Curbside Consult with Dr. Jayne 12/2/24

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/25/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/21/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/18/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/14/24

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/11/24

I’m always on the lookout for interesting research, and this recent article in JAMIA did not disappoint. The title was certainly eye-catching: “The number of patient scheduled hours resulting in a 40-hour work week by physician specialty and setting: a cross-sectional study using electronic health record event log data.” That’s a mouthful, but it calls attention to one of the pressing issues in ambulatory care today – packed physician schedules. It also alludes to the significant concerns around burnout and lack of work/life balance for clinicians, who are typically working longer hours than they want to.

A large amount of physician work occurs outside the confines of the office visit. These tasks include things like managing phone and patient portal messages, reviewing and managing laboratory and diagnostic testing results, collaborating with other members of the care team, crafting insurance appeals and compiling documentation for prior authorizations and referrals, completing documentation, and reviewing correspondence.

Efficient physicians who have strong support staff can often tackle many of these during patient care hours, i.e., they cram the tasks in between patients. Organizations that can afford scribes or ambient documentation solutions help physicians complete their visit notes before they leave the patient room, which frees up time that was formerly used for patient documentation that can now be used for all the other work.

Organizations that don’t prioritize that kind of support leave the physician to manage the rest of the burden themselves, which creates other issues. Physician burnout is one, which can lead to physicians leaving a practice for alleged greener pastures elsewhere, retiring early, or leaving medicine altogether.

Another issue is avoidance, where physicians are so overwhelmed they just don’t do the work, either leaving it to accumulate in their inboxes or just clicking through it without reading or addressing it. This approach creates patient safety issues. Some organizations have strong policies around it, but others wait until the levels of delinquent work reach ridiculous levels before taking action. Those actions are typically punitive rather than supportive, so one can guess at their level of effectiveness in making the physician want to behave differently in the future. 

The authors start with an introduction about the current state of clinical schedules versus physician time worked, noting that the average full-time US physician works 54 hours. More than 40% of us work more than 55 hours per week compared with 10% percent of workers in other fields. They also provide statistics on something that many of us have experienced first hand – that part-time work isn’t part time, with physicians who are working as 0.8 FTE (full-time equivalent) still averaging 46 hours per week.

The authors set about trying to answer this question — what is the appropriate number of scheduled patient care hours that would result in a 40-hour work week for physicians of various ambulatory specialties? They looked at 186,000 physicians from nearly 400 organizations and used data from November 2021 through April 2022.

I have to say that the timeframe caught my eye. We were still dealing with a substantial burden from COVID at that time, and also those months coincide with respiratory illness season, which disproportionately impacts some specialties. It made me wonder whether the results might look different if they looked at a larger time span that would help control for seasonal variation or one that was more typical and without the additional burden of COVID and its extra work notes, FMLA paperwork, and other administrative tasks.

The authors used EHR metadata to calculate a so-called PSH40 to depict the ideal number of patient scheduled hours that would result in the desired 40-hour work week, noting that the lowest numbers were in the specialties of infectious disease, geriatrics, and hematology. In my experience, patients who are seeing those specialists tend to have complex histories and challenging conditions, so I wasn’t surprised.

The highest numbers were in plastic surgery, pain medicine, and sports medicine. Those specialties had the lowest burden of work to be done outside scheduled patient hours, which the authors described as WOW (Work Outside of Work). Specialties that had fewer than 500 physicians in the sample were excluded, as were non-physician specialties such as dentistry, optometry, and podiatry.

The authors also looked at other practice characteristics, such as academic versus non-academic status, whether a practice was considered part of a safety net, and whether a specialty was considered primary care, a medical specialty, or a surgical specialty. Not surprisingly, academic, safety net, and non-surgical specialties all had lower PSH40 numbers due to their larger volume of WOW.

Although this concept of PSH40 is new, the authors state that, “We believe that health system leaders and physicians will benefit from data driven and transparent discussions about work hour expectations.” They note that current expectations “have been set by historical norms, are not based on objective data regarding the total work hours associated with a given number of PSH, have remained stable despite a growing volume of care outside of PSH through the patient portal and EHR inbox and are a source of uncertainty for organizational leaders and physicians.”

They call for future studies that look at different support staff structures and team care environments to see how the PSH40 might vary. They emphasize that work hours matter, with negative health outcomes associated with work overload. The fact that working more than 55 hours per week is linked to higher rates of heart disease and stroke was a new one for me.

The authors emphasize that physician burnout is linked not only to longer work hours, but also to lower patient satisfaction, lower quality and safety scores, higher rates of medical errors, and higher costs of care. These are all reasons that organizations should care about the data. Even if they don’t care about their physicians’ personal health risks, they definitely care about costs of care.

The authors note some limitations in the data used for the analysis, namely that it was from a single EHR platform (Epic) that has specific constraints about how it tracks physician activity. They recommend that organizations that want to use the PSH50 metric perform calibrations using local specialty-specific data from their own EHR.

The authors also note the limitation that EHR log data doesn’t capture non-EHR work such as phone calls and discussions in the office. Additionally, there would be complexity using the measure for specialties that also see patients in the inpatient environment or in ambulatory surgery centers.

Overall, I enjoyed reading this paper, which is not something I usually say when perusing academic publications. It’s an important topic and one that also impacts physician contracts and compensation.

An informal survey of some of my family medicine colleagues noted that their contracts required anywhere between 32 and 40 patient scheduled hours to be considered full time, with some agreements specifying a number of administrative time hours and others not mentioning that at all. This kind of measure gives institutions the power to monitor whether changes in processes are effective in reducing work outside of work and whether they have the potential to improve patient access.

Is your organization looking at a measure like this, or assessing work outside of work? Are things moving in the right direction to reduce burnout and improve patient care? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/7/24

As many patients with traditional health insurance do in the US, I scheduled some additional medical appointments for the fall and early winter once I realized that I had met my insurance deductible. One of those appointments provided examples of how poorly we manage certain elements of healthcare.

The adventure started with a string of phone calls the week prior to the appointment, with a confusing voice mail about lack of insurance authorization for the visit. Since my insurance doesn’t require authorization or a referral for this kind of appointment, I tried to call back. The office was closed and I was transferred to a billing service that couldn’t help.

After much phone tag, it turned out that the office had requested multiple authorizations for service and had misplaced the original response from my insurance company that told them that I didn’t need an authorization. The office is still using a paper process and my particular paper was in a drawer.

In the following days, I received several text messages in the days before the appointment to remind me to arrive 15 minutes early. It offered no ability to do check-in tasks online. As part of the front desk paperwork, I was given a special consent form to opt in to the practice’s patient portal, so I was grateful that they’re finally coming into the modern age.

However, it went downhill from there. They marched me back to a chair in the hallway, slapped a blood pressure cuff on my wrist, and told me to hold my arm up at the level of my heart while the cuff did its thing. The assistant bent over me trying to look at the screen, which folded up next to my body since I was holding my write-up as directed.

For those who might not be clinicians, that’s just about the most inaccurate way to take a blood pressure that one can consider. Even if you have non-medical people gathering vital signs, there are better options out there for a more accurate reading. As expected, my reading was high because I had just raced from a packed schedule of calls to a crowded parking lot, but no one asked me about it.

I was also surprised that the office didn’t have my allergies in the chart despite the fact that I’ve been seen there half a dozen times. I’m not sure why they added blood pressure to their pre-visit tasks if they’re not going to do anything about it. The clinician didn’t seem to have too much of a problem with the method in which the blood pressure was taken. I’m going to have to just keep shaking my head because I can’t bring myself to write another cranky letter to a faceless medical director.

From Conference Diva: “Re: HLTH. I was cleaning out my bag from the conference and found the urine dipstick that I picked up in the women’s restroom. I don’t know if the advertising placement in the restrooms was a formal paid exhibitor placement or more of a side effort by the vendor.” Digging back through my pictures, I found an image that I captured that went along with the test sticks, which were taped to the doors of some of the stalls and also on the counter. Due to my short time at HLTH, I’m not sure if other vendors were doing the same in different parts of the venue. It’s certainly an eye-catching way to place your product, but I would be interested to know how many serious leads the effort actually generated and whether it was worth it from a cost perspective.

Hearing from a reader about HLTH reminded me that I had sessions whose recordings I wanted to watch because they were in conflict with other sessions I was attending. Although it was easy to find the sessions on the HLTH website, I was surprised by how much of the background noise was reflected in the recordings. I have a love/hate relationship with the setup of conferences like HLTH and ViVE, where the sessions are smack dab in the middle of the exhibit hall craziness. Although it’s nice to be able to pop in and out of sessions and it’s convenient to get to networking opportunities, I find the excess noise distracting. Having listened to enough live albums in my lifetime, even back to the vinyl days, I know that it’s possible to engineer out the background noise from the recording.

It makes me wonder if HLTH doesn’t care, didn’t want to spend the extra effort, or thinks that the relentless hum adds to the conference’s cool factor. HLTH described itself in a post-conference email as “The Event That Broke the Internet” without further explanation or discussion of how they claim to have done that. They also described attendees as being “in the midst of history” being made, so I’m suspecting that it’s the latter.

Another pic I saw from my captures at HLTH was this Physician Side Gigs booth. It was interesting to see a physical representation of what started out as a Facebook group, then grew to a website and an online community that describes itself as a “virtual physician lounge.” Rest assured, that group is not the virtual lounge to which I refer at times. It’s a for-profit enterprise that is chock full of sponsorships and affiliate links. It is populated by large number of physicians who are trying to side gig their way to escaping clinical practice. I wonder how productive HLTH was and what kinds of interactions they might have had with payers, health systems, or vendors.

I was interested to catch this mainstream news article that claims that AI-powered transcription tools that hospitals are using are inventing “things no one ever said.” The article lists specific comparisons between what was said and what was transcribed. The hallucination examples that were given are certainly more problematic than the mix-ups that we used to see when people used dictation services in crowded medical records rooms.

The article is a good read and provides not only specific examples, but also statistics about the frequency of hallucinations. Researchers found that 40% of hallucinations were concerning or potentially harmful. The article gives examples of hallucinations that added inappropriate racial context as well as violent language. Based on conversations with my colleagues, it sounds like there is little editing or review being done by some physicians who are using these systems, so patients (as well as consulting healthcare professionals) should proceed with caution.

Another interesting article this week looked at smart but bored teenagers as being the next big cyberthreat. TechCrunch refers to these individuals as “advanced persistent teenagers” and notes their propensity to access systems through manipulating people rather than high-tech hacking. With time on their hands, perpetrators use voice spoofing and phishing along with other techniques to obtain logins and passwords that are then used to cause mayhem. I’ve been around some incredibly smart teens in the last few years and some of them have tech skills that I could only have imagined at that point in my life. Here’s to hoping they find ways to use their skills for good rather than being drawn to groups that are doing these kinds of things.

What do you think is the biggest threat to healthcare IT in the coming year? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/4/24

Every year when the leaves begin their fall color change, I wonder if this will be the year that my healthcare system will get its act together to synchronize patient reminders with care that is already scheduled. Unfortunately, this year was the same as all the others, when I received a formal letter that reminded me to schedule my mammogram that has actually been scheduled at their flagship imaging facility for more than 365 days.

Because I’m a concerned patient who doesn’t want to delay her screening, and because I’m trying to run my own business and have already blocked my calendar for that day, I have to take the time to log in to my patient portal, confirm that the scheduled appointment is still there, and become generally aggravated by the process.

What bothers me the most is that among all the problems that healthcare organizations are coping with, this is a relatively easy one to fix. It also has a direct cost savings when paper mailings are eliminated, and depending on how the organization handles those mailings, the savings can be significant. It’s also better patient care, but no one at this organization seems terribly motivated to fix the issue.

While I was still feeling the low-level aggravation of the situation, I ran into a catchy headline: “Why Medicine is Bad at Customer Service – And How to Fix It.” The article starts with a recitation of the conveniences that many of us use on a daily basis – online shopping, streaming entertainment, and rapid delivery of food and consumer goods. It contrasts those with the struggles that people face trying to conveniently access medical services.

It offers good reminders of the relevant statistics, including that healthcare constitutes more than 17% of the US economy, with per capita spending averaging over $13K. It summarizes the hassles of individuals who are trying to access care, ranging from inefficient phone calls to provider offices to the complexities of insurance referrals, appointment scheduling, and time-sucking office processes. It asks the question, “What other business treats its customers so poorly, so frequently, and so predictably?”

As is typically seen in these kinds of articles, the author mentions other industries and how they compare with healthcare. Although airlines have low consumer rankings, they at least have price transparency and collect payment up front, which allows comparison shopping. The article also mentions cable TV as an example of a service that executives didn’t feel that consumers could do without, yet where there has been a revolution where customers opted for other services based on convenience.

The author says, “It’s time for the medical business to view customers as people with busy lives, not just a collection of body parts that periodically breaks down and generates revenue.” Having worked with multiple health systems in my career, I found that statement telling, but also that it leaves out part of the story. Health systems bank on the income from revenue-generating procedures in their communities and even seek it out. It seems like almost everyone has an orthopedic “Center of Excellence,” and those that I’ve seen have a higher advertising budget than any primary care or preventive service lines combined.

The article calls for healthcare organizations to embrace customer service and access by investing in telemedicine and neighborhood-based health services. It advocates for expansion of home-based treatment options. As someone who spent some time in a non-US healthcare environment it sounds a lot like what other developed nations have been doing for decades.

It also mentions the horrific appointment lead times that patients are experiencing for basic healthcare services. In my area, even with good insurance that has a wide network, the wait for a new primary care physician is up to 12 months. With Medicaid, the wait for certain subspecialties is approaching infinity because providers have stopped seeing those patients due to low payments. The article addresses this by calling for realignment of financial incentives, which isn’t a new topic. It notes that the shift to value-based care should drive greater attention to consumer desires.

Those of us who have worked on the care delivery side know that healthcare is a lot more complex than the processes that are needed to order an Uber to take you to the airport or to set up a recurring delivery of household products and groceries to your house. One of the elements that adds to complexity is our fragmented multi-payer system, where a patient’s access to care (as well as the cost of that care) can change every time they encounter a so-called life event, whether it’s a job change or a change in marital status. Even with stable insurance coverage, providers are constantly opting in or out of different plans as reimbursements change and they seek to cultivate an optimal payer mix for their practices. Budgeting for services also changes depending on where patients stand with respect to meeting their annual deductibles.

Another element is the for-profit system that adds rebates and kickbacks into pharmaceutical purchasing, sometimes making it so that patients can buy drugs cheaper without using their insurance than they can with it.

Speaking of being for-profit, another level of complexity includes providers that are hawking cash-pay procedures that may not be indicated for a particular patient based on established guidelines, further eroding patient trust in the medical system. One of my relatives recently ran into this with an optometrist who was pushing digital retina photographs for an otherwise healthy 18-year-old patient. Guess what? That procedure is not covered by insurance because its hasn’t been proven to be beneficial in patients. When the patient said no, they were treated like they were failing to follow medical advice, despite the fact that the person telling them that they needed the service was a receptionist with no medical credentials. In my opinion, trying to do that kind of retail-style upsell on patients who are seeking medical services is simply unconscionable. But it’s just another day in healthcare, apparently.

There is also an incredible amount of inertia present among healthcare organizations. Just try to talk about opening up patient self-scheduling with a care delivery organization that isn’t already allowing it and you’ll hear dozens of arguments against it even though countless organizations have implemented it successfully. I guess when a health system controls a certain percentage of the market due to choice-limiting payer contracts, they have less incentive to make things more convenient for patients because they know they have a captive audience.

When inertia has been present in the past, US lawmakers have stepped in to force change. It will be interesting to see if some of the new legislators who may be coming in following this week’s election have an appetite to improve the patient experience, or if we can expect more of the same.

If you could wave a magic wand and improve one thing in healthcare, what would it be? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/31/24

It’s Halloween, and there’s nothing spookier to me than Oracle Health’s announcement of a new EHR that is coming in 2025.

Those of us who have been in the EHR space for a long time immediately had questions. How far along is the development? How much have they spent already? Who do they plan to have pilot it? What is their certification plan? Do they have physician informaticists working on it? And of course, the rhetorical but honest “Are you kidding me?” So many questions here.

I reached out to some Oracle (and former Cerner) pals as well as CMIOs of current systems that are using the product formerly known as Cerner. Their comments ranged from eye roll emojis to no comment. If you have the inside scoop, do let us know, we’ll be happy to preserve your anonymity.

The fact that Oracle thinks Millennium has a “crumbling infrastructure” is interesting. If I held the CMIO title at an institution that is using the product, I would probably be using it as an excuse to try to get funding for a rip and replace to Epic rather than listening to years of promises about an as yet unseen system. My experience in the industry is that the devil you know is better than the devil you don’t know about 80% of the time. I wouldn’t want to risk my career plunging into the abyss with Oracle.

My other thoughts on the Oracle announcement. Their mention that it’s largely voice driven isn’t reassuring to me, because sometimes menus or drop downs can be useful to remind a busy physician of something they should be thinking about. Taking those away means that we’re reliant on memory or having the right data framework in our head, which can be difficult to do at the end of a 24- or 36-hour shift or even after 12 hours in a busy urban emergency department. The article has examples of this – asking if the patient has had lung cancer screening is dependent on the clinician remembering that the patient was a smoker and other risk factors. There’s also the issue that many of us process faster through visual and motor pathways than we do through speech, so it will be interesting to see data on how fast these visits go.

I didn’t see any folks with clinical titles from Oracle speaking about the product in the major media reports. We had a senior vice president for product management and of course Seema Verma quoted in most of them. Do they even have a CMO or CMIO? I’d love to hear from the people in those roles, regardless of their actual titles, and understand how they think about this. It would be good to understand who the patient safety and regulatory experts are and how they’re contributing to the effort, as well as understanding who is approving the build requirements from a clinical standpoint.

From Booth Crawl Betty: “Re: HIStalk’s guides to the major shows like HIMSS and HLTH. Exhibitors should list what kind of food they are offering in their booths. At HLTH there were some good options including Twilio, which had espresso that could be ordered in advance using a QR code, as well as booths with snacks, ice cream, and liquor outside the all-show happy hour time frames.” Nothing beats the scones that used to be baked at HIMSS, so I’m fully in support of a foodie’s guide to the shows. Last year’s HIMSS also had some amazing chocolate chip cookies that weren’t baked in the booth, but were better than 90% of the cookies I’ve had, and that’s saying a lot.

From Optimize Prime: “Re: inboxologists. It’s an interesting term to describe taming patient message beast.” I’m not a fan of the term, but I’m a fan of the concept. In fact, most of us who do process improvement work with medical practices have been championing that idea for the last two decades. It’s the old “work at the top of your license” concept under a new name. For those of us who practiced in outpatient offices pre-EHR, this is similar to having a triage nurse who fielded the majority of phone calls, bringing patients onto the physician schedule if they needed more than could be appropriately managed over the phone. In many organizations, the rise of EHRs meant those messages could be routed directly to the physician, even though they probably shouldn’t be. Practices looked at it as a way to cut costs — most of the primary care offices in my area don’t have nurses, and some barely have trained medical assistants — without looking at the bigger picture of shifting that work onto higher-cost resources like physicians.

Another not-so-shocking finding using tech-enabled workflows: Patients who receive electronic communications that encourage them to get influenza vaccines are more likely to get a vaccine than those who get no communications. The six electronic letters used in the study varied in effectiveness, but all of them were better than no letter. These kinds of patient-facing campaigns are just about the easiest thing you can do with an EHR and a patient portal, so if you’re not doing it, please encourage your patients to get their flu vaccines.

As I see for-profit entities sucking the “care” out of healthcare, I enjoy a good skewering of those who are not acting in the patients’ best interests. A recent report from the US Senate Permanent Subcommittee on Investigations looked at how Medicare Advantage plans are gaming the system using prior authorizations to deny care and boost profits. Long story short: they’re counting on the fact that physicians and their office staff are exhausted and simply won’t appeal a certain percentage of those denials. Health plans claim they are doing this in the name of savings, but those savings are a big part of what creates profit for the plans. They’re certainly not giving any money back to patients, providers, or the taxpayers who fund Medicare.

From Put a Ring On It: “Re: your recent post about the Happy Ring that recently received FDA approval as a medical device. If no one has acted on your suggestion, I recommend you buy an Oura ring for yourself, because life is too short to not buy your own jewelry.” Although it’s also a cool looking wearable, I found this New York Times piece that talked about the device’s shortcomings. According to the author, the device and its accompanying app rated his sleep as “good” despite seven awakenings, noting that “this was a classic case of an algorithm failing to objectively measure the very subjective nature of how I was supposed to feel about my sleep.” He also cited inaccuracies in step count and a comment from the company that it plans to update its algorithm in 2025.

Are tech/wearable rings worth the money or should I stick with my preference for ethically sourced vintage jewelry? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/28/24

I recently had the opportunity to participate in a roundtable discussion with other CMIOs. As one would expect, “what is your organization doing with AI tools” was one of the questions given for discussion. It seemed like AI-assisted or ambient dictation was the most commonly used technology, with AI-driven patient engagement solutions in second place.

Although people initially talked with some enthusiasm about their projects, the conversation drifted to the topic of budgets and how much money is being dedicated to AI-based solutions. Although the CMIOs felt that they would be able to deliver a solid return on investment for those two solutions, there was quite a discussion of other tools that they are implementing that feel more like AI for AI’s sake rather than being focused on pressing problems.

Several individuals at the table discussed their ongoing needs for budgetary support to continue doing what they consider to be the basics, such as optimizing EHRs that they have spent hundreds of millions of dollars implementing, but that need funding to keep them current and to take advantage of new features. One spoke of her organization’s ongoing implementation fatigue, where not only is the informatics team running ragged, they feel that physicians are not tolerating the pace of change because IT projects are being deployed at the same time as operational projects around coding and compliance and clinical quality.

Another CMIO spoke in follow-up about the need to ensure that change management tasks are included in any proposal for new solutions. His hospital has a tendency to roll out new things without funding to cover the time that is needed to build consensus, ensure buy-in, and identify those on the medical staff who might openly sabotage an effort before it even gets out of the gate. His clinicians are tired of “too many solutions with too many promises and not enough improvements” to the point where they will vocally oppose changes to the system that introduce any new clicks or expanded work for the clinicians.

Another mentioned that his institution had been implementing a separate solution to help manage chronic conditions through a partnership with one of their payers. Although he originally voiced concerns about patient matching and data integrity, he was reassured that everything would be fine and that the payer’s solution had experience integrating with his particular EHR. Unfortunately, the system’s ability to integrate had been grossly overstated. After months of dealing with patient matching issues, the project was placed on hold while they worked to sort it out. It seems that at this point in the evolution of clinical informatics, we should have a solid handle on patient matching, but it’s often more difficult than it needs to be. Lack of a universal patient identifier in the US continues to be one of the difficulties.

One of the CMIOs mentioned ongoing problems trying to reconcile gaps in care across his organization. They’re a large health system and have acquired multiple independent physician groups over the last couple of years, slowly working to integrate all the platforms. His predecessor didn’t ensure due diligence with data mapping and adjustment of clinical quality reports, which means that physicians aren’t getting credit for their patients having appropriate screening tests or treatments because the system isn’t recognizing them properly.

After doing some digging, he discovered that certain reports were looking for particular character strings in the names of lab tests rather than looking for test codes or even something more standardized like a LOINC code. Since there were variations on the test names sent by outside systems that are now inside, they had to embark on a large project to fix the issue. Of course this wasn’t part of the 2024 budget, so now he’s scrambling to get it fixed as quickly as possible before end of year reports are generated while simultaneously cutting other projects they had planned to finish before 2025.

Others at the roundtable mentioned that they would like to be able to implement new features of existing systems, but simply don’t have the money to do so. One mentioned going through the budget cycle for 2025 and being concerned that he will likely receive about 60% of the funding that he requested since the hospital is running with negative margins.

That led to a discussion of which health systems have been in the news for laying off IT and other non-clinical teams. That got heated since several at the table are in positions of having to trim headcount and are trying to do it through retirements or other more natural sources of attrition rather than having to conduct a layoff.

One of the topics that had nearly everyone participating was that of workforce planning for clinical informatics. Although the majority of those in the conversation believe that we need more experienced clinicians helping with informatics projects, they agreed that their organizations don’t necessarily want to provide financial support in exchange for the expertise of those clinicians. One mentioned that his organization’s non-clinical leadership has an attitude that physicians should be grateful for the opportunity to have input on clinical technology and should not expect to be compensated because the solutions don’t benefit anyone else.

I thought this was an interesting comment, but didn’t have time to dig into it. Does it mean that physicians aren’t involved in multidisciplinary projects, or is the organization not doing any multidisciplinary projects? Either answer would indicate some less than ideal priorities.

Another mentioned the influx of physicians who are burned out in their original specialties and are looking at informatics as a way to potentially get out of the clinic. The majority of those individuals don’t have formal informatics training and don’t understand why they are not selected when roles open. Some are not willing to put in the time to complete informatics courses and build a more formal skillset. Others think that they can command the same salaries as they would earn in their clinical specialties even though they don’t have any experience.

It sounds like it makes for many difficult conversations between experienced informatics physicians and those who are trying to use it as an escape. I’ve certainly run into those folks myself, and they always seem shocked that I’m not willing to bring them on as highly paid consultants simply because they’ve used an EHR.

The group is scheduled to meet again in six months, and it will be interesting to see whether the overall priorities are the same or whether there have been small changes or even dramatic ones. I enjoy building these kinds of relationships over time and was thrilled to be part of the roundtable, so I’m looking forward to catching up in the spring.

If you’re a CMIO, what do you think of these topics? Are you dealing with the same issues or do you have completely different ones drawing your attention? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/24/24

Dr. Jayne Goes to HLTH

I managed to swing by the HLTH conference earlier this week, en route to other client work. Even though HLTH positions itself as the hipper and cooler of the healthcare technology conferences, it is still plagued by attendees behaving badly.

I was shocked at the number of people who stopped in the middle of high-traffic areas to read their phones, or who wandered oblivious of their surroundings because they were heads down. It’s not hard to step off to the side, and a little courtesy might just keep you from being slammed into by the crowd rushing from stage to stage trying to catch hot topic presentations.

Normally I am annoyed by people who are whistling — in the same way I’m annoyed by people who are having loud video chats on their phones or watching movies without headphones — but I had to smile a little when I realized that the guy walking in front of me was whistling one of Bach’s Brandenburg Concertos.

From my tour through the exhibit area, kudos to Steel Patriot Partners and its booth team for being on the alert and greeting passers-by with strong eye contact and using attendee names and titles, which was doable at this conference because the font on the badges was large enough to read as people were passing. The company is always solid in the hall, and I wish more teams would follow their example in being outward facing and engaging. My day continued on the upswing with a brief Jonathan Bush sighting and a trip to the Puppy Park, which always puts a smile on my face.

The Zappos team also had a strong booth work ethic, greeting people promptly and fielding questions about their employee engagement program. If you’re looking for something that’s more fun than the usual logo-bearing tchotchkes, they’re worth checking out. Especially with organizations encouraging team members to move more and improve their own personal health, making sure that everyone has appropriate footwear makes sense.

Speaking of footwear, IMO again brought a strong sock game as well as the usual highly polished dress shoes. This picture highlights the weirdness of the exhibit hall aisles, where there was bare concrete between the borders of exhibitor booths and a spongy purple runner that was placed down the centers of the aisles. The problem with the purple runner is that the sides curled up midday in some areas, creating a trip hazard. It was also weird to stand talking to people and having that uncarpeted no man’s land at the edge of the booth. I know that everyone is trying to save money, but it just felt a little too industrial, not to mention that one good slip-and-fall lawsuit will surely wipe out any savings that was had from the strategy.

Several booths, including behavioral health vendor Headspace, had arcade-style claw machines. Other eye-catching features seen on the show floor included the tried and true “spin the wheel and win a prize” gimmicks as well as notebooks, stress balls, and plenty of logo-bearing socks. I spotted a “Top Gun” Val Kilmer Iceman impersonator several times, complete with flight suit. He was amazingly close to the character in looks and bearing, including full swagger. I was never successful at figuring out what booth he was with, or in catching a good photo, so if you know the story or have a good picture, please share.

Nurses are superheroes, and these were even wearing the capes to prove it.

I made a couple of logistics notes during the meeting, the first of which was this sign that was placed near where attendees entered the exhibit hall through a tunnel of stage lighting. As a physician, I don’t feel very good about knowingly excluding a subset of attendees on the basis of a medical condition. It seems that as a healthcare conference we should be able to chill on the stage effects in order to include everyone.

There were also issues with lunch timing, as buffets were fully set, but with expo center staff blocking their opening. One line had a staffer who was doing 30-second countdowns as the lines grew, telling attendees “5 minutes” then “4 minutes 30 seconds” and so on. Finally, a HLTH team member came by and told them to go ahead and open the lines at the one-minute mark. I know they don’t want to open lines early if everything isn’t in place, but that wasn’t the case here. Swinging by again towards the end of lunch service, I noticed that they had one lunch area entirely closed with 45 minutes left in the lunch time, and in another area, three of four buffet lines were shut down with 35 minutes to go.

Part of the way that HLTH justifies its high prices is the food service, and it seemed a little lackluster compared to when I attended a couple of years ago. I also heard several complaints about the lack of adequate table seating during lunch, especially when food was served that required use of a fork and knife. Most people are less happy about trying to eat a piece of steak with a plastic knife and fork while sitting on a white sofa compared to using a table.

Although there was a good amount of lounge-style seating around the hall, I saw plenty of individuals who had just plopped in the middle of a sofa rather than choosing a seat at the end so that someone else could perhaps use the other end. That’s not HLTH’s fault as much as attendee manners, but future logistics plans might want to take that into consideration and add more individual seating for those who like to avoid being next to anyone. An architect friend of mine has a tremendous amount to say about the psychology of seating design, so I’m sure brilliant event planners can figure it out. Maybe someone can chip in an AI solution to generate suggestions.

Alas, it was a long day in the exhibit hall trenches and I had a plane to catch, so I left through an alternate exit door where I found this sign. I thought it was funny since it was facing the doors I had just come through. The other side was blank, so if they really wanted people to not use those doors, they probably should have turned it around, especially since it was (at least in my opinion) pretty funny.

I visited a couple of vendor parties during the evening. Despite us being in a post #MeToo era, I experienced some sexual harassment for the first time in a number of years. Too much alcohol definitely brings out the worst in some and doesn’t make boorish behavior better in others. One reader shared a picture of someone sleeping in a hotel hallway wearing their conference badge the next morning at 6 a.m. I’ll hold off on sharing that picture because it’s bad enough to wake up that way, let alone potentially lose your job over it, since we don’t know if they were just tired, lost their room key, or were under the influence of something else.

If you attended HLTH, what were your highlights? Anything you would change for next year? How was the Busta Rhymes show? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/21/24

When I decided to pursue a career in family medicine, I saw the specialty as promoting three primary goals: health promotion, disease prevention, and helping patients live longer and healthier lives. As a third-year medical student, I had little understanding of all the factors that would be working against me in that pursuit.

I knew that there would be insurance companies that would put prior authorizations and other blockers in the way of recommended treatments. I knew that I would have challenges finding resources for patients who are without insurance and with low health literacy. I didn’t know that I would also be fighting an uphill battle against corporate America in the form of tobacco companies, giant food conglomerates, and many others that are reaping profits from reinforcing unhealthy behaviors and addictions.

As I moved into clinical informatics, we saw ways in which technology could help us do more with less and to better identify patients who were in need of health interventions. When we started looking for the needle in the haystack trying to find patients who had fallen through the cracks on preventive screenings, more often we found a giant pile of needles needing attention because so many patients had fallen through the cracks. Even after we had identified the patients, we still had to convince them to adopt healthy behaviors and undertake recommended screenings and treatments, which was an entirely different undertaking. It became discouraging to watch data pile up and not have the resources to act on it.

Fast forward to the world of wearables and the quantified self. We became excited about the ability to put data in patients’ hands on a daily basis, motivating them to make changes in their health status. The rise of wearables highlighted economic disparities when some patients had multiple different kinds of devices – from step counters to sleep trackers – and others were struggling with basic subsistence needs. As a primary care physician, that evolution created a bit of whiplash in the office as I moved from room to room. Some contained patients who brought printouts and jump drives so I could see their data. Other room had patients who were lucky to take a blood pressure reading at Walgreens once or twice a month. Although some employers and insurance companies developed programs to get devices to their patients, those were few and far between in my practice.

We are now 15 years past the release of the Fitbit, which made tracking more accessible for many, but I’m not sure that we are any healthier. Recent articles that looked at life expectancy show that the improvement curve of the last century has hit a slowdown, even in economically advantaged nations. Public health interventions and new medical treatments have been a primary driver of those improvements, but we still haven’t cracked the code on how to help our patients overcome many of the challenges that they face, from lack of health resources to the ability to cope with the decreases in function that come with normal aging.

Ten years ago, when getting together with physician colleagues over drinks, we could expect to talk about interesting cases that we had seen at the hospital, or we might be kvetching over student loan repayment. Now, we’re more likely to discuss how we are juggling our own health issues or the challenges of managing health needs for aging parents and loved ones. As part of a family whose members routinely approach 100, it’s a topic with which I have experience.

The article contains a discussion of research around life expectancy that has been done over the last three decades. The authors conclude that we’ve reached a point where it’s increasingly difficult to drive life expectancy upward. I found their discussion of the percentage of patients that could be expected to live to be 100 years of age most interesting. To make this happen, they note that we would need ways decelerate death rates among older people, and due to the costs involved in such a project, I’m not sure the world is ready to spend that kind of money.

Additionally, having been around plenty of people who are in their mid to late 90s, the ones I know aren’t terribly interested in radically longer lives. Although they have had tremendous life experiences, they have also had to grow used to living without their friends and loved ones and sometimes seeing their children and grandchildren predecease them. One of my relatives continually asks why she’s still here when so many others have gone, and it’s terribly sad. It’s certainly something that should be considered when we’re talking about changing how we look at medical interventions.

In thinking through this topic with the understanding of where we are with healthcare spending in the United States, it makes me wonder whether we have the right information to try to solve the problem of truly helping people live longer healthier lives, or whether we will continue spinning in circles.

We certainly know that some relatively inexpensive interventions, like vaccinations, help. However, we’re fighting an often losing battle in convincing patients to partake of these interventions due to conspiracy theories, fears related to debunked not-so-scientific research, and for some, a genuine belief that doctors only recommend vaccines because of personal profits. As a primary care physician, I can attest that the latter is most certainly false, but it’s difficult to convince patients. Improving nutrition is one of the areas that has the most potential to boost health, but it’s not sexy or exciting, so it languishes as a not-so-hot topic. 

We know that it costs money to improve patient health, whether through improved nutrition, health coaching, medications, or procedural treatments. However, because of our fragmented healthcare finance system, insurance companies pay for those interventions on younger patients but don’t realize the long-term savings, which sometimes don’t happen until patients are covered by Medicare. This phenomenon, along with our profit-driven insurance companies, drives the willingness of payers to try to deny treatment, which starts a cascade of activity by patients and physicians that unfortunately in some cases leads to everyone giving up before the patient actually receives the care that they need.

I’m still looking for the technology silver bullet that cuts through all this mess and matches the right patient with the right treatment at the right price at the right time. Maybe AI will help create that solution, but it’s also going to require a lot of individual commitment and political will that seems to be lacking.

Before we had so much data, we didn’t know if  we were doing a good job for our patients. Now we have lots of information, and although it shows that we do a lot of good things, it also shows ongoing deficiencies that still need attention. Maybe I can convince some of the smart folks who I work with to create an app to give me a weekly reminder of “great things we’ve found in the data and have been able to act on” so that the other findings we encounter don’t seem so discouraging. Although it might have been easier back when we knew less than we do now, knowledge is power, and it just reminds us of what is yet to be done.

How well does your organization drive outcomes using data? Are you helping move patients to improved health or are people running in circles? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/17/24

The hot topics around the physician lounge this week included new alerts in the EHR to help clinicians manage IV fluids efficiently. If you’re not aware, Hurricane Helene damaged Baxter International’s production facility earlier this month. The single facility is responsible for nearly two-thirds of the IV fluids that are used in the US, which is problematic, especially considering that we’ve read the plot of this story before in the wake of Hurricane Maria in 2017, which damaged a Baxter International facility in Puerto Rico. The US government has invoked the Defense Production Act to try to help get the facility back to production while Baxter is ramping up production at facilities in Europe and China. Meanwhile, hospitals are postponing surgeries due to the fluid shortages, which is devastating for patients who have been waiting for carefully timed procedures that may not be emergent or urgent but are still important.

Another hot topic was a research letter about billing for patient portal messages that was published in the Annals of Internal Medicine earlier this week. It summarized changes to physician and patient attitudes when organizations decide to bill for patient messages. Some of the highlights: patients weren’t thrilled about being billed but were willing to accept it, but there was confusion about which messages would lead to billing. When patients were to be billed, they expected “speedy, detailed replies.” Ultimately patients said they would be more likely to call the office than to use the patient portal to avoid being billed. Physicians also began to receive messages where patients specifically asked not to be billed. The physicians talking in the lounge were split on whether billing for portal messages was a good thing or not, although two said they no longer manage portal messages at all – anything that requires physician input becomes a scheduled appointment.

I’ll admit I was lured by this headline: “Surgeons use PlayStation controller for long-distance endoscopy.” The procedure was performed in by a surgeon in Switzerland, with the research subject being a pig in Hong Kong. Although endoscopy is not without risk, it’s less risky than surgical procedures where tissue is removed or altered. The magnetic endoscope was steered using a magnet outside the pig’s body. Researchers note the potential for this technology to assist in remote locations. The first thing I thought of was for workers overwintering at the South Pole where resources are scarce and where the late Jerri Nielsen treated her own breast cancer while serving as the station’s physician. Reliable high speed internet is essential for the solution to work, which unfortunately may be a limiting factor for its use. Still, it’s an interesting idea and we’ll see how far it evolves over the next few years.

I love wearable tech, although I’m still sad about the untimely demise of Ringly and still wear my smart bracelet as a plain old bracelet. Happy Health just received FDA clearance for its new Happy Ring smart ring that can track pulse, temperature, and blood oxygen levels. It’s also a sleep tracker and can monitor “brain activity,” but I haven’t seen details on what exactly that involves. From an aesthetic perspective, it’s a bit chunky and certainly wouldn’t be mistaken for actual jewelry, but I suspect people that want those features are less likely to be fashionistas. The press release notes that it has “a near-indestructible, diamond-hard ceramic design,” which makes the emergency physician in me cringe a little bit, having fought the battle against a number of titanium rings in an effort to salvage fingers that might have otherwise been lost. The company will launch its first clinical program in the coming months, targeted at sleep health. For the people in my life trying to get ahead on their holiday shopping, I’m a size seven.

From Hoopster: “Re: health system sponsorships. Kaiser Permanente has become a founding partner of San Francisco’s WNBA expansion team.” Financial details weren’t shared publicly, but a previous deal with the National Women’s Soccer League was estimated at $850,000 per year. Kaiser filed multiple layoff notices in September and October, so I can’t imagine employees being thrilled about the new expense. Having worked in the software industry, I know how care delivery organizations think about ROI (return on investment) whenever they’re asked to spend money. I’m not familiar with the math around this kind of sponsorship ROI, but I imagine it must be there if so many organizations are taking the plunge. Either that or there’s just a cool factor around it. If you’re in the know, feel free to drop me a line.

Has anyone else’s LinkedIn inbox become a dumping ground for spam? The majority of my invitations are from people I don’t know who are trying to promote services I don’t need, ranging from financial advice to career coaching. I had two invites today from people promising to “get you more patients,” which is not a problem that 99% of primary care physicians have in the US today. Another one was pitching weight loss services for busy physicians. I hope the platform gets it under control, because having those kinds of messages makes me not want to access it and makes it likely that I will miss something that I really do want to see. I’m not a robust user of the platform, so maybe if I engaged differently with it, I might have a different experience, but it’s hard to engage when my feed is full of reposts that seem to beat the same few topics to death.

Many of our readers are prepping for HLTH 2024, where the who’s who of the industry will again come together. Many will be launching new solutions, schmoozing potential clients, identifying new partners, and trying to close deals. Others will simply be trying to “outcool” each other, and I’m deputizing all attendees to send me their best footwear and fashion pictures so I can feel in the loop. Word to the wise for first time attendees: the name of the conference is pronounced “health” as opposed to “H-L-T-H” which I continue to hear in conversations. Pronouncing it correctly can only add to your cool factor. I’ll be popping in for a single day only, so if you’re exhibiting, make sure your sure your shoes are shined and your phone is safely tucked away so you can engage the people walking by.

I also noticed that they announced a new “Main Stage” speaker for Wednesday, Dr. Jill Biden, First Lady of the United States. She’ll be discussing the future of women’s health research. My first thought was “what kind of extra security is this going to add to the event,” especially given how the HLTH conference floor plan is configured. If there will be additional measures, HLTH owes it to attendees to explain it well in advance. Many of the people I know who are attending are planning to fly out Wednesday morning (after recovering from the Busta Rhymes event), so it will be interesting to see what attendance looks like.

If you’re going to HLTH, what’s your game plan for the event? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/14/24

As a longstanding supporter of virtual health care, an article published this week in JAMA caught my attention. It addresses the issue of disability rights and accessibility in virtual healthcare.

I’ve been involved in discussions of accessibility in health tech for more than two decades, watching features evolve from those that are requested by software customers as “enhancements” for young EHR products to those that are mandated by federal certification requirements. Some of these are fairly straightforward, such as ensuring appropriate contrast for text, ensuring that color is not used as the sole indicator of something being an alert or concerning value, and compatibility with screen reader technology. Others are a bit more nuanced and generate discussion, but those conversations taper off when people realize they aren’t going to get around a certification requirement.

At one point in my career, I was working entirely in the realm of certified EHR technology and began to take these things for granted. Only when I moved into consulting and working with technology startups did I realize how some vendors lacked an understanding of basic usability principles, let alone accessibility standards. I can’t count the number of conversations I’ve been in where I’ve had to explain that the requirements are linked to specific health conditions, such as red-green colorblindness or macular degeneration, and that health tech companies should probably try to do the right thing regardless of whether they have a regulated product or solution. I understand that adding features adds to development costs, but often it costs the same to develop a product that’s compliant as it does to ignore the needs of end users. Font and color / contrast are good examples of this.

There are reasons other than documented health conditions to develop in certain ways, one being the needs of an aging workforce. Now that I’m past a certain age, I would wholeheartedly support efforts to help early-career solution developers understand the various physical changes that come with age. They may not be enough to qualify as a “diagnosis,” but for many of us, the likelihood that we can get meaningful work done on a 13-inch laptop versus a 24-inch monitor is low. I’m more sensitive to bad ergonomic configurations than I was 20 years ago, that’s for sure. For me, some of these factors are merely an inconvenience, but for patients and clinicians who have additional needs, these factors serve as barriers to the giving and receiving of quality care.

The JAMA article notes that this summer brought new federal regulations that cover the accessibility of websites and mobile apps for state-run and federally funded health programs, including Medicare, Medicaid, and public hospitals. However, it notes that “disabilities are diverse” and the lack of one-size-fits-all solutions means that many resources are simply inaccessible. It goes on to specifically explore the inaccessible nature of many virtual health solutions, including “incompatibility with screen-reading software, a lack of captioning, and interfaces that are difficult to navigate.”

I recently tried to explore a virtual health solution using my phone, but couldn’t even request an appointment because the calendar interface that was selected by the developers prevents you from keying in your date of birth. Instead, you were supposed to scroll back month by month to your date of birth, which in the case of some people in my household, would have required 600 swipes. How’s that for welcoming people over 50 to the platform? Frankly even if I were much more youthful, I wouldn’t want to use such a horrible user interface.

The accessibility requirements extend to entities that accept Medicare, Medicaid, or other government funds, including small independent care providers. Those types of entities have three years to meet the requirements, where larger organizations have two years to do so. Third-party solution providers will need to gear up to meet the needs of their clients on the appropriate timeline, since failure of an organization to comply violates the law. I’ll be interested to see how quickly technology providers begin promoting themselves as “WCAG compliant” since it’s version 2.1 of the Web Content Accessibility Guidelines that are required in the new regulations. Bonus points to the first exhibitor I see at HLTH that promotes this designation.

I’ll admit that I don’t know the details of compliance since it’s not an area that I’m working in. But in thinking of all the third-party or homegrown chatbot and patient portal solutions that are out there, I’m betting that consultants are at the ready to assist as organizations work to assess where they stand. I’m also wondering whether this might push some smaller practices to begin to assess the pros and cons of opting out of Medicare (which many are already considering) versus having to replace technology solutions. I have a number of colleagues who have transitioned their practices to Direct Primary Care models where they don’t interact with public funding at all, and if people are on the fence about that change, I bet something like this might just be the thing that pushes them over.

Although I do love me some good Federal Register reading, I’m not exactly feeling it tonight. I’m hoping readers who are experts in this area might consider pointing me to some summary resources, or even send me their comments to share in a future post.

I would also be curious to know whether the patients who these regulations are intended to help think that the regulations are adequate or if more needs to be done to improve accessibility on a faster timetable. I’m also curious whether any part of these regulations address the diverse needs of healthcare providers or whether they’re entirely patient-centric.

If you’re with a third party that is addressing these requirements or is already compliant, I would enjoy hearing how the process worked for you and what the relative effort was like. It’s important for all of us to understand the work that goes into healthcare IT to make it work for everyone who uses healthcare services.

What’s your take on accessibility in virtual care? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/10/24

Just in time for the winter respiratory virus season, the Centers for Disease Control and Prevention has released new respiratory illness resources. New Community Snapshot content shows viral activity in different ways, including overall viral activity, wastewater viral levels, and emergency department visits. The site is scheduled to be updated on Fridays, with additional data elements added over time, including hospitalization trends.

Although COVID is on the decline in my area, we are just starting to see an uptick in RSV and influenza, so don’t forget to wash your hands, stay home if you’re sick, and make sure that you’re up to date on appropriate vaccinations. Given the respiratory crud that plagues many of us during conference season, I made sure I’m current for both COVID and influenza before hitting the ground at HLTH.

From Foodie: “Re: dangers of AI in clinical documentation. Have you seen this piece about the dangers of AI-created recipes?” I hadn’t seen it, but appreciate the share. I enjoy cooking and difficult enough sometimes to get a recipe to turn out correctly even when it comes from a reputable and well-tested source, so I’m not usually a fan of recipes from food influencers. (I admit, however, that I recently transcribed a recipe for crumpets from an online chef, which resulted in the need to acquire crumpet rings, and at some point, I will be testing it out so I’m not going to say never on that one.) The article lists examples such as one where a Twitter user entered prompts that led a recipe generator to suggest mixing bleach and ammonia, which creates fumes that are incompatible with life. Food bloggers are understandably worried about AI competition and note that AI can’t explore food from a sensory perspective to determine whether the recipes it creates are good. Other recipe creators have the same concerns that many have voiced about AI, including lack of attribution when content is used to train a model and intellectual property concerns.

Speaking of food-related adventures, a Harvard medical student decided to become his own science project and consumed 700 eggs during a month-long experiment. Despite taking in a tremendous amount of cholesterol, his own cholesterol values declined during the month. It should be noted that the subject’s cholesterol values were good prior to the experiment and that he’s a young, otherwise healthy individual, which is not the case for anyone. You and I don’t hare a physician / patient relationship, but this doctor is telling you not to eat 24 eggs a day. The student embarked on the project to make a point about messaging around diets as well as to encourage greater research in the field of metabolic health.

Several recruiters have reached out to me in recent weeks to try to lure me back to the in-person adventures of the emergency department. I know from speaking with former colleagues that quite a few emergency physicians have hung up their stethoscopes in the years since the beginning of the COVID pandemic. Maybe it was the feeling that your hospital felt that you were expendable and the lack of personal protective equipment. Maybe it was the idea that you weren’t ever allowed to be sick yourself or that taking a day off was unfair to the team. Maybe it was also being expected to deliver primary care when you’re not trained to do so, and not having the resources that you need to feel like you’re doing the right things for the patients in your care. Working in an emergency department can be exhilarating, but it’s also incredibly stressful and physically and mentally exhausting. There’s always the risk that you’ll miss something.

Emergency medicine has long been a proving ground for data-driven approaches to care, and a recent article from the American College of Emergency Physicians looks at the role of triage in the care of emergency patients and if it can be improved with better use of data. The authors note recent studies that estimate triage errors to be as high as one in every three patients, with vulnerable populations being at the highest risk. They propose the creation of new data-driven approaches to patient complexity that can take into account the numerous data points that are being captured on patients when they present for care as well as their histories and other elements that might be available to clinicians. They propose expanding the use of AI to synthesize available data and provide individualized risk profiles for patients at the point of care, noting that such models have been in place for several years at some institutions. It will be interesting to see how these solutions are incorporated at smaller emergency facilities and especially at those in remote areas that don’t always have in-house physicians. If you have experience with these solutions, drop me a note.

I recently ran across this study that looked at adverse diagnostic events impacting hospitalized patients. Although it has the limitation of being done in a single location, it reveals some significant findings. Researchers looked at harmful diagnostic errors, which included delays, process failures, and issues with subspecialty consultation. They estimated that a harmful error happened for one of every 14 patients, with the majority of errors being preventable. Although the authors call for additional approaches for diagnostic error surveillance, I think this work should be a call to action for error prevention as well.

In research like this, general terms such as “errors” or “harms” mask what really happens to patients in these situations. The article makes it a bit more clear: minor harms had mild symptoms or short-term impacts, while the other end of the spectrum included major harms that could have led to lifesaving surgical or medical interventions, shortened life expectancy, permanent loss of function, or even a fatality. Diagnostic errors include failure to make a clear diagnosis, misinterpretation of laboratory or other tests, incomplete workups, and other scenarios where patients don’t get the care they need.

The authors note that incorporating artificial intelligence could be helpful for the detection of “complex patterns of risk factors and clinical events that represent markers of risk or suboptimal diagnostic processes.” Tools to help with these scenarios have been around for many years, but have been slowly incorporated by care delivery organizations due to cost, lack of perceived benefit, and willingness to tolerate a higher level of risk than may institutions hold today. I look forward to seeing more solutions implemented over the coming years and for researchers to be able to quantify the number of lives saved or functionality preserved.

Is your organization using AI or other solutions to reduce diagnostic errors? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/7/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/3/24

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

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

The reader mailbag has been rich this week:

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

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

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

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

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

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

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

Email Dr. Jayne.