t about AI run amok, but was about more than 400 Grail patients receiving notices that they may have cancer. The company immediately pointed fingers at its third-party telemedicine vendor, PWNHealth. In digging into the details of the issue, more than half of those receiving the erroneous letters hadn’t even had their blood drawn.

The test in question is Galleri, which can screen for 50 kinds of cancer through a single blood draw. Large healthcare organizations like Mercy have jumped on board with it, offering the tests on a cash-pay basis even though they aren’t part of guidelines-based recommendations. The test costs $950, and if I had paid that kind of money, I would be doubly aggravated to receive an erroneous letter before I even had my sample collected. I had heard of the test when Mercy first started advertising it, but didn’t realize until I read the articles this weekend that it has not completed human clinical trials. There’s a study in the UK that’s at the halfway point, though. Despite that, more than 85,000 patients have spent the money to have the test performed, with only a handful of insurers providing coverage.

I’ve been on the other side of an erroneous medical testing result and it’s a horrific experience, leading you to wonder even if your corrected result is valid. In my case I had my pathology slides re-read by an outside pathologist because I didn’t know which reading to trust. Not every patient has the knowledge to ask for that or the resources to pay for it. Also in my case, the test orders were placed by a local physician who knew me well and with whom I had a relationship, which was a great support as we worked through the issue. Grail, whose owner is DNA-sequencing equipment Illumina is already under fire from regulators in both the US and Europe due to monopoly concerns. It will be interesting to see how this unfolds.

The third story wasn’t about healthcare IT as much as about AI in general, looking at specifically how AI would compare to humans on judging whether rules have been broken. A study done by Massachusetts Institute of Technology examined how AI would handle such things as a post violating a site’s rules or a dog being in violation of apartment rules. Researchers concluded that since AI can be trained on data sets that don’t include human validation, results may skew more harshly. A researcher in the field, Professor Marzyeh Ghassemi, is quoted as saying, “Humans would label the features of images and text differently if they knew those features would be used for a judgment. This has huge ramifications for machine learning systems in human processes.” Definitely something to think about when it feels like everyone is clamoring for more AI.

I would be remiss if I didn’t say happy birthday to the HIStalk team as the healthcare IT universe celebrates its 20th anniversary. One of my vendor executive friends recommended it to me when I first started my healthcare IT journey, and I never dreamed I would be part of the team. It’s been quite a ride with a lot of ups and downs in the industry, and I still remember sending my application to join the team by way of my trusty BlackBerry. Looking through old posts and revisiting what we thought was wild and crazy at the time, some of those news items pale in comparison to the issues of today. Here’s to the future of HIStalk as it continues to chronicle our topsy-turvy industry and to be everyone’s favorite source of healthcare news, opinion, rumors, and gossip.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/1/23

Midwestern health systems BJC Healthcare and Saint Luke’s (Kansas City) have announced plans to join through a $10 billion merger. They have been previously connected through participation in the BJC Collaborative, which Saint Luke’s joined in 2012 as the organizations sought to share resources and cut costs.

Announcements from the organizations note plans to operate under their existing brands and operate from headquarters in both St. Louis and Kansas City. Detailed plans for the merger are slated to unfold through the rest of the year, with a goal of closing the deal by the end of the year. I reached out to some Midwestern friends who know both organizations well and it sounds like there may be some significant cultural differences that come into play. It should be an interesting one to watch.

I receive dozens of cold call emails every day despite my best efforts to filter them into junk mail or spam folders. My favorite of the week was one that gave three different stylistic treatments to the healthcare entitlement program for seniors: MediCare, MediCARE, and ultimately Medicare. Maybe their marketing team will eventually create a style guide so that they can remain consistent, but since I made use of the block sender functionality, I hopefully won’t be seeing it again.

I don’t practice as often as I used to, but when I do, there’s always a patient who asks about something they saw on the internet and how it might relate to their reason for seeking medical care. A recent Forbes article discusses data that more than a third of members of Generation Z trust TikTok more than doctors. It’s not the only player in the equation – another 44% of adults surveyed visit YouTube before contacting their physician. One in five respondents trust health influencers more than they trust medical professionals, citing access, cost, and avoiding judgment from medical professionals.

The article goes on to emphasize the need for care providers to meet patients where they are. I agree with that approach. I’ve not seen many mainstream health organizations fine tuning their social media sites to go after that demographic, but I’ll keep an eye out. There is plenty of medical misinformation out there that needs to be countered, but competing against influencers might be an uphill battle.

For health systems and other organizations that are trying to build their brands (and often renaming themselves in the process), they might want to target older demographics. A recent article notes that members of Generation X and Baby Boomers are twice as likely to trust brands than members of Generation Z. Topping that brand list and possibly providing inspiration for marketers: Band-Aid, UPS, Amazon, Lysol, and Kleenex followed by Cheerios, Visa, Dove, The Weather Channel, and FedEx. The survey noted that Generation Z doesn’t trust many brands to do the right thing – non-profit brands were the only category to which it responded well. I tried to poll a couple of the members of Generation Z about the topic, but hit a dead end because they were heads-down on their phones.

I have a visit later this week with a new physician who is part of the medical group where I’m already established. I was relieved to receive an electronic check-in notice through the patient portal. My previous physician left the practice for health reasons, but I’ve been a patient in both the practice and its database since 2019 (and in its precursor, which was converted, for a decade prior) so it should have been smooth sailing.

I completed the electronic check-in and was met with a notice that “you might be asked to complete additional paperwork in the office,” which jogged my memory that indeed they had mailed me a packet six months prior. I found it in the file sorter on my desk and was dismayed to find that it contained four pages of materials that are redundant to my existing chart, including the pharmacy information and medication list that I just confirmed during the electronic check-in process. When I scheduled the appointment, I made it clear that I was transferring from her former partner. Since I’ve been seen within the past three years by a physician of the same subspecialty who bills under the same tax ID, I’m technically an established patient even though I’m new to her. I assume they send the “new patient” paperwork to everyone, but it’s still disheartening.

No one wants to arrive at the office and be turned away because they don’t have the (totally unnecessary) paperwork, so here I sit filling out information when I’m 100% confident that it’s all in the chart already, because I’ve seen it in my past visit notes. The real kicker was when I arrived at page four and found the “physical examination do not write below this line” section, where presumably the physician (who has a multi-million-dollar EHR) will not be documenting my exam because her contract requires her to use said EHR if she wants to get her annual bonus. I helped institute those contracts in a past life, and according to my former colleagues, they are still in place, so that should make for a fun conversation when I get to my appointment. The photocopies themselves are no longer crisp and are marked by smears from repeated copying, which is just sad.

Getting to the end of the paperwork, I realized that it didn’t even ask for some of the key elements of my history that are important to the topic of the upcoming visit, as well as being critically important for a physician in that subspecialty regardless of whether they’re a topic of this specific visit or not. As a physician, I know this is a big deal, but many patients might not volunteer that information if the physician doesn’t specifically ask for it.

Based on the paperwork and the pre-visit experience, I’m not confident of what to expect from this visit. For an organization that is worried about patient experience and their patient satisfaction ratings, I’ll be sure to give appropriate feedback when the inevitable survey arrives in my inbox. If they’re interested in some management consulting and EHR optimization, I might just know someone.

What’s the most frustrating healthcare IT-related issue you encounter as a patient? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/25/23

A recent article in the American Academy of Family Physicians’ journal FPM summarized “Clinical Workflow Efficiencies to Alleviate Physician Burnout and Reduce Work After Clinic.” The first of their four suggestions was for EHR users to make use of macros and defaults in their systems so that they can easily insert content into their visit notes.

I continue to see physicians who won’t take advantage of basic system personalization. When I was in traditional primary care practice, my goal was to be able to do visits using as few clicks as possible and there’s no way I could have been as fast as I was without defaults for common physical exams and orders. It’s still difficult for me to understand the psychology where a user will waste time visit after visit, day after day, week after week, but won’t spend 90 seconds to create a default. The article even includes a link to a blog with a starter list of EHR macros for those who might have users who are reluctant to take steps to make their lives easier.

One of their other recommendations was to “consider cutting note bloat by writing in short phrases rather than full sentences and including only what is essential.” My first EHR made it easy to create notes in a format that was more akin to a bulleted list than beautiful, flowing prose. For many, reading a list like that is easier than reading a block of text, so I agree that it’s a valid strategy.

They also go on to mention that the EHR should be used as a database and not as a way to recreate the paper chart. Providers are encouraged to ask for help and to take advantage of organizational resources such as clinical informaticists, or even to get help from more efficient colleagues.

Even as a CMIO, I’m always willing to sit down with our clinicians to coach them through more efficient workflows. One of my early clinical informaticist roles involved implementing some challenging users. I miss the days when I could work with them and watch the proverbial light bulb go on when they had figured out how to breeze through their visits.

Many of the organizations I work with are big on telehealth, and I hope all organizations are making their plans to move to HIPAA-compliant telehealth technologies now that the public health emergency has ended. Organizations have had three years to move to compliant tools, but there are always going to be groups that wait until the bitter regulatory end before they do the right thing for patient privacy. The Office for Civil Rights is providing a 90-day grace period, but penalties for HIPAA violations will resume on August 10.

In the interim, organizations should look at their telehealth programs and technology, conduct a risk assessment, and confirm that they are using HIPAA-compliant tools. I suspect some purchases may be on the horizon and can imagine some vendors salivating at the organizations that left their transitions until the bitter end.

From Jimmy the Greek: “Re: marketing. Check out some of the language on this corporate website. ‘We create value by making sustainability an integral part of our vectors of superiority.’ There’s also ‘Improving lives for generations to come with irresistible superiority that is sustainable.’” Wow.” Any time I see the word “vectors,” my infectious disease brain immediately thinks of rats, flea bites, ticks, and other disease vectors. These linguistic gymnastics are found on the Procter & Gamble investor site, which is an otherwise interesting read if you’re so inclined. Given their product lines, I suggest that P&G might be better served by a tagline such as, “Assimilation through personal care, one buzzword at a time.”

Speaking of buzzwords, I’m currently disliking this one the most: omnichannel. The way I keep seeing it used, it falls squarely into the “I do not think it means what you think it means” category more often than not. I’ve also recently run into a resurgence of “circle back,” which I think should be eradicated from the business lexicon, along with “synergy,” “new normal,” and “out of the box.”

I had a visit at my primary care physician’s office this week. I scheduled it online and had my choice of a next-day visit that didn’t work for my schedule or one the following week, which I booked. Online check-in was a breeze, and the patient questionnaire related to my issue was easy to navigate.

The only blemish in the workflow was when the medical assistant had to free text every field when documenting my vaccine administration. At a minimum, I would have hoped the EHR would have had a vaccine inventory management system that would have presented things like the lot numbers and expiration dates as dropdowns or pick lists to help reduce errors and manage inventory. Even the site had to be free texted despite the fact that there are generally only six places on the human body where intramuscular injections are administered. She also had some kind of paper sheet that she was performing dual entry on, so I’m not sure what was going on with that and was afraid to ask.

When I arrived home, I was pleased to see that my patient-visible note contained an accurate History of Present Illness and that the exam matched what was actually performed, which is a big contrast to a visit I had with a specialist in the group last year. However, as I was reading my note, I realized that they never asked to collect my co-pay. Since they’re owned by my former employer, I know that collecting the co-pay at the time of service is a requirement. It’s also an industry best practice that everyone should know about. It helps avoid statement costs as well as the risk of never receiving the co-pay.

This means that I’ll get an annoying statement in the mail (I haven’t been able to turn off paper statements despite trying) and then have to go online and make a payment. Usually, I don’t receive an electronic statement notification until after the paper one has arrived, which seems to be a less than optimal way to configure your revenue cycle.

What makes you cringe when you visit a healthcare facility and see that best practices aren’t being used? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/22/23

I’m a big fan of experiential learning, especially after having just finished teaching some Outdoor Classroom sessions for a local youth organization. It’s great to see people use the skills you’re teaching as they interact with each other and try to solve problems. It works best, however, when you have a good blend of instructional time with practical or application time.

Having hands-on time can be great if you at least understand the concepts that are being presented and the goal is to either learn them at a deeper level or become more capable in performing them. I liken it to a surgical skills lab. First, you learn about wound repair, and make sure you understand how skin will heal depending on the repair technique and how different types of sutures will work in different ways. Then, you actually practice either with a simulator, or back in the dark ages, we practiced with pigs’ feet. You don’t just start throwing stitches into live patients without understanding the fundamentals.

I have a couple of certifications on EHR products that I rarely use, but for which I like to stay up to speed. One of the vendors rolled out a new product that I’ve not been certified on. Given my past work with the application, they offered me the opportunity to take the certification classes for the new product.

I was excited about the opportunity and ready to prepare for the classes. Unfortunately, there wasn’t any kind of preparatory work – no pre-class readings or training videos. There was a PDF for the class, but what was in there looked mostly like exercises without any foundational content. I wasn’t sure if I was missing materials or whether it was intentional, but I decided to head to class with an open mind.

I have to say that it was one of the most frustrating classes I’ve ever taken. The entire thing was taught in a hands-on fashion, with no structured presentations or materials that summarized the functionality. Each module was a situational vignette, and after reading it, we were expected to go into the application and figure out how to take the necessary steps.

It was completely frustrating. I knew the general layout of the application and the main menus, but I didn’t know all the shortcuts that this class apparently expected us to not only know, but use. It was made worse by the fact that many of the desired tasks had more than one way for them to be accomplished, but you only deduced this after working through the scenario a couple of times. At no time did the instructor explain why one might want to embrace one workflow over another.

Not having any kind of initial summary or teaching also made it difficult to figure out what the various options were. I felt like I was more focused on writing things down in my notes so I could try to put it together in a cohesive manner rather than trying to understand how to manipulate the different scenarios. Because of that, I found myself missing key information because I was still trying to figure out something that happened a minute or two earlier in the simulation scenario.

Even if I would have been given a one-page summary that listed the different workflow possibilities and explained why a user would select one compared to another, it would have been a significant step up. A handout of the system’s keyboard shortcuts would have been helpful as well. After completing the class, I ended up spending several hours in the system’s demo environment running through common scenarios and seeing if I could figure out how to execute them on the platform.

At the end of the course, there was an evaluation that contained a couple of the question formats I hate the most. The first was what my medical school used to call “multiple-multiple choice” questions, which typically had four answer options (A, B, C, D) but then would have additional options like “A and B” or “A and B and C” and other combinations. Inevitable you’d find more than one thing on the list that was likely to be correct, but you spent excess time trying to psych yourself out about which items to exclude.

The other most hated question format (which unfortunately continues to also be present on my medical specialty board certification platform) is the “choose the best answer” type question. “Best” is really a subjective question, especially when you’re talking about patients and how they might take or not take a medicine. There have been campaigns for many years to get those kinds of questions off the recertification exams, so I’m used to seeing them more rarely. However, those questions were all over this software training, with the problem being that finding the “best” solution depends on many more factors other than just the test taker.

For patient care, the best solution might be one that balances clinical effectiveness with cost and makes it easier for patients to take their medications they way they intended. Best could also mean the treatment that will give a patient the most longevity, or the highest quality of life. But it can also represent treatments that might save your life, but that also might cause horrific side effects and deterioration in your quality of life at the same time.

This can also be true in the healthcare IT side of the house. The term “best” might represent the solution that has the most bang for the buyer’s buck. It could also be the solution that has the lowest risk of patient care errors. Or perhaps the one that takes the least amount of time for nurses to complete their workflows. When you put on your client hat while reading test items like that, one can’t help but overthink them or overanalyze similar decisions you’ve made in the past.

After feeling like I had been led astray but the hands-on training and then burned by the confusing test questions, I was ready to give up. Sure, I could follow the instructor to perform a bunch of different tasks, but I had no idea how the application would help my daily work or benefit my organization. I’m a pretty decent test-taker, so I ended up passing the evaluation step, but I still don’t feel like I know anything as far as being able to operationalize the functionality.

One of my co-presenters at Outdoor Classroom has dyslexia, and working with him made me think about how others would perceive the class. Similarly, people who learn best from reading rather than watching an instructor perform tasks and then try to emulate them might be out of luck. Organizations need to do more thought around different learning styles and need to spend time crafting strategies that will work for the diverse groups of users that their products will certainly encounter.

What are the best and worst types of software training you’ve experienced? Any advice that you’d give those who create the strategies? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/18/23

A colleague clued me in about an article that was published in JAMA Network Open last week, “Perspectives on the Intersection of Electronic Health Records and Health Care Team Communication, Function, and Well-being.” The associated qualitative study looked at the habits of more than 70 attending and resident physicians and found that the EHR dominated most inter-office communication.

Although it can be helpful for management of patient-related tasks, they found that communicating through the EHR limited the “rich communication and social connection required for building relationships and navigating conflict.” The authors suggest that “the technology shifts attention away from the human needs of the care team, and interventions to cultivate interpersonal interactions and team function are necessary to complement the efficiency benefits of health information technology.”

Digging into the study design, I found it interesting that the participants in the qualitative interviews were separated in time, with a significant event in the middle with the emergence of the COVID-19 pandemic. The first of the two cohorts was interviewed from March to October 2017 with the other being interviewed from February to April 2022. The authors called this out as a limitation of the study. They also noted that the first study focused on EHR-related distressing events and their role in physician emotions and actions, where the second study focused on EHR use and “daily EHR irritants.”

I would propose that in a post-pandemic world, even the smallest of daily annoyances is felt much more acutely than it might have been in 2017. This is exacerbated by the staffing and financial pressures that have been magnified since the pandemic’s start in 2020. I’d be interested to know what the relative level of staffing was during the two cohorts’ interview periods, since a significantly understaffed practice will yield different sentiments than one that is running with adequate staffing. Interestingly, information on respondent demographics wasn’t collected.

The authors also note that communicating through the EHR was felt to negatively affect team function and team well-being, namely by “promoting disagreement and introducing areas of conflict into team relationships related to medical-legal pressures, role confusion, and undefined norms around EHR-related communication.” There was specific discussion of physicians being expected to manage EHR-related messages across multiple platforms such as in-basket, email, and text.

One interviewee compared this to driving a car before stoplights were developed. “Some of my colleagues text; some of them send it in… email; some of them send it as Epic provider-to-provider messages. What a mess… there’s no sort of manners and rules. Right? Sort of like… before they developed stoplights, and there were starting to be more and more cars. Right? Man, this is nuts. It’s like, ‘Who’s going first. Who’s talking to who?’” I feel that frustration, especially when you look at the fact that different platforms might offer different subsets of functionality that can be confusing.

In some of my experiences with startups, we ran into this with differences in what IOS versus Android platforms would support, and even with IOS, on what might work on iPhone but not on iPad. This is magnified when you’re dealing with a full-feature EHR that people are trying to use from disparate platforms. You can also throw in some desktop support requirements and the Apple Watch and it’s a doozy.

I tend to only perform “real work” on a laptop or desktop, so I can’t imagine the cognitive overhead that people who try to manage on different platforms are experiencing as they try to remember which device will allow them to do what. Especially with portable devices, people are also trying to use EHR-based communication while doing other things, such as attending events with family, which adds a layer of distraction to what might already be some fairly brief communications.

Others in the study noted that “now that I can place an order from anywhere, everyone assumes I can place an order from anywhere, and expects me to do so anywhere, anytime.” In my experience, this blurring of personal and professional time adds to clinician burnout and resentment towards the workplace.

I was saddened to read the part of the article where they discussed the EHR being used to air disagreements, including clinicians who “would document petty, kind of nasty comments in the EHR about residents.” Others noted that concerns about potential litigation may “put people under the bus” in the EHR with documentation about who was paged and when, and whether the response from the contacted clinician was to their satisfaction. There were also the expected comments that delivery of care to the patient has “completely been subsumed in documentation requirements.”

The authors noted that there is a need for greater understanding of optimal EHR use and that “the development and improvement of local work culture is critical and may have a greater influence on physician burnout than EHR improvements alone.” They go on to suggest that “organizations support physicians in implementing small, structured peer-group discussions to enhance team function and individual well-being.” I’m a big fan of the concept of self-organizing teams and the latter comment resonated with me. People need to be able to talk about how they like to be communicated with, and any additional needs they have in processing information, but may not be likely to address these needs unless it’s clear that the workplace is supportive of accommodating them.

I received quite a bit of reader mail about my recent Curbside Consult that talked about May being graduation season. Many readers have graduates in their families and it sounds like there is an even split between those going into technology-related fields and those pursuing careers in the arts and humanities. A couple sent pictures of their graduates and it was great to see the proud parents and the excited faces of the graduates in the photos. One correspondent noted that her daughter is headed to work for Epic, with another sending a child to a public health organization. They’re looking forward to seeing what their children think about the industry after seeing it from another side. I’m sure new entrants to the healthcare field have an entirely different idea of what it will be like than many of us did 10 or even 20 years ago.

What did you think healthcare IT would be like when you first started in the industry? Has it met your expectations or crushed your dreams? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/15/23

May can be a busy time for families who have graduates. When I was in Madison last week, I saw plenty of people who were taking pictures at the state capitol wearing caps and gowns. It was fun to see their excited smiles and to wonder where they are heading next on life’s adventures.

This weekend, I attended a graduation at my state’s flagship engineering and technology school, and it didn’t disappoint. It was inspiring to see so many people going into careers in science, technology, engineering, and math fields. It was particularly gratifying to see the number of women graduating in fields that have been historically male dominated, including geophysics, mining, metallurgy, and explosives engineering.

Due to the size of the ceremony, graduates of various departments were recognized in groups by their majors before coming to the stage individually to receive their diplomas. Although mechanical engineering was dominant at the ceremony I attended, there were quite a few aerospace engineers and a surprising number of metallurgical engineers who had the most stylish hair, shoes, and eyeglasses in the crowd. In addition to computer science and computer engineering, degrees from a new program in information systems and technology were also conferred.

The “best decorated graduation cap” honors goes to the biology major who had three Petri dishes affixed to her cap, along with the metallurgical engineer who had gilded designs on the top of hers. Several of the biology majors had plush bacteria toys dangling with their tassels after being gifted them from their department chair. During the departmental recognitions, the audience figured out that there was a lone economics major among the hundreds of graduates, and he received some extra applause and cheering.

I sat next to the mother of one of the information systems graduates and was learning a bit about the new program and how it was founded as part of a major donation to the university. That funding led to the addition of a college that covers entrepreneurship, information systems, technology management, and more. Although some of those disciplines existed previously as part of the college of engineering, it’s interesting to see them grouped together under a new umbrella.

My assumption is that the new organizational structure also helps ensure that they’re funded in the way that the donor intended, rather than the money being washed through a larger department and potentially sidetracked. Since the new college carries the donor’s name, it also needed to contain actual departments, so I’m sure that was a factor as well. According to his mother, that new graduate interviewed at a healthcare software company, but she wasn’t sure which one it was.

Being well into my career, it’s sometimes easy to forget what those milestones that our younger selves experienced meant to us at the time. I don’t have deep memories of my college graduation other than lining up in the bowels of the basketball arena with other graduates in my department and singing our school song for what would be my last time. (I admit, I haven’t visited since graduation, but I’ll be doing that later this month as part of a milestone road trip with my former college roommate.) I remember my medical school graduation in great detail, especially the processional that involved bagpipers and a parade down a couple of escalators. With the bagpipes and the gowns and hoods and having been through the wringer during the four years prior, it seemed quite surreal at the time.

I also remember the fact that the main speaker failed to follow the program, which led to us not being administered the appropriate oath (in our case, the Oath of Geneva rather than the Hippocratic Oath) during the ceremony. They tried to rectify that after the ceremony concluded, but many of us had already scattered to meet with families and loved ones.

I’ve made use of that fact at least once in my career, when a patient was upset that I wouldn’t give her what she wanted and told me that I had to do it because “you took an oath.” I said very calmly that actually I didn’t take that particular oath, but that wasn’t going to keep me from giving her high-quality, evidence-based care regardless of the fact that it wasn’t what she wanted on that particular day. I think most of us in medicine would agree that the core values we follow are ingrained in us long before any oaths become topics of discussion, and that we don’t need to say prescribed words to do the right thing. Quite a few medical schools allow their incoming classes to write their own oaths during the first year, enabling them to memorialize values and intentions that are important to them.

There are situations where oaths are important, and I was able to experience one of those as well while attending my first ROTC officer commissioning ceremony as part of the graduation festivities. During that ceremony, a military officer administers the Oath of Office to each newly appointed Second Lieutenant, and then family members or loved ones help pin on their ranks. They also receive their first salute from an enlisted service member who has been important to them. It was interesting to see who the cadets chose to perform the different parts of the ceremony. Some of them had relatives who were officers administer the oath, one had a former scout leader who was a naval officer do his, and one woman received the oath from her husband who graduated and was commissioned last year. The most touching was the cadet who had his grandfather, a Korean War veteran, give his grandson the first salute. There were few dry eyes in the house after that one.

It was inspiring to see these young people, most of whom could have headed off to solid careers in engineering or technical fields, commit to serving their country. Instead of following the money, they’ll be supporting our military as cybersecurity resources, civil engineers, logistics coordinators, pilots, and missile operations officers.

The latter job role is one that most people don’t think about. It feels strange to understand that in a world where so many people are focused on what they see on TikTok or Instagram, we have officers underground 24×7 ready to launch what might be world-ending missiles should the order arrive. Knowing that gives me a new perspective on my daily work struggles or the things that some of us think are emergencies on any given day. There’s a lot of uncertainty in the world that these newly minted officers are headed into, but I have high hopes that this generation has leaders among it that can do a better job than what we might be seeing today.

Are you headed to any graduations this spring, and what are your hopes for the futures of these recently degreed individuals? Are graduates gravitating to technical fields or finding their futures in the arts or humanities? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/11/23

I’ve been in Wisconsin this week attending the first week of Epic’s annual XGM, or Xpert Group Meeting. Although there’s always a lot of chatter about the fabled User Group Meeting in late summer, I hadn’t heard of XGM until a couple of years ago. I’ve spent the majority of my clinical informatics career working with other EHR platforms (McKesson Horizon, anyone?) and had only interacted with Epic in an end-user capacity previously, but this has been my favorite of the Epic conferences so far. XGM is split across two weeks.

This week seemed more clinical in nature, with the more technical sessions following next week.  Although I’m confident that I could learn plenty at either, this is the one that worked best with my schedule, and it’s been jam-packed. Unlike some of my experiences at HIMSS, I’ve been surrounded by thought-provoking presentations that have a lot of applicability to my ongoing work, and I’ve met lots of people who are beyond energized about working in the industry. 

Some random thoughts. Epic requires you to attest to being fully vaccinated as a condition of registering for the conference. For those of us who came home from HIMSS with the plague, I appreciate it. I’ve seen a number of people who are wearing masks, including plenty of staffers. It seems prudent when you are interacting with large numbers of people, because there are plenty of circulating viruses other than COVID that I wouldn’t want to bring home to my family, and interacting with a couple of thousand people from across the country and around the world is a risk factor. I saw a couple of N-95 masks on people’s elbows or clipped to their backpacks, which isn’t doing anyone much good, but there were quite a few being worn properly as well. Distancing was possible in most of the sessions, and although mealtimes were busy, there was the option to take a carry-out box outside except for the day when it was raining.

The sessions that have been the most packed include those on clinical decision support and Epic’s Cosmos database, which includes de-identified data from millions of patients. Telehealth sessions were also popular, as were those on optimizing clinical alerts. It feels like a lot of attendees are serious about making sure that their technology investments are generating value for clinicians and making sure that patients are being included as beneficiaries of those efforts as well as clinicians and other end users.

As far as the sessions themselves, the Epic moderators run a pretty tight ship, keeping sessions on time. They’re also good at making sure that audience members who are asking questions remember to use a microphone so that the session recordings include all the questions. Of course, there are still some people who don’t want to wait for a microphone and jump right in, but the presenters were good at addressing those, too. As with any conference, there are always audience members who confuse the Q&A portion with their own personal story time, but it seemed less than what I have encountered recently at other conferences I’ve attended.

Even the “attendees behaving badly” weren’t that bad, although I was ready to throttle the person I’ll call “crinkly bag guy” who seemed to have everything in his messenger bag double-shrouded in cellophane, resulting in a tremendous amount of noise every time he looked for something, which was often during the 40 minutes we were together. His nearest neighbor even shushed him librarian-style. There was also the guy who spilled coffee on the bus (and also on himself) because he put his partially full coffee cup in the side pocket of his backpack.

Generally, though, everyone was pleasant and patient with any lines or crowded situations, which made the entire meeting feel smooth. The weather was fantastic Tuesday and Wednesday and I was able to get out and stroll the campus and have some random interactions with other attendees who were doing the same thing. The continued campus construction was a common topic, as was the legendary Epic culinary department. Highlights of the menu included the spinach-asiago breakfast tart as well as a chocolate cake that was enrobed in a delightfully crispy coating.

A couple of presenters got into the ChatGPT spirit, with one using the tool to write the introduction to his presentation and another asking it to detail some thoughts about the future of patient experience. I took what felt like a million pages of notes, trying to capture every useful thing I heard. Many of the client presentations dealt with issues that are common no matter what EHR platform you use, and I’m surprised that they’re still being discussed. This includes such advice as “put the things you want used most often at the top of a menu and the things you want used least at the bottom of the menu” which can make a huge difference for providers being able to order common tests as efficiently as possible. It can also make a difference when you’re trying to steer patient behavior, such as encouraging them to use a refill request workflow or an appointment scheduling workflow rather than just defaulting everything to a message to their primary care physician.

Reducing the continued increased in post-pandemic patient portal messages was a common theme, with several clients sharing their strategies as well as Epic giving information on its features to support their efforts.

Speaking of features, one non-technical feature that I’ve only seen at Epic conferences is the inclusion of local and regional businesses for attendees to shop in between sessions. Several Wisconsin-based businesses were featured, including one that had handmade soap and gift items, gift boxes, everything badger-themed, and local snacks. There were also chocolatiers and creameries selling a variety of cheese, snacks, honey, sweet and savory pecans, truffles, and more. This is on top of the Epic shop, where attendees could pick up themed t-shirts, notebooks, jackets, water bottles, and other items that are offered at cost. The conference also knocked it out of the park from a sustainability standpoint by having dedicated recycling and trash bins everywhere you turned, but also by including recycling instructions on the standard slides that played in the meeting rooms between sessions.

The Epic campus is known for its quirky art. The piece that gave me the most delight on this trip was this planter that appeared to have microscopes mounted on it. Instead, the eyepiece revealed a kaleidoscopic view of the plants that changed as the planter was spun, reminding the viewer that what you see is not always exactly as others see it. This will be important to remember as I bring back a virtual treasure trove of presentations of cool things that work at other institutions but might not work at my own or might be beyond what my own users are ready to experience at the moment. I met some new people who will be great to bounce ideas off of down the road as well as some who can commiserate with the challenges I run into on a regular basis.

I’m sad that I’ll miss the second week but trust that my team will bring back lots of other ideas.

What’s the best idea you’ve picked up at a conference in the last year? Leave a message or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/8/23

I’m back in the air this week with some weekend travel, which I don’t usually do. My flight was nearly all vacation travelers. The boarding process started with someone spilling his coffee all over the exit row, which led to a string of urgent maintenance issues and caused confusion and delay. Since he soaked nearly all of the seat belts in the exit row, those had to be changed out. Additionally, the flotation devices under the seats also had to be checked. Meanwhile, no one was able to board into that row or adjacent rows while the spill was being addressed, causing a lot of grumbling.

I’ve seen so many spills and messes at the airport and on planes due to Starbucks and fast food cups that it’s a miracle there aren’t more delays than they are. I don’t understand how people think they’re going to board with a roller bag, a shoulder bag, and a non-secured beverage and expect everything to turn out OK. I also see a lot of impractical shoes, which isn’t going to help anyone in the case of an emergency. I think most people never think of the fact that they might have to emergently exit a plane, but as someone with an interest in disaster preparedness, I’m always ready to deploy that exit door and head out in my trusty running shoes.

One of my projects for the day involves helping a former client. They reached out to me earlier in the week about a custom application that I installed for them way back in 2011, and I was frankly surprised to learn that it was still chugging along. It was designed to help with routing of laboratory results, and it sounds like its simplicity is what led to it still being in service more than a decade later. Since it was a custom build, the client opted at the time for a no-frills approach with a straightforward user interface. I figured they would have retired it long ago as they transitioned from a dedicated ambulatory EHR to an enterprise application, but apparently they continued to use it for some non-employed private practice clients who had steadfastly refused to migrate to the enterprise platform. The last of those physicians is retiring at the end of June and they were looking for advice on how to wind down his laboratory feeds as he transitions out of practice.

As a consultant, I’ve helped with a number of practice and provider “disengagement” processes over the years, so I was able to dust off some existing documentation and point them in the right direction to manage some of the non-application tasks that need to be addressed before they shut it down. Although they were more worried about what to do about the technical infrastructure, I let them know that the issue will largely resolve itself once the lab vendors stop feeding information. Fortunately, the physician is a subspecialist who orders very few laboratories and has been good at tracking outstanding orders, so the odds of a rogue result needing management in the practice’s final days are slim to none.

I enjoyed catching up with the analyst who was tasked with winding down the practice from the information technology side since I had worked with him when we initially configured the system. It’s rare to see someone continue to support a one-off application like that for the duration that they had with this one, but it was fun to talk about where the industry has gone in the years that have passed since we were both relatively new to the clinical informatics world.

My other project for the day is finishing a sorely overdue library book. I’ve had a lot going on in both my professional and personal lives and the amount of time I’ve had for those kinds of pursuits has been largely non-existent. Fortunately, my library has a no-fine policy, but I feel bad about keeping this book out of circulation, especially since someone has now put a hold request on it.

Since I’m spending the rest of the weekend in a hotel, it’s not like I can work on household projects, putter in the yard, do laundry, switch out the winter clothes in my closet for summer ones, or do any of the dozen other projects that are looming. I’ve got some downtime at my destination later in the week and I hope to see some of the sights and do a little shopping, so it will be a good change from my normal routine. Sometimes it’s good to just change things up, so we’ll see what the rest of the week brings.

I’m also still recovering from the respiratory funk that I picked up at HIMSS. Although it wasn’t COVID, it has put a dent in my activities, and I’m realizing that I don’t bounce back like I used to. Even though I no longer work in person in the emergency department or in a high-acuity, high-volume urgent care situation like I did during the height of the COVID pandemic, I feel like those experiences have taken months if not years off my life. I’ve watched nearly everyone I worked with during that time leave frontline healthcare roles, so I know I’m not alone in feeling like the experience was a turning point.

Some of my former colleagues have moved on to subspecialty positions that have more predictable working hours, but others have left clinical medicine entirely. When COVID started, we all promised to see each other “on the other side,” but several were lost along the way, including one to suicide. Thinking about them reminds me how important it is to savor every day even if you don’t feel well or if it’s particularly stressful. It’s also a good reminder of how we need to look after each other because you never know what’s going on in the parts of someone’s life that you don’t see.

Once the business component of this trip ends, I’ll be zipping home to get ready for some family functions. I’ve also got an upcoming girls’ trip that I need to plan, so hopefully I can knock a big chunk of that out on the flight home as long as wi-fi cooperates and we don’t have any major in-flight issues. After June, I can finally enjoy some long-needed R&R.

How do you spend your travel time? Is it full of catch-up tasks, or do you manage to find time for yourself? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/4/23

I was back in the patient trenches this week, having my regular trip through the scanner to determine whether the next six months will be smooth sailing or something else entirely.

What I didn’t plan for was a bumpy preregistration and appointment confirmation process that was scheduled to occur while I was supposed to be off the grid enjoying the outdoors. I just happened to be in cell phone range when the first call came, asking if I had time to complete preregistration. All of the questions I was asked to answer or confirm could have been easily served up as part of a patient questionnaire via the patient portal (as they are when I see the surgeon who is part of the same institution) and could have been sent well in advance of the procedure.

About 20 minutes later, a call came in from the radiology department. This one was a recording, and my Google Assistant picked it up without me realizing it. I had pulled out my phone to check the weather forecast and noticed the call already in progress and recognized the hospital prefix and picked it up. I had to listen to the recording loop through and could finally confirm my appointment. Again, this could have been done through email and/or a patient portal message.

Still, I was left wondering what would have happened had I been truly off the grid as planned? Would they have canceled my appointment, which had been painstakingly scheduled six months in advance and for which I had canceled and rescheduled work meetings? Or would they have accommodated me if I rolled in without confirming? We’ll never know.

Even with that pre-confirmation, things were not smooth on arrival. When I reached the registration desk six minutes before my allotted arrival time),I had to stand there for a few minutes while the registrar copied my details (first initial, last name, time of study, type of study) out of the computer and onto a little sticky strip of paper.

She phoned back to a registrar, who came out and picked up the sticky strip, then hustled me back to the registration area where she rushed me through the process saying, “we can’t have you being late to the waiting room.” Mind you, it was just now my arrival time. She then stuck the paper strip to a notebook in her work area, asked me to confirm my name and DOB, and then asked me to sign on an e-signature pad without even telling me what I was signing. According to the text at the top of the pad, it was my consent for treatment, but I was never offered a copy or advised as to what I was signing. As a physician I know what’s in a typical consent, but the average patient doesn’t, and either way, the consent is invalid unless a patient actually reads it.

From there I was led down the hall at a rapid clip to the appropriate radiology sub-waiting room, where I was handed the proverbial clipboard and asked to complete three sheets of questions, none of which were even remotely populated with my information. As a CMIO, I know it’s entirely possible to generate forms that already have key patient information on them, and for the organization to continue to make the patient print their name, date of birth, and Social Security number on each page is just poor patient experience.

After filling out loads of information that was already in the EHR, I turned in the clipboard and proceeded to sit for a full 10 minutes before I was taken to the changing room. I had enough time to notice the trash under the chairs in the waiting room, and since I was one of the first appointments of the day, it was likely from the day before.

In the changing room, in addition to some fantastic gowns, I was greeted with dust bunnies the size of a plum that had probably been there for several days based on the look of them. I know that all organizations are struggling with retaining lower-wage workers such as housekeeping staff, but I had to ask myself if the president/CEO of the hospital or the members of the board would be proud of their facility. For an institution with billions of dollars in the bank, maybe they could loosen the purse strings a little bit to help recruit and retain staff.

Fortunately, the clinical staff was outstanding. It was one of the best IV starts I’ve had in a long time, and a friendly radiologic technologist had the positioning process down to a fine science. She also honored my request to sleep through the procedure. I’ve had it enough times that I don’t need to be warned every time a new sequence starts, and given the early test time, I was grateful to grab some extra shuteye before heading back to work. At least this time they subsidized the first $1.50 of the parking fee. I always find the idea of paid parking at a world-renowned cancer center to be repugnant when the organization is sitting on a Scrooge McDuck level of reserves.

I usually get my results within 24 hours, but this time it took two full days, which was somewhat agonizing. When the patient portal notification finally came through, I discovered that my biometric settings no longer worked, and the hospital wanted me to log in using my password and then re-enable biometric authentication. Having been a biometric user for years, I didn’t have my password saved within my password manager, so that was a race to try to get the results before going to my next meeting. I was surprised to see that the results had been reviewed by a provider prior to release (usually they release directly) so I’ll have to ask my clinical informatics contacts at the institution what the story is with all the changes.

Although the process was frustrating, at least it took my mind off the other frustration of the week, which involved organizations that I spent a substantial amount of time with at ViVE who have yet to follow up. I’ve got money to spend and time to dedicate to these particular projects, but my patience is flagging. I sent a last round of emails, so we’ll see who responds and which project will get to start first. The others may just have to wait.

Have you had any recent patient adventures? Were they positive or negative? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/1/23

Over the last couple of years, I’ve been trying to learn more about marketing. It’s a critical part of what we do, whether it’s trying to promote a company, advertise a hospital, or convince patients to adopt healthier behaviors or take advantage of cancer screening tests.

When I was training to become a physician, I thought that it would be about learning all the science and figuring out how to apply that to examining patients and identifying a diagnosis and treatment. Over time, I learned that identifying the diagnosis and making a treatment plan was only half the battle. Convincing the patient to get on board with the proposed plan was a tremendous lift. I learned more about persuasive speech and sales techniques than I ever expected to know, except I was using them to try to convince patients that taking a cheap generic medication to treat their conditions would actually be a better option than the flashy drugs that they had seen advertised on television.

Working for a large health system, I also learned a lot about the ways that organizations market themselves. Sometimes this was productive, trying to increase community awareness about available services. For example, when we launched a mobile diabetes screening unit, there were multiple marketing campaigns to drive awareness and create buzz about the importance of diagnosing diabetes early. Things became more challenging when those patients were actually diagnosed but ran into insurance issues or inability to get the care they needed. I wish that the campaign to launch the mobile unit had included training for primary care offices on how to best handle the influx of patients we were seeing, especially in a startup office like mine.

I also saw plenty of counterproductive marketing efforts, such as when two hospitals that were part of the same health system launched competing orthopedic surgery marketing campaigns, both aimed at the same patient population in the geographic area where I also lived. It seemed like every time I opened the mailbox, I had a competing flyer from one of the programs. Since the flyers had the health system branding as well as the individual hospitals’ branding, I’m sure it was confusing for patients. As a physician who was on staff at both hospitals, it created plenty of confusing conversations with patients and without the requisite talking points that would  have been good for staff physicians to have at their fingertips.

This article about Mercy’s personalized healthcare marketing strategy caught my eye. I originally thought I was going to learn something about how precision marketing can help patients, but unfortunately, the first quote in the story left me somewhat baffled. The health system’s chief marketing office, Kristina Dover, stated, “One of the examples I really like to use is that a 55-year-old male OB-GYN should never see our mother-baby advertising if we’re doing our job right.” Actually, I think the midlife, male OB-GYN is exactly who should understand the health system’s mother-baby marketing strategy, because it’s his patient base that is the target of that advertising. Who better to understand a hospital’s advertising tactics than those who are expected to deliver on its promises? Expectation mismatch is a key factor contributing to patient dissatisfaction so that the care delivery team is well-served by understanding those expectations.

Other comments that Ms. Dover made were confusing. She mentioned trying to balance supply and demand through personalized advertisement, by pointing patients to service lines with openings at the time. She is quoted as saying, “We are honestly having conversations every day to say, ‘We have the access for inpatient primary care visits today, let’s increase our marketing or let’s dial back a little bit,’” which makes no sense. I wonder if she can even define what an “inpatient primary care visit” is or whether she understands that you can’t just go out trolling for inpatients as a way to increase your census. As a former emergency department physician, there were plenty of patients that I would like to have been able to admit, but factors like insurance, acuity requirements, and more were always standing in the way. How wonderful that a marketing team has found a way around all of that.

Of course, I’m being facetious, and for Ms. Dover’s sake, I’m hoping this was some kind of misquote or misunderstanding on the part of the reporter. Helping patients understand their healthcare choices is complex, and I struggle to understand how it can be reduced to an Amazon-like shopping experience regardless, given all the drivers such as insurance coverage, acuity, provider experience, accreditations, and more. It’s not exactly a retail commodity, and trying to reduce it to that level might not be the best thing for solidifying a medical home or providing continuity of care that drives outcomes. It’s been a decade since the two marketing examples I discussed at the beginning of this piece happened, but it seems like there is still plenty of dysfunctional marketing out there.

I’d like to get a better understanding of how health systems might take a more informed approach to marketing. Do they consider the opinions of patients, caregivers, providers, and employees as they create their campaigns, or are they created in corporate lock-ins or Madison Avenue-style conference rooms? Do health systems consider previewing their campaigns to their internal constituents so they are prepared for any patient questions, and if so, do they ever make changes based on feedback they receive? Maybe I’ve just been in health systems that didn’t give us a sneak peek, but I’m eager to learn what’s going on in the greater healthcare marketing universe.

I’d also like to learn other opinions on personalized marketing strategies. Are other organizations using different tactics than what the article described is happening at Mercy? Have you found that new strategies have made a difference in how patients and potential patients receive marketing messages? What do you think about hospitals moving towards consumer-focused marketing as a way to drive volumes? Are we all eventually going to be a commodity? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/27/23

Lately, it seems like my travel is never uneventful. The trip home from HIMSS added to my recent adventures.

I scored my usual exit row seat and everything went normally during the emergency briefing. However, we had a delay on the tarmac and one of the passengers in the exit row in front of me started asking “have we left yet?” followed by chanting “let’s go, guys, let’s go, guys” over and over before ultimately quieting down. After we reached altitude, though, his behavior became more erratic and he was bothering the passengers next to him while asking over and over if we had taken off yet.

The flight attendants were on top of it, arriving in a group to invite the passenger to move to a seat in the back of the plane near the galley. He acted a bit disoriented, but was able to follow instructions, although the lead flight attendant had to tell him several times to stand up, grab his backpack, and follow them. As he passed by my row, there was a strong smell of alcohol, which made me wonder whether he chugged his drink at the gate to comply with the rules to keep alcohol in the terminal or whether there was something medical going on.

It was a short flight and the police were happy to meet us upon landing and escort the gentleman to an alternative destination, but I hope he was OK. I’ve got a few more flights planned for the next three months and I’d really like to have just one where nothing noteworthy happens.

While I was flying, a couple of readers sent me some pics on the last day of HIMSS:

Biofourmis had custom branded sneakers. Thanks to a reader for sending this picture along.

Spa Girl says she saw these in a shop on the Magnificent Mile and thinks I need these for my next beach trip. They are undeniably cute, but probably not the most practical for travel. I could see wearing them around the house with a plush robe, however, in the mode of a Hollywood starlet.

As long as the Wi-Fi works properly, I’ve found that I’m pretty productive on the plane. While cleaning up email, I spotted this article about the ongoing debate about policies that require workers to return to the office. The piece mentions a bizarre call where Clearlink CEO James Clarke questions his own employees’ ability to manage work/life balance. Apparently, there has been some confusion within the company over the last couple of months as to whether employees would be asked to return to the office or whether they had been hired under the assumption of a remote-first culture. The first group of employees asked to return include those who live within 50 miles of the company’s Utah headquarters.

During a company town hall meeting to explain the changes, Clarke went on a rant about employees that had not used their laptops for a month, which is as much a management issue as it is an employee issue in my book. Did those employees’ supervisors not notice that they weren’t working, or was Clarke just making this up? He went on to ask employees to increase productivity by “30 to 50 times” normal and challenged employees to outwork him. He went further to praise an employee who had gotten rid of the family pet as a result of the change to in-person work.

Not wanting to exclude anyone in his unhinged speech, he also criticized working mothers specifically and working parents in general, saying “only the rarest of full-time caregivers can also be productive and full-time employees at the same time.” Sounds like it’s time for the HR department to provide some education and the company’s executive leadership to consider an alternative direction.

Another article that caught my eye was about a golf cart accident at Wake Forest Baptist hospital in North Carolina. The tragic crash resulted in the death of a patient and injuries to the cart’s two other occupants. The cart had been used to transport patients and visitors between the facility and parking structures. An investigation is underway, but I hope it will prompt other facilities to look at how they’re using different modes of transportation on campuses. No one wears a seat belt on a golf cart, and in the event of a sudden stop or a collision, it’s not a lot different than being on a motorcycle as far as being ejected is concerned, except that you’re probably not wearing a helmet. The articles I saw didn’t specify whether the fatally injured party was a rider or was struck by the cart. My sympathies go out to the family of the deceased and those involved in the incident who will be forever impacted.

A recent article in JMIR Human Factors looked at the use of speech recognition technology in the exam room. This wasn’t the fancy AI-driven kind of speech recognition, but rather the old school dictation-style voice recognition approach that many of us have used in our careers. In the study, physicians completed the Assessment and Plan portions of the patient’s after-visit summary while still in the exam room with the patient. The summary was then printed and a survey performed. Compared to “usual care” without an in-room dictation, patients felt that providers were better at addressing patient concerns and felt that they better understood the providers’ advice. The authors concluded that patients have a positive perception of speech recognition use in the exam room.

I first saw this approach in probably 2011 or 2012, while shadowing one of the Oklahoma Family Physician of the Year recipients. He dictated every visit in the presence of the patient and gave them the chance to ask questions, and it had been part of his routine for years. It’s difficult to believe that more than a decade has gone by without more people using this fairly straightforward strategy.

As a clinical informaticist, I see plenty of examples of clinicians and their teams struggling to adopt strategies that have been proven to improve efficiency and reduce documentation burden. Nearly every health system I’ve worked with has a super-user program and many also have robust physician champion programs. However, there are always physicians who don’t want to take advantage of those options. I see people who will do the same inefficient workflows over and over because they don’t want to take an hour or two to personalize EHR features or save their own default Review of Systems or Exam templates. I see providers manually typing differential diagnosis paragraphs that they could save and use as a base for future notes when seeing common conditions. They say they’re too busy to save them as quick phrases, but I would argue that they’re too busy to not take the time to make their future lives easier. I’m not sure what the answer is or how to motivate some of the more resistant providers, but I’m open to ideas.

What good ideas can be found in your bag of EHR optimization tricks? Leave a comment or email me.

Email Dr. Jayne.