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.

Curbside Consult with Dr. Jayne 7/15/24

I was talking with some clinical informatics folks this week about how we try to keep up on industry happenings. Most of us read a combination of different newsletters and of course HIStalk. Newsletters can be challenging, though, since many of them are either pay-to-play or heavily influenced by submissions from public relations folks. It takes time to learn to read between the lines as far as what the purpose of a given “news item,” might be and it takes experience to try to understand how helpful the given solution or technology might be to a given organization.

A recent write-up in Becker’s Health IT mentioned an Epic app called AutoDx that was created by UChicago Medicine. AutoDx stands for “automated diagnosis,” and according to the write-up, the app identifies patient-specific diagnoses and risk factors and automatically adds them to the visit note template.

The system’s CMIO was interviewed for the article and said that “providers have the option to delete them if they disagree,” but my initial reaction to the tool is that it’s a lot like copy and paste, where there is a fair likelihood that users will just leave these items in the note whether or not they addressed them. The CMIO goes on to say that the risk factors brought forward by the tool “are crucial for coding and billing, external rankings, quality reporting, and other statistics that many institutions, including ours, care about.”

That statement certainly gives some insight as to why the tool was created. Patient care wasn’t even on that list, nor was any mention made of helping physicians better document the care they’re already giving. In my book, those two reasons should be at the top of the list, not compliance with regulatory requirements or trying to play the billing and coding game.

In the past, physicians — especially those in primary care specialties — were known to document fewer problems than they actually managed on a given visit. I think the number was something along the lines of managing five or six issues per visit, but only documenting 3.5. The arrival of the EHR was touted as a way to fix that problem and allow physicians to actually code and bill for the work they were already doing, which makes sense.

Unfortunately, everyone started playing the same game, and the perceived “upcoding” didn’t have as much value as initially thought because payer pressures led to downward rate adjustments, putting people back at square one (or square negative if we’re talking about Medicare reimbursement rates). We’ve seen plenty of examples where organizations are working hard to elevate the documented complexity of the patients for which they are caring so that they can get more money. I recently saw an organization recruiting for unsuspecting physician “chart reviewers” who were expected to review charts and document conditions that the patient may or may not actually have, but which might have been mentioned at some point in time in a patient’s chart.

I dug a little deeper on this particular solution, noting that the creators of the tool had published a paper recently in Applied Clinical Informatics. The paper positions the tool as an alternative to the coding queries that providers often receive, where certified professional coders and others review patient charts and ask if providers can document additional factors in the patients’ charts. These queries happen after the fact and create a disjointed workflow where physicians and providers are asked to update notes sometimes weeks after the visit.

The tool was initially developed to address three diagnoses, including electrolyte deficiencies, obesity, and malnutrition in hospitalized patients. It was piloted by hospitalists and then expanded to the neuro intensive care unit after more diagnoses were added, at least according to the Becker’s article. When I pulled the actual paper, a section header mentions the neonatal intensive care unit, which is a drastically different environment than a neuro ICU. I guess good editors are hard to find.

The pilot showed a 57% decrease in coding queries around the targeted diagnoses compared to a 6% decrease across other high-volume conditions. The authors also noted an increase in the case mix index, which is a marker of complexity and severity of cases within a hospital.

Theoretically, not only should the tool fix the disjointed workflow, it should prompt providers to address conditions at the point of care that they might not otherwise have addressed. Hospitalized patients are often complicated, and hospitalists are expected to manage ever-growing patient rosters. The initial release of the tool created message alerts in the patient note that prompted the provider to select a diagnosis and required that all alerts be addressed before the note could be completed. That certainly sounds a lot more patient-focused than talking about how much it impacts billing and metrics.

Interestingly, the pilot began in mid-February 2020, right before COVID-19 was about to rock all of our worlds. Post-implementation data was gathered for the full month of March of that year and compared to the full month of January as the pre-implementation baseline. The expansion to the NICU didn’t occur until May 2022. The paper has multiple mentions for neuro and neonatal, although I suspect it is supposed to be the former based on certain context elements such as the list of included diagnoses and mentions of things like “patients transferred from other services” that doesn’t necessarily apply to the neonatal ICU, which is usually where critically ill neonates start their hospital stays and remain until they can move to a lower level of care.

Overall, it sounds like the tool can positively impact patient care and reduce burdensome post-encounter queries that are sent to clinicians. Alternatively, it could be a way to enable “autopilot” behaviors where clinicians are acknowledging and adding things to visit notes without thoughtful consideration. I would have liked to see post-intervention surveys to the users about how the intervention impacted care. For example, did it truly identify things that they were addressing but not documenting, or did it provide a safety check to make sure that they were addressing conditions that they may have overlooked? Those are the kinds of benefits that can really drive patient outcomes. I would encourage those who are creating tools like this to include that kind of data gathering and analysis in their research.

I’d love to hear from Chicago readers who may have personal knowledge of the tool or its implementation, or from readers in other places who have used similar tools. What other feedback did you get from clinicians and from coding staff? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 7/11/24

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/8/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 7/1/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/27/24

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/24/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/20/24

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/17/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.