Curbside Consult with Dr. Jayne 9/16/24

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/12/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/9/24

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/5/24

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/29/24

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/26/24

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/22/24

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/19/24

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/15/24

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/12/24

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/8/24

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 8/5/24

Throughout my career in healthcare IT, I’ve seen the unintended consequences that can be found with the implementation of new technologies. As an example, we can look at EHRs and how they made it easier for physicians to capture the details of the care they were providing and to bill accordingly for it. As a result, previously bell-shaped distributions of billing codes started skewing towards more complex (and therefore higher revenue) codes, leading to increased audits and insurer crackdowns. The additional documentation that was generated by EHRs was treated with more scrutiny, and some physicians became reluctant to use the solutions that were supposed to make things better, manually lowering calculated billing codes to avoid the hassle of audits.

As clinicians begin to incorporate technologies such as generative AI into daily practice, it’s important for researchers to diligently assess the solutions to ensure that they are enabling safe care and to monitor for unintended consequences. Every time I see a real-world study addressing this issue, it reminds me how rewarding it can be to practice clinical informatics. A study was published last week in JAMA Network Open that looked at the issue of using large language models to generate responses to the communications that patients send to their care teams through EHR patient portals.

The first thing that I noticed about the article were the listed author affiliations. Although they were all from New York University, they represented not only the NYU Grossman School of Medicine, but also the NYU Stern School of Business and the NYU Tandon School of Engineering. The specific question the authors were investigating was this: can generative artificial intelligence (GenAI) chatbots aid patient-health care professional (HCP) communication by creating high-quality draft responses to patient requests?

The study was conducted at NYU Langone Health, specifically using responses that were created in three internal medicine practices that were piloting a generative AI solution. Sixteen primary care physicians were then asked to evaluate messages but were blinded to whether the messages were drafted by GenAI or by human healthcare professionals.

The primary care physicians who were evaluating the messages were recruited from the organization’s internal medicine listserv, with only 16 of 1,189 physicians volunteering. That’s barely more than 1%, which although surprising at face value, really isn’t that surprising, given the stresses that many primary care physicians face on a daily basis. The sample was 50% female, with practice locations split between NYU Langone Health, Bellevue Hospital, and the Manhattan Veteran’s Affairs hospitals. They rated the messages on content quality, communication quality, and whether the reviewer felt a draft was usable or whether they’d prefer to start over with their own response.

During an initial survey, reviewers received five to eight pairs of responses without any follow-up questions. A subsequent survey contained 15 to 20 pairs of responses with additional follow up questions to assess characteristics such as empathy, personalization, and professionalism. The response pairs for the first survey were drawn from 200 random in-basket messages that were extracted from the organization’s EHR in September 2023. Messages that required outside context, such as laboratory results or medications, were excluded. Those from the second survey were pulled a couple of weeks later, with an initial sample size of 500 messages. The same exclusions were applied.

The study corroborated one finding that we’ve seen before, that GenAI responses may demonstrate greater empathy than human-crafted messages. However, I was surprised by some of the other findings. AI-generated responses tended to be “longer, more linguistically complex, and less readable” than those that were created by human respondents. The authors concluded that these could be problematic for patients with lower health literacy, or those for whom English is not their primary language.

The authors also found that certain types of messages, including those involving laboratory results, may need enhanced prompt engineering to be useful. They noted some limitations to the study, including the fact that it was conducted at a single facility and that the sample size was small. It would be interesting to see how physicians at community hospitals or community health clinics would rate the responses in comparison to colleagues who are practicing at larger medical centers or hospital-affiliated clinics. They also noted that they didn’t assess whether templates were used for those extracted messages that were drafted by healthcare providers and recommended that templated responses should be treated as a separate comparison group in future studies.

It will be interesting to see how similar responses might be graded over time, as people become more used to seeing AI-generated responses. Similarly, technologies may evolve to include more human or colloquial speech patterns in AI-generated drafts. For those of us who have moved from region of the country to another, or who have transitioned from academic medical center environments to community health centers, we could also see our own speech and writing patterns change accordingly. This may also vary generationally depending on when physicians completed their residency training and by specialty.

For example, some specialty training programs, including primary care, give more attention to health literacy and communication topics than do others, such as the procedural subspecialties. As a primary care physician, when I’m graded on how well I can use words to convince my patients to receive a vaccine or to go for a colonoscopy, I think much more carefully about what I’m saying and how I say it than others who are not scored in such a manner. As large language models evolve and appropriate feedback is applied, we should see responses that grow closer to what we need to provide the best care for our patients.

I’ll be on the lookout for additional studies that look at these topics, but I know my limits as far as being able to see everything that turns up in the literature. Here’s to hoping that my colleagues clue me in when they see one of these topics, and I always appreciate it when our readers give us a heads up that something interesting is available for our perusal.

What do you think about using AI-generated drafts to help clinicians respond to patient messages? Are you using it in your organization and how is it going? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 8/1/24

I’m catching up on a lot of healthcare IT news after coming out of a whirlwind of travel. I’m just reading the HHS press releases about the changes at ONC. I always struggle with typing the wrong thing when organizations rebrand or merge, so I’m thinking I’m going to have to just set my autocorrect to ensure I stay current with ASTP/ONC moving forward.

My inbox is bursting at the seams and my work calendar is full, so I’m sure I’m missing interesting newsy tidbits along the way. I have a couple of large projects wrapping up soon and will be happy to have some catch-up time once they do.

The US Senate passed two pieces of legislation this week that would create additional safeguards to protect young people online. Both the Kids Online Safety Act (KOSA) and the Children and Teens’ Online Privacy Protection Act (COPPA 2.0) passed with overwhelming majorities. KOSA, which has been working its way through the halls of Congress since 2022, requires social media platforms to incorporate “reasonable” technologies to reduce the risk of cyberbullying. Features like autoplay that are designed to keep children and teens glued to their phones would be restricted. COPPA includes provisions to ban advertising that targets minors. It also allows young people or their parents / guardians to delete their information from online sites. It’s unclear what will happen with the companion bills in the House of Representatives, where committee hearings won’t even be an option until September.

From Get A Room: “Re: return-to-office policies. I have to go into the office despite the fact that no one on my team lives in this city. I just got to hear an entire Zoom call in stereo, because the participants were sitting on either side of me.” I asked my correspondent if the attendees knew they were in the same office and he wasn’t sure. With the ubiquitous presence of noise-cancelling headsets in the office, it’s a distinct possibility. I think I would have been tempted to send instant messages to both of them, adding my own commentary to their call just to be sassy. Another option is to use in-house scheduling functionality to have a conference room send an appointment to both of them.

One of the hot topics in the virtual physician lounge this week was what one described as the “escalating arms race” of AI-enabled insurance preauthorization requests, denials, and appeals. Tired of struggling to get insurers to cover expensive treatments that they believe would benefit their patients, physicians have begun to leverage tools like ChatGPT to summarize patient information and increase the changes of approval. Payers have responded by using AI-powered systems to deny requests even faster, leading to AI-generated appeals. There was a new physician in the conversation who recently graduated from his residency training program and he was incredulous at the discussion. As a reminder, folks: for-profit insurance companies have to deny care in order to drive value for shareholders. They’re willing to pay for an enormous infrastructure to do so. Those who don’t think we ration care in the United States need to consider the definition of rationing.

Another hot topic was that of private equity groups purchasing hospitals and physician practices. A research letter that was published in the Journal of the American Medical Association this week certainly spiced up the conversation. Key points from the article: PE firms spent half a billion dollars on health care between 2018 and 2023, with a strong track record of loading them with debt and selling assets to increase shareholder profit. The authors compared acquired facilities with non-acquired controls, matching for year, region, and bed count. They found that acquired hospitals had nearly 25% less assets after two years. They note that further study of the impact of private equity ownership on patient care is needed, and I would bet that the vast majority of physicians trying to provide care in PE-owned facilities would heartily agree.

I ran across an article this week about virtual MRI programs. Rather than transfer inpatients from one facility to another for advanced MRI services, AdventHealth is allowing community hospitals to perform the procedures under standardized imaging protocols. The program allows seasoned staff to collaborate with those building their skills, through a combination of audio / video and chat features. It reminded me of a conversation I had with the team that was conducting my own MRI a few months ago. One technologist mentioned that they had completed a research protocol, copying a longstanding program in Germany where radiologists managed MRI scanning at multiple locations from a centralized command center.

Although the clinical outcomes were similar, the program encountered resistance here due to concerns about liability and regulatory compliance. Clearly other parts of the country are more accepting of this kind of change, so it will be interesting to see how many years it takes my region to think outside the box. In the mean time, I just have to hope there’s not a snowstorm or ice storm when it’s time for me to go for my next exam, since trying to reschedule will introduce at least a 90-day delay due to lack of available slots at the academic medical center.

I was excited to see the launch of the All of Us project several years ago, charged with better understanding how genetics, lifestyle, and environment play a role in health outcomes. More than 770,000 patients have enrolled in the program as of March 2024. As a way of sharing the value of research with study participants, leaders of the project provided summaries of the research done to date. A recently published article looked at the impact of those summaries, specifically with how participants engaged with digital communication. The summaries reached more than two-thirds of participants, exceeding the rates of other program communications. Those most likely to engage with the summaries included those with higher income, age greater than 45 years, and higher levels of educational attainment. The authors conclude that more personalized summaries may yield even greater engagement in the future.

Have you ever participated in a research study, and at what point did you learn about its results? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/29/24

I had the chance to hang out with some OG healthcare IT friends this weekend, many of whom have been in the industry for more than 30 years. It was a chance to talk about where we started, how things have gone along the way, and the work that is yet to be done. There was a lot of conversation around the idea of disruption and whether it has worked to make patients healthier.

My first run with disruption was after completing residency. A large health system decided to try to shake it up by placing a number of startup primary care practices in an underserved area. There were plenty of primary care physicians in the city, they just weren’t sorted out in a way that matched physician locations to community needs. Patients in certain areas would have to travel too far to access a family physician, so they simply didn’t. For many, their health was worsening, and they didn’t even know it because many of the downstream effects of chronic conditions don’t become apparent for years.

The hospital that sponsored my practice was committed to building a primary care base and had plans to launch a dozen primary care physicians into the community over the following five to six years. They built attractive offices that were easy to access, often in strip malls next to retail spaces and restaurants. I had asked about how they determined where to locate the practices and was told they were using the “Walgreens method.” Essentially, after doing all kinds of market research and traffic studies, they determined that the best locations ended up being right near where Walgreens was building new retail pharmacies. Both organizations’ research had ended with similar conclusions for the first few planned practices, so they decided to just follow the pharmacy giant’s lead.

The phrase “If you build it, they will come” definitely applied, and as each practice opened, we were busier than expected. When I began seeing patients, I was the only primary care physician within 20 miles who was accepting new Medicaid patients, and before I knew it, my patient panel was overflowing. Unfortunately, in that fee-for-service world, the low revenues that were paid by the state didn’t cover my overhead, and my practice was losing money due to some cost-shifting shenanigans where I was being charged with the construction costs of building the new practice. In contrast, the new physicians who had joined practices in more affluent parts of town with a better payer mix were quickly making more than their guaranteed salaries, leaving those of us in the underserved areas struggling to stay afloat.

Additionally, the organization failed to understand the additional support that was needed to care for patients who had been without a physician for an extended time. Many patients came in with serious complications that had to be managed, leading to specialist referrals and the ability to get patients connected with someone who would see new Medicaid patients. The family physicians were left holding the bag, trying to do the best care they could but without subspecialists to share the load.

Our practices were staffed according to the organization’s standard ratios that assumed a mature practice and a stable patient population. They didn’t account for brand new physicians straight out of training, brand new staff straight out of a nine-month medical assistant program, and in particular for my practice, the added work of being the only practice in the health system that was implementing an EHR.

Over the next five years, the reality was that seven of eight new physician startups in my part of town failed as their physicians left for greener pastures, but hey, we disrupted things! We brought thousands of new patients into the health system and put them on waitlists with subspecialists as far as 30 miles away, even though we didn’t have the ability to coordinate transportation. We asked young, idealistic physicians to do everything possible trying to care for these patients, sometimes putting their licenses on the line managing conditions that they weren’t trained to manage. We deployed an EHR and were able to instantly report on our inability to care for patients the way they deserved, and how our outcomes measures were continually below the targets that had been set by group leaders at practices that had more resources, more staff, and more money.

The health system then decided that further disruption was going to solve the problem, so they replaced the departed physicians with nurse practitioners. These new providers quickly figured out that running a primary care practice was hard work, especially when your supervising physician was physically in your practice only one day per week. Instead of lasting four or five years, the nurse practitioners fled even faster, with most finding better salaries and work-life balance at retail clinics within two years of their start. Within a decade, the community was back to the same number of primary care physicians, with any gains being offset by retirements.

The next disruption was building “convenient care” clinics where patients could receive immediate care and primary care services as a strategy to address rising emergency department volumes. They may have helped shift the patient load, but they did little to reduce care fragmentation. Patients ended up being seen by a different provider at each visit, where the focus was typically on one problem and not on the whole person. If we couldn’t pull off appropriate longitudinal management in a primary care setting, with board-certified physicians specifically trained in the specialty, I’m not sure why they thought they could do it in that setting. Ultimately the clinics were a bust because they couldn’t keep them staffed.

By now, we were firmly in the digital era, when organizations thought they could just throw more technology at a problem to solve it. No available appointments? Let’s roll out a billion-dollar EHR so that patients can use the patient portal to access their physicians! I seriously wonder why it didn’t occur to leadership that spending that amount of money on a technology project when frontline staff had taken a pay cut was going to be a hot button issue. Once that patient portal was live, it was as if it had never occurred to anyone that asking physicians to provide uncompensated care was going to be a dissatisfier. Physician burnout climbed.

A neighboring health system had figured out how to crack the code, building a huge primary care base though generous salaries, capable staffing, and integration with multidisciplinary care teams. They were doing digital outreach, so of course the other systems in town had to keep up with the Joneses, launching campaigns that seemed to succeed at clogging the brand new digital front door due to lack of capacity. But then COVID came, and with it a whole new set of challenges, and ultimately here we are  with health outcomes that are only marginally better than they were 20 years ago despite tens of billions of dollars being spent.

What is the answer, people ask? I think there are a number of issues that need to be addressed and they start with understanding the concept of humanity. We need to treat our patients and their care teams like humans, each with their own dignity and potential. Let’s spend our money on things that matter. This isn’t something you can rebrand your way out of, and blowing money on efforts that just embitter the people working in the health system trenches every day. We need to select technology solutions that make sense and benefit caregivers and patients and not just the bottom line. Cheaper isn’t always better and a race to the bottom doesn’t help anyone. Let’s spend some money optimizing the solutions we already have rather than just going after the next shiny object. Let’s dip into those multi-billion-dollar endowments and fund things like school-based clinics, public health, and vaccines. Let’s celebrate primary care as a mechanism to save lives in the same way we celebrate cardiac and neurosurgeons.

We’re living in an era with tremendous potential, and we need people to elevate the dialogue instead of just pointing fingers. Who’s with me? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/25/24

Although technology continues to advance, we are still leaving patients behind. The Washington Post reported recently that 40% of women are delaying their recommended health screenings. The top reasons cited include time constraints, cost, anxiety, and worries of pain during testing.

Other interesting findings: 31% of Gen Z respondents found it difficult to find relevant information on screenings, and 63% of respondents said they struggled to prioritize their own health. We talk a lot about insurance in the US and trying to make sure services are covered, but the reality is that a large number of workers don’t have paid time off for medical appointments or other health-related matters.

When you figure that a single preventive service can eat up a half day of time (travel, filling out forms, waiting, having the service, and returning home) and there are between five and 10 services needed each year for average-risk women, you can see how it adds up. Organizations should be doubling down on strategies to make screening services more accessible, whether it’s online scheduling, completing pre-visit forms from the comfort of your home at the time of your choosing, or reducing anxiety by providing an efficient results communication process.

Given the number of healthcare conferences that are being held now, it seems like there is more competition to prove which will be hipper or cooler than the rest. HLTH has opened submissions for its Art Gallery, asking those on its email list “Could you be the next Andy Warhol?” The call for submissions notes that “this unique fusion of healthcare and artistic expression highlights the connection between wellbeing and art, creating a sanctuary where science meets the soul, and personal stories of hope come to life.” That’s quite an aspirational goal. Art will be displayed as digital prints and should be created by someone who has undergone medical treatment or works in healthcare. There are no prizes, and if you’re selected and want to see your work on display, you’ll have to buy a ticket at the then-current price. Registrations are $2,895 as of this week and will go up to $4,100 towards the end, so I hope all the artists are saving their pennies.

I learned a new word this week, as an article in the Harvard Business Review discussed AI-generated inaccuracies. According to the authors, “botshit” is “made-up, inaccurate, and untruthful chatbot content that humans uncritically use for tasks.” I have no issues with how they’ve defined it and am glad they added the last piece about the role of humans incorporating bad information into their workflows or decision making. I know of several clinical colleagues that are using commercially available nonmedical generative AI to help create clinical documentation, and it’s amazing how unconcerned they are with the potential for introducing errors into patient charts. Lest my jaw spend too much time on the floor, I remind myself that some of these individuals are probably those who had a macro added to their chart notes that said something along the lines of “Dictated but not read, signed by staff to expedite” or other such nonsense.

In my clinical practice, the greatest use I’ve found for generative AI tools is to help me confirm something that I suspect or already know, but haven’t encountered in a while. For example, is what I remember as the first-line drug for treating Lyme disease still preferred? Since I live in a state where Lyme is not endemic, I rarely see the condition, but on the other hand, it always seems to pop up as a board certification question, so I can’t let it fall too far by the wayside. It’s less useful for the situations where I think it could really be beneficial, such as trawling the world’s literature to try to figure out what is the next best step for a complex patient with certain parameters. As a physician, that’s where I really need help since the textbook answers rarely take into account such factors as the patient’s insurance coverage or ability to adhere to a treatment plan.

From Remotely Employed: “Re: return to office policies. They continue to plague tech companies. Check out this article about Dell employees who fought back in response to the company’s negative actions toward remote workers.” The annual Tell Dell employee engagement survey apparently got an earful, with the employee net promoter score dropping from 63 to 48 over the course of the last year. Of course, a Dell spokesperson tried to spin it, mentioning that “Dell is still well above industry averages.” The old “yeah, but other people are worse” deflection hasn’t worked well for many organizations in the past, so negative points for lack of imagination in their response. Dell had announced earlier this year that employees who were remote as opposed to hybrid would have fewer opportunities for career advancement. They also began color coding employees based on how often they were in the office.

The comments on the article are reflective of dissatisfaction with in-office roles that workers feel can be done equally well on a remote basis One noted that costs of commuting are a major concern, and another described the HR policies as “ham-handed” and recommended that the organization “focus on productivity and an individual’s contribution to the operation, and make personnel decisions based on that.” It’s a novel concept now that we’re seeing more organizations treating employees like children. One of my neighbors who worked remotely for years is on a team that has no other members in our city. Still, he dutifully goes to the office three days a week, attending video calls with others across the country. I’m guessing management thinks his quality of work is somehow better after an hour commute in stressful traffic.

I’ve been walking a mile in my patient shoes this week, waiting for pathology results that were significantly delayed. The practice is attributing the problem to CrowdStrike, although I’m not sure I’m buying that excuse. I know a lot of diagnostic vendors had problems with their dictation software, but where was the downtime plan? Did they just stop reading pathology slides while they waited for the dictation software to come back up?

Based on a phone call I received on Friday, my slides were being read that afternoon, so it’s been a maddening wait over the weekend and into this week. I encourage anyone who deals with healthcare IT systems to spend just a minute thinking about the patients on the other ends of all these transactions, and what it might feel like to them when something like this happens. Let’s get our downtime ducks in a row, folks. Would you really want your loved ones to be treated this way?

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/22/24

The big news of the weekend was hearing about the response of organizations to the CrowdStrike debacle on Friday. Despite official statements that everything was fine and patient care was proceeding as usual, comments from worker bees at several local hospitals revealed significant issues that did impact patient care.

At one facility, patients who had mammograms performed on Wednesday and Thursday and were told to expect results by end of day Friday were left in the lurch, since the hospital’s cloud-based dictation service was down. Apparently there was confusion about whether there was a backup plan and what it might be, so radiologists stopped reading studies, bringing everything to a halt. There was no proactive communication to impacted patients letting them know that results would be delayed, causing a great deal of anxiety.

One physician friend who was impacted as a patient reached out on a local physician forum to find out whether her study was being delayed because it was abnormal, which is a common thought among patients. She had no idea about the CrowdStrike situation, but a number of hospital-based physicians chimed in about the patient care nightmare that was unfolding across the region. Several affiliated hospitals canceled elective imaging, including screening mammograms, on Friday. Other physicians reported delays in getting operating room systems started and an inability to get through to internal help desks due to a high volume of calls.

Since I work with various organizations and have company-issued laptops for each of them, I was able to experience firsthand how different places handled the problem. One organization was extremely hands on, sending messages via text starting in the wee hours of the morning. They’re not on my overnight priority list, so the text thread was muted, but I was impressed because they sent hourly updates. Fortunately, my laptop wasn’t impacted and I wasn’t scheduled to do work for them that day, but I followed along because that’s what a good healthcare IT reporter does. By around 7 p.m. in the company’s primary time zone, they sent another text indicating that mitigation efforts had concluded. I checked that company’s email over the weekend to see what other communications they might have sent and was pleased to see an overall summary and debrief communication.

Another company was radio silent, acting like nothing was happening. I guess it’s good that none of their systems or hardware were impacted, but it would have been nice to receive some kind of communication letting employees and contractors know that there was a worldwide issue and that vendors, external systems, or patient pharmacies might be impacted. Since they’re a virtual care company, I would be interested to see whether there was any increase in the number of failed prescription transmissions or patient callbacks asking for medications to be prescribed to a different pharmacy because of the outage.

My laptop for another health system was impacted by the outage and they didn’t send out any communications until two hours after I discovered the issue. I had reported it to the help desk via email by using my phone, so I knew I was in the hopper. Since everyone’s accounts are on Office 365, I was able to do the small amount of work I had for them by using my personal computer, which I’m not sure is entirely permitted based on the vague wording of their privacy and security policies. No one blinked when I said I was using my own device, though, so I’m assuming that I’ll ask for forgiveness if it becomes an issue later since I didn’t ask for permission. I was ultimately able to perform the fix on my laptop myself, which was good because the help desk didn’t get back to me until Saturday afternoon when I was nowhere near my laptop.

Mr. H reported a list of impacts in this week’s Monday Morning Update and they included surgery and procedure cancellations, appointment cancellations, closure of diagnostic facilities, and holds on shipping laboratory specimens due to delays with FedEx. Mr. H noted that Michigan Medicine reported a “major incident.” I’m not sure what that means at the institution, and whether something truly serious happened or whether it was classified as major due to the number of impacted systems, or something else. I’d be interested to hear from anyone at that organization as to what exactly that report means.

Since one of the more serious impacts occurred with 911 emergency call centers, it will be difficult to quantify the full effect on patients. Several state systems were down and analog backups were pulled into service in multiple places. It’s difficult to perform reporting and analysis on events that didn’t happen, but one could extrapolate from the historical call history as to how many calls weren’t received compared to a typical summer Friday. Given the typical percentages of different types of critical calls – cardiac arrests, penetrating trauma, motor vehicle accidents – one can start to do the math to understand how many lives might have been either seriously impacted or lost due to what others minimize as a “computer glitch.” I’m sure the loved ones of those individuals who were frantically trying to call 911 for help might have other words for it.

I spent a fair amount of time this weekend following the Relive Apollo 11 thread (@ReliveApollo11) on the service formerly known as Twitter. I’ve always been a space junkie and being able to share the experience in a reenacted real time way was kind of thrilling. Through one of the links, I found the Apollo 11 Flight Journal, which is a fascinating read of the transcripts from mission communications. Other cool resources I found during my trip down the rabbit hole included a guide for using Google Earth to explore the moon, and in particular, the landing sites.

It’s hard to believe the level of accomplishment that took us to the moon, with human computers and slide rule-wielding engineers leading the way. The technologies are considered much less powerful than what most of us hold in our hands on a daily basis, but people achieved great things. It should be inspirational, especially on those days when we feel that we are making little progress.

I also learned a piece of information I didn’t previously know. The Apollo 11 mission patch doesn’t include the names of the crew members because those three astronauts wanted the patch to represent all of those who were involved in the mission. It’s a refreshing departure from the “me” culture with which we’re all too familiar.

For those of you who experienced Apollo 11 or other moon landings at the time they occurred, what are your significant memories? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/18/24

Former US Food and Drug Administration Commissioner Scott Gottlieb, MD published a call to action this week in JAMA Health Forum that asks Congress to update FDA regulations for medical AI. He begins the piece by summarizing the events leading up to the FDA’s approval of the Apple Watch in 2018 for identifying irregular heart rhythms, noting that the FDA cleared the device largely based on its developer’s validation and quality approaches rather than on a review of the hardware itself. He states that “this same concept is uniquely suited to the regulation of artificial intelligence (AI) medical devices that can augment patient care.” Bills are pending in both the US Senate and the House with the so-called Verifying Accurate Leading-edge IVCT Development Act (VALID Act) creating laws around this regulatory approach.

Gottlieb says that change will allow the FDA “to oversee the methods used to develop a technology and validate its reliability, rather than trying to decouple the product’s construction” and draws parallels between device regulation and the need to regulate medical AI, especially with regard to rapid innovation and development cycles during product development. He goes on to discuss developers’ approaches to mitigating any FDA uncertainty, including avoiding having their solutions be classified as devices. Clinical decision support software isn’t subject to the same level of scrutiny as medical devices, which allows a faster go-to-market approach for developers. It will be interesting to see if Congress passes the VALID Act and if they then in turn move forward with policies to address AI technologies.

Bad news for night shift workers. A recent study that was published in The Lancet suggests a higher risk of diabetes for individuals who were exposed to the most light between 12:30 a.m. and 6:00 a.m. Study participants wore light sensors to capture personal light exposure, which strengthened the reliability of this study compared to its predecessors. The sensors captured light in all forms, such as the sun, lamps, or screens. After eight years of tracking, researchers found that those with lower overnight light exposure had a lower risk of type 2 diabetes. Those with the highest exposures had a risk increase that was similar to that for patients with a family history of the condition. It’s suspected that atypical light exposure alters the body’s circadian rhythm, which can have an impact on how it handles sugar. I guess I need to get more sunlight during the day to counterbalance the late night monitor light that I’m exposed to while writing for HIStalk.

I’m playing catch up with my journal reading, so I’m just now seeing this piece from the March Journal of the American Board of Family Medicine that looked at the differences in hospital readmission rates for patients who received their follow-up care in person compared to telemedicine. The authors found comparable readmission rates regardless of the follow-up modality, concluding that “telemedicine poses little threat of negatively impacting HEDIS performance” and may be as effective as traditional in-office transition of care visits. The authors note some limitations in the study, including reliance on provider accuracy to capture discharge follow-up codes and the inability to capture the information patients who had follow-up visits outside the EHR whose data was used for the study. They also noted that the telemedicine sample size was small and had a younger population. Larger multi-site studies that incorporate intentional use of telehealth would be of benefit to create stronger evidence.

I consume a lot of study write-ups as part of my regular reading, so I’m familiar with how to critically appraise data and determine if the authors of a particular piece are trying to lead readers to a conclusion that might not fully correlate with the data. I was skeptical when I saw headlines this week about the physician burnout rate falling below 50% for the first time in four years. The AMA is claiming this result from their “exclusive survey data” that compares record-high data from 2021, where 63% of physicians reported burnout, to more recent data collected in 2023. Data was collected as part of what the AMA calls its “Organizational Biopsy” and represented 12,000 physician responses across 31 states.

Since this is proprietary AMA data and not a peer-reviewed publication, it is unclear whether or how it was controlled against previous data. Were the respective physician panels representative as far as specialty, age, and gender? What about practice setting or full-time status? How about employment status and the stratification of academic physicians against private practice or those in an organization that is owned by private equity?

I’m not a burnout expert, but I’ve talked to hundreds of physicians in the last several years, and here is my private hypothesis. The most burned out physicians have retired early, cut back, or otherwise left direct patient care. I receive at least a dozen requests each month from physician contacts who want to learn more about “how to get off the hamster wheel” and whether they can just make the jump to clinical informatics or a technical role. (Spoiler alert: it’s not as easy as you think.) Many of them get pulled into unsavory arrangements that essentially amounts to their renting their medical licenses to companies that are looking to make a buck. I wonder how or if those physicians have been represented in the AMA’s data gathering efforts.

Based on an email I received today, HIMSS must be desperate for revenue, because they’re promoting sales of the recordings from the HIMSS24 conference earlier this year. On top of the 150 recordings from this year, they’re throwing in bonus recordings from HIMSS22 and HIMSS23. I can’t imagine that many attendees who are thinking back to those conferences and wishing they had a recording of a particular session. If I’m seeking deeper information about a conference presentation or topic, I’m likely to just reach out to the presenters, who are generally excited to correspond about their pet projects. If you’ve got cash to burn and time on your hands it might be for you, but to me it feels like a sad attempt to squeeze revenue out of former attendees.

CMS has issued an invitation to its Leadership National Call Update on August 1 at 3:30 p.m. ET. Administrator Chiquita Brooks-LaSure and her team will be updating attendees on advancements related to the CMS Strategic Plan. I’ve never attended one of these calls and was surprised to learn that the registration link leads to a special Zoom for Government site. I wonder what features are different from a corporate Zoom account or even a paid individual account? Inquiring minds want to know, so if you have the details, leave a comment or email me.

Email Dr. Jayne.