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.

EPtalk by Dr. Jayne 6/13/24

I get a lot of emails advertising webinars and educational opportunities. I don’t usually take advantage of them because my schedule is busy and the invites don’t arrive with enough notice to allow me to attend. However, a recent email from one of our local HIMSS chapter sponsors caught my eye.

It met all the criteria. I received it several weeks in advance, the topic was interesting, and it was advertised specifically as an educational session. I blocked my calendar and registered. I logged in well in advance, only to find a blank screen and no indication that I was receiving the audio or video feed. I appreciate a moderator who addresses attendees with some kind of “Thank you for joining, the session will begin in three minutes” kind of welcome so that you know you’re in the right place and everything is working.

It was well after the top of the hour and the webinar hadn’t popped up yet, so I refreshed the window and discovered that it had already started and I had missed the intros. It also was less of a formal education session than talking heads, with no agenda or educational objectives. I had yet to hear anything about healthcare IT in the first 20 minutes (although I did hear a lot about AI being used to predict the likelihood of a criminal reoffending and about autonomous vehicles), so I gave up.

If you’re putting on a webinar, here are my recommendations. Advertise your offering accurately. If it’s not going to be a formal educational session, don’t make it sound like one. Words like “chat” or “roundtable” indicate a less-formal presentation. Also, know how your platform works. If it won’t automatically refresh for early-arriving attendees, add a chat message to advise them to refresh the screen regularly so they don’t miss anything.

Anyone who has ever been in a clinical role in a hospital is used to hearing “The Joint Commission requires it” about policies that may or may not be subject to Joint Commission review. The Joint Commission recently released an update that clarifies its position on using secure texting for patient information and orders. Organizations can use that modality for orders as long as the information is secure, encrypted, and captured in the EHR with timestamps and author information. This brings The Joint Commission into line with CMS policies, although having providers enter orders directly into the EHR remains the best practice for order entry.

A friend clued me in to Spacetop, an augmented reality laptop that is under development and is available for reservation. Along with “the first spatial OS designed for productivity,” the G1 model is priced at $1,900 and will start shipping in October. Prescription lenses for the retro-looking glasses are included, although I would be more impressed if it included technology where the user could input the details of their eyeglasses prescription and have the system adjust the visuals automatically. It advertises a 100-inch visual canvas with a form factor that “fits a standard laptop bag with the glasses safely stored in hardcover.” The glasses include speakers and microphone for use during online meetings, although unless I’m interacting with a bunch of users with the same device, I think that would seem a little strange. If the company is looking for beta testers, I know a sassy CMIO who would love to give feedback.

From LaSalle Gal: “Re: MyChart. My health system sent me an email recommending that I turn on all the notification settings. Although it had technical instructions for toggling the notifications on, it seemed like a missed opportunity to educate patients on what it means to receive notifications, especially for patients who may not want to see test results before they receive a communication from their physician.” I reviewed the original email and I agree. It would have been easy to insert a sentence or two about how the organization releases results along with instructions for suppressing notifications that you don’t want to receive. I also thought this section was funny: “Even if a toggle is already green, you might not have all notifications turned on. To make sure all notifications are enabled, just switch each toggle off and then back on.” That doesn’t instill confidence to this user that the settings are accurate and functional. I’d be curious to see data about how many patients may have accessed the communication preferences settings in the weeks after this communication was sent.

Based on my comments about certain clinicians struggling with handwritten orders during downtime events, another reader sent this piece from NPR’s “Shots” blog that addresses the benefits of writing by hand. It summarizes some of the benefits of handwritten work, including better letter recognition in children and better conceptual understanding of material when adults take notes by hand. I own a set of amazing medical student notebooks from the 1920s (thanks, eBay!). It’s interesting to imagine the student sitting there, jotting his thoughts about the fact that “we are really just starting to understand the mysteries of the thyroid.”

Pet peeve of the week: the phrase “building an organizational muscle.” At best, it makes me think of bodybuilders oiled for competition, and at worst it reminds me of an old drug company ad for a diabetes medication that anthropomorphic characters such as Hungry Muscle, Burned-Out Pancreas, and Upset Stomach. (Side note: in trying to remember what the drug was, I discovered that you can buy the Hungry Muscle plushies online, so I know I didn’t imagine it. I also learned that there is a thing called the Medical Advertising Hall of Fame.) Whether you’re building an organizational muscle for change, for quality, or some other buzzword, there are better terms: “a culture of change” or “a commitment to quality” come to mind.

I spent part of the morning being a patient at my local health system. For the most part, the information I provided during the online check-in process was used, including an update to my health history and a review of systems. They required a new scan of my insurance card, however, even though I’ve had another appointment within the last 30 days and the card was scanned then. The receptionist also asked me the standardized COVID exposure questions that were appropriate several years ago, including whether I had any international travel within the last year or the last 30 days. I’m not aware of any recommendations for travel screenings in healthcare environments, so it felt like an organization that just isn’t staying current. It made me wonder how often the organization is reviewing its patient experience, as well as its ability to keep current with infectious disease recommendations.

How often do you reassess your patient registration and check-in processes? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/10/24

I have a lot of friends who work in the healthcare technology vendor space, and they are always curious to know my thoughts about health system priorities. A lot of them are on the sales side of their respective organizations and are trying to meet quotas, figuring out how they can get a hook with the health system executives that make purchasing decisions.

Of course, when they ask my opinion, they get just that. I can only comment based on the health systems that I know and the conversations that I’ve had. Priorities can vary based on community and regional factors, as well as based on specific challenges that a given organization has faced in recent months, such as cybersecurity incidents, labor challenges, and natural disasters.

McKinsey & Company recently released a report that looked at the investment priorities of health systems. AI always makes the list as something that organizations think will help in their transformation efforts, but it is unclear how much individual systems are investing in those technologies. McKinsey cites a 2023 working paper from the National Bureau of Economic Research as stating that machine learning could result in reductions of healthcare spending of up to $360 billion. However, McKinsey notes that while the majority of respondents to its survey say they are making digital transformation a priority, they also report challenges in resource allocation and planning.

In looking at data on already implemented capabilities, top priority areas include virtual health, revenue cycle management, digital front door, acute care throughput, and ambulatory care efforts. Leaders who were surveyed reported that those areas that might have the biggest impact include AI at the top, followed by virtual health and digital front door.

It’s interesting to see that the most impactful area fell lower on the spectrum of implemented technologies and roughly middle-of-the-road in being ranked as “unplanned” by leaders. From my discussions with leaders, it sometimes feels like AI isn’t being planned for in the same way as other technologies because of overall uncertainty in how to approach it.

The McKinsey survey gathered data on barriers to executing digital and AI transformation in the next two years. The item most commonly earning a number one ranking was “budget or capital limitations,” followed by “legacy systems are difficult to upgrade.” I was surprised that “unaware of the right digital solutions available” scored so low, with only six of 200 respondents ranking it as number one. That makes me wonder if those surveyed really believe that or if they’re just not admitting how challenging it is to find the right answers to some of the sticky situations that they are facing.

The report goes on to recommend five ways that health systems can evolve, including embracing the cloud, building partnerships, cautiously moving to AI, looking beyond off-the-shelf solutions, and changing up how they operate. For the latter two, they offer advice that I’ve been giving healthcare organizations for two decades now. Their example for looking beyond available solutions involves optimizing workflows “to enable more appropriate delegation” in order to save on nursing costs.

Process improvement advocates have been pushing the idea of delegation for years, yet I still regularly encounter physician offices that don’t have delegation policies for medication refills or scheduling overrides. I continue to see organizations that refuse to use proven strategies, such as data-driven float pools for staffing. Maybe now with the idea of technical enablement for delegation, as mentioned in the piece, people will get on board since adding technology often makes things appear more exciting.

As far as the recommendation to operate differently, the article calls for structures with “flatter, empowered, cross-functional teams,” which management consultants have been pushing for as long as I’ve been in the industry. In thinking across my career, I’ve probably only worked on three truly empowered teams the entire time. Too often, I see teams that are withering due to micromanagement and barriers they can’t seem to remove, such as absent organizational support, questionable corporate values, and lack of funding for key resources.

I asked a friend who is a health system administrator to weigh in on the recommendations. She agreed that many organizations need to get back to basics and to focusing their efforts on initiatives that might not seem sexy but that are needed to help build a strong base after the challenges of COVID. These include things like making employees feel valued, providing adequate resources for training and onboarding, and having a dedicated focus on removing the barriers that keep teams from meeting their objectives.

She told me a story about an operating room utilization project that another part of her organization worked on for months, crunching data about supplies, staffing, and room turnover rates. Despite recommendations from their on-the-ground process improvement staff, leaders wouldn’t negotiate with other departments to make frontline operating room staff available for interviews or workflow mapping activities.

It’s hard to fully understand a problem when you’re just looking at data and not talking to the people who do the job day in and day out. And if you’re not talking to the stakeholders, you definitely can’t get their buy-in or their support for your proposed changes.

The process improvement team was frustrated by the leadership barriers and their inability to make progress. They ultimately spent six months and who knows how much money designing a solution that made people feel disenfranchised, which automatically reduced its chances of success from the moment it was announced. After a failed pilot, the organization reopened the project and figured out a way to remove the barriers, with the team performing a significant amount of rework as they were able to get the input of those with the greatest knowledge of the process.

What would the outcome have been if the team had been empowered to do the job they were trained to do in the first place? In addition to providing process improvements six months sooner, they would have had the satisfaction of knowing that their expertise was respected and that they were treated as valuable members of the organization. I wouldn’t be surprised if the members of that team are a retention risk over the coming months, and anyone who has had to crunch staffing numbers knows that it’s always more expensive to replace someone then to use resources that you already have in place.

What do you think about the McKinsey survey and report on organizational investment priorities? Do their findings match what is happening where you are? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 6/6/24

ONC is seeking feedback on a recent white paper that highlights its vision for Health Equity by Design. The organization is formulating strategies to reduce healthcare disparities by including health equity throughout the creation and implementation of health IT policies, programs, and workflows. The approach aids in identifying gaps and disparities and creates an environment where “technology itself anticipates, avoids, and reduces, not exacerbates, health disparities.” Additional outcome goals include mitigating systemic inequities and improving person-centered decision-making, implementing population health interventions, and strengthening public health. Comments can be provided through June 10 at 11:59 p.m. ET.

Having worked in emergency and urgent care settings for the majority of my career, I’ve seen how the lack of easily accessible mental health services adds to overcrowded waiting rooms and delays patients from receiving appropriate care. A recent initiative in Oklahoma equips police officers and Certified Community Behavioral Health Clinics with IPads for telehealth visits, helping reduce the number of emergency visits and hospitalizations for mental health issues. More than 30,000 devices have been deployed to the field, allowing faster patient interventions in a less resource-intensive manner.

Police officers no longer have to wait with patients at the emergency department, and patients have a shorter wait time for lower-acuity care that better matches their needs. The statistics are impressive – a 93% reduction in inpatient hospitalizations for mental health crisis over a six-year period, and $62 million in savings. The program has expanded to provide IPads directly to behavioral health patients, further reducing the need for costly interventions. I hope other states, counties, and cities take note of this program and consider implementing it in their own areas.

A project for one of my clients led me to dig into the new final rule from the Office for Civil Rights (OCR) and CMS that is designed to prohibit discrimination in AI based on data points such as age, gender, race, and ethnicity. It’s great to have regulations, and this one in particular brings 558 pages of PDF joy, but it’s unclear how this will be enforced. AI bias can be difficult to detect, and when identified, there’s a chance that organizations will be subject to their own biases in determining how to address it. The presence of a formal rule opens the door for whistleblowers and reports of problems from end users, which should help keep the industry honest.

One of the important elements in the rule is the definition of the term “patient care decision support tool” as “any automated or non-automated tool, mechanism, method, technology, or combination thereof used by a covered entity to support clinical decision-making in its health programs or activities.” That definition encompasses everything from EHR-embedded AI clinical decision support to paper checklists found at the bedside, and everything in between. Hopefully this will serve as a catalyst for organizations to ask some questions about tools they have in place or are considering, including reviewing the data being used to trail the model or validate the tool, making the tool’s decision-making process transparent, identifying how people will be involved in the implementation and monitoring of tools, and describe the steps that will be taken if there is a suspicion that harm has occurred.

With that in mind, it’s timely that Epic Systems has released a new “AI Trust and Assurance Suite” that is designed to help clients test and monitor their AI models. According to announcements from Epic, the software is designed to automate data collection and mapping and to ensure consistency. Since one can’t really see Epic’s documentation unless one is an Epic customer (or someone violates all kinds of rules by slipping one a copy,) it’s unclear how this tool will work for the numerous Epic clients who have custom fields and their own unique ways of using data.

Epic says it will release the tool’s monitoring templates and data dictionaries as open-source software this summer, which should help clients who have custom AI models or who are using tools from third parties. Still, that’s a significant burden on clients who will have to analyze the tool and its functions carefully. I doubt many organizations have analysts budgeted to address it, so we’ll have to see what the speed of uptake looks like.

I’ve been mentoring a resident physician who is considering a fellowship in clinical informatics. One of our recent conversations was around the role of generative AI in academic pursuits. Most organizations I have encountered have come to the conclusion that they can’t prevent students from using the latest and greatest digital tools, but that guardrails need to be in place to preserve academic integrity. Oregon Health & Science University Professor William Hersh, MD has a clear policy for the “Introduction to Biomedical & Health Informatics” course that provides guidance to students. Key points include that generative AI systems can be useful tools but should not be used to substitute one’s own knowledge; and students can ask generative AI systems for content, but final responses — including those in discussions, quizzes, tests, and term papers — should reflect the student’s “own thinking, judgment, and language.” It is also noted that students shouldn’t shortchange their learning by relying on generative AI, and that the need for a fundamental core of knowledge and understanding is needed by practitioners in the field.

Pediatric dermatology researchers are celebrating their victory over ChatGPT as detailed in a recent study that looked at accuracy rates on board-type questions. They tested ChatGPT versions 3.5 and 4.0 using questions from the American Board of Dermatology as well as “Photoquiz” questions from the journal Pediatric Dermatology. Although ChatGPT 4.0 gave human pediatric dermatologists a run for their money in some areas, the humans outperformed both versions overall. Researchers call on clinicians to understand the tools and how they might be helpful in practice.

The Institute for Safe Medication Practices has released additional guidance on actions needed to prevent drug name selection errors when facilities are using automated medication dispensing cabinets. Although vendors have taken steps to improve their products, some features require a customer to opt in to the newer safety features through manual configuration or software updates. The Institute is calling on vendors to support dynamic search functions and standardized medication names, and for care delivery organizations to educate staff, analyze workflows, and require indications for certain overrides.

I spent some time this week helping teach CPR to a local youth group. Attendees were amazed at how much easier it looks in movies and television. Some of the participants were smaller physically and couldn’t generate the force needed to do effective compressions, but they were great at recognizing the signs that CPR is needed and demonstrating how to take charge of a scene. If you’re not certified in CPR and use of the AED (automated external defibrillator), consider taking a class. At minimum, consider learning about hands-only CPR from our friends at the American Heart Association and identifying where AEDs might be kept in your daily travels. Bystanders recently initiated CPR at my local Costco. Will you be ready if the time comes?

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 6/3/24

I use HIStalk as a primary source for healthcare IT news as much as the next person, so I was interested to see the recent Morning Headlines call-out about Google’s AI Overviews. I had seen them pop up in searches, but didn’t think too much about them since the last couple of weeks have been a whirlwind of meetings and deadlines with travel to a conference sandwiched in the middle.

I had a little bit of downtime this weekend and was planning to use it to complete my mandatory Maintenance of Certification questions that I have to do every quarter to maintain status with my specialty board. The online quarterly questions are open book and you’re allowed to use online resources. Normally I use well-trusted sites such as the United States Preventive Services Task Force, various professional journals, and UpToDate to research the answers if I don’t know them outright. This time, I decided to use Google to see what it would come up with.

Due to the honor code involved with the quarterly questions, I can’t share the exact queries that I did during the project, but I’ll share the results of some questions that recently came up related to continuing medical education quizzes and conversations with colleagues.

Asking Google how much calcium I should be taking in each day resulted in the AI overview that displayed the same data that appears on the website of the National Institutes of Health’s Office of Dietary Supplements. It showed values by age range and sex, since Google wouldn’t necessarily know how to define “I” in the query. However, asking it for tips on selecting the best blood pressure intervention for a female patient with a blood pressure of 200/90 didn’t provide an AI Overview. (UpToDate won that one, hands down, with multiple articles addressing the topic.)

The recommendations for breast cancer screening in the US recently changed. I asked Google for the current mammogram guidelines and was greeted with four sponsored results and then a result with a link to the US Preventive Services Task Force site, so that was a plus since it was a direct link to the primary source material. Of the sponsored links, the one from Mercy wasn’t even about mammograms, but rather a promotion for its multi-cancer-screening blood test. Another one of the sponsored links, from a local fitness organization, was last updated in 2020 and provided incorrect information. As a clinician, I was pleased to find that the search for “are COVID vaccines bad” returned two websites from the Centers for Disease Control and Prevention followed by one from Johns Hopkins Medicine.

I then turned to more routine primary care questions, such as “do I need penicillin for sore throat” and was pleased with the information the AI overview provided, including that “antibiotics only help with bacterial infections, not viral infections” and “most sore throats are caused by viruses , such as the common cold, and will go away on their own within a week without treatment.” It went on to suggest reputable home remedies including rest and gargling with salt water as well as links to appropriate articles from UpToDate, GoodRx, and the National Library of Medicine.

I also asked, “what is a sinus infection” and although the information that returned was appropriate, I was thrown by the weird punctuation and capitalization that came with it: “Sinus infections can be caused by a number of things, including: An inflammatory reaction, Allergies, A code that doesn’t get better or gets worse after 7 to 10 days, and Smoking.” Even my Microsoft Word editor function caught that one and didn’t want me to send it along to Mr. H. I was pleased that it got the Oxford comma right, however. The AI Overview blurb also included some solid home remedies, such as reducing stuffiness by drinking lots of fluids, using nasal saline spray, and putting warm wet washcloths on the face.

By this point, I was fairly enthusiastic about some of the responses, since they included basic self-care items that a lot of the patients who come to see me in emergency and urgent care settings don’t seem to know. I see too many patients who present for care without having tried any kind of remedies at home, so I asked a tricky one: “Should I treat my child’s fever?” I see a fair number of parents who don’t give their children any fever-reducing medications when they are sick, under the pretense that they didn’t want to treat it because they “wanted the doctor to see how high it was.” Speaking generally for the physicians in my generation, unless your child is an infant or has one of a few chronic health conditions, we trust your use of a thermometer and want you to give your child some acetaminophen when they have a fever because it will help them feel less miserable.

The AI overview was spot on, advising caregivers to treat a fever “if it’s making them uncomfortable or preventing them from drinking fluids.” It also advised that treatment might not be needed for toddlers and children who are eating, drinking, playing, and sleeping normally. Sometimes I see children who are running fevers, but zooming around the exam room eating Cheerios and drinking apple juice, so this kind of information might have saved parents a $50 or $100 co-pay as well as prevented a couple hundred dollars in overall costs to the healthcare ecosystem. The overview was followed by links to content from UC Davis Health, Stanford Medicine, and Cleveland Clinic, so I felt good about the overall results of the search.

From there, I asked Google for symptoms of abdominal aortic aneurysms, and received an AI Overview. The second item on the list of symptoms, a pulsing sensation in the abdomen, can also be completely normal. The overview then recommended that anyone with the symptoms listed “should see your doctor as soon as possible.” In reality, if someone is having symptoms from this condition, they need to be in the nearest emergency department because it can be a life-threatening emergency requiring immediate medical management and the potential for emergency surgery. I’d give that particular response a D-minus if not an F since the potential for catastrophic consequences is high.

I asked the question again in a different way: “Do I have an aortic aneurysm?” and was told that “many people with aortic aneurysms don’t have symptoms until the aneurysm ruptures” and had to scroll off the screen to see any kind of recommendations for evaluation or care, so on the overall topic of aneurysms I would give Google an F.

In summary, I thought the technology did decently well for basic questions that I deal with every day, although it bobbled a little on the aneurysm question. Given the lack of basic health education in many communities, including how to treat minor illnesses and injuries, Google’s AI Overviews might be a nice step towards improved health literacy. It certainly makes the “finding” health information component easier, especially for patients and caregivers who might not know how to access the website of a local health system or other respected health information organization. It also did pretty well on the board certification questions, although some of them were more specific and therefore didn’t generate an AI overview. I’ll give the tool a solid B-plus as today’s grade but will keep an eye on it to see how it does in the future.

Happy Birthday, HIStalk! Congratulations on officially being old enough to buy a round of drinks. As is fitting for a publication created by anonymous people across the country, I celebrated with pastry for one. Healthcare IT has evolved in ways that I never dreamed it would, and I’m happy to have been along for the ride with HIStalk.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/30/24

I was talking to a colleague this week. We had a stroll down memory lane about the changes that have happened in the healthcare technology sphere during our tenures in the industry. I had made a comment about “doing electronic healthcare records since before Meaningful Use was a thing” and the conversation just spiraled from there.

We’ve seen practices opt out and take the penalties for non-participation, and we’ve seen practices overhaul themselves trying to get the most out of the bonuses. We’ve also seen a lot of organizations in the middle of that spectrum that just seem perpetually lost because they struggle to keep up with everything that’s going on in the regulatory world.

For those organizations in the swirl, the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) registration is open for the 2024 practice year. Organizations that plan to report an MVP can register through December 2, 2024 at 8 p.m. ET. That seems a bit of an arbitrary choice on the time and date to close out registrations, but I’m far from being the clock or calendar police. Organizations that plan to register should identify the MVP they plan to report, whether they’re going to use the Consumer Assessment of Healthcare providers and Systems (CAHPS) for MIPS Survey, and the population health measure they would like to be evaluated on. There are several other decision points, such as participating as an individual versus group versus subgroup, so if you’re not familiar with all of that, it might be time to do some reading.

I haven’t heard much about data being used in this way, but Vanderbilt University Medical Center is using data to identify outlier clinicians who are receiving a high number of patient complaints. Once the physicians are identified, trained physician peers review the data and provide feedback that is targeted towards behavioral modification. The program has lowered malpractice claim costs for the identified physicians by 83%. Although the work at Vanderbilt was only done in orthopedic surgery, it would be interesting to see how similar initiatives might pan out in other specialties. I’m curious how other organizations might be using patient complaint data – it’s not something I hear much about in the informatics community.

Speaking of data, I can’t wait to see some actual research on this new solution. Crescent Regional Hospital in Lancaster, TX has deployed a solution that creates life-size holograms of physicians in patient care areas, “creating an immersive, engaging, interactive experience.” It sounds exciting and all, especially when the hospital CEO uses the word “teleport” to describe what is going on, but other than being in 3D and requiring specialized equipment, it’s a very fancy video visit. It is being described as a “non-touch” visit rather than a virtual visit or video visit. I’d love to see a head to head study comparing this type of solution with in-person care and non-hologram virtual visits. I suspect it will score similarly to the latter, although there’s a potential for it to score worse if there are technical issues. I wholeheartedly support the use of video / virtual care, especially in areas where it’s challenging to recruit clinicians, but I can’t help but remember something else that creates an “immersive, engaging, interactive” environment – live physicians.

Depending on the specialty, some departments have been slow to integrate virtual care into everyday practice. A recent submission in JAMA Pediatrics looks at the incorporation of clinician-to-clinician e-consults within pediatric care organizations. Ideally, it would allow primary care physicians to collaborate with subspecialists about the care of a particular patient. However, researchers found rates for the under-18 population that were significantly lower than other patient groups. The authors note key areas that need to be addressed in order to expand the use of the modality: specific payment mechanisms, EHR interoperability, operational processes, consent, privacy, and patient engagement. It will be interesting to look back at this topic in a few years and see if advances have been made.

As I was wrapping up my recent trip, the idea of innovation labs was a hot topic. Apparently Atrium Health is building a 20-acre “innovation district” in Charlotte, NC that includes research buildings, a residential tower, retail shops, and a hotel. It will surround the medical school that is planned for the area.

Plenty of large health systems have innovation centers or programs. I’ve heard of them ranging from high-performing units that can create and commercialize solutions to buzzword-friendly boondoggles. One of my drinking buddies shared a feature from The Hustle that suggests that the innovation lab concept has lost its sparkle. Examples of non-healthcare innovation labs that were cited in the piece include Estee Lauder and Microsoft “to infuse AI into your beauty routine (whatever that means)” along with Major League Soccer, Mars (home of M&Ms and Snickers), Sephora, and Visa.

That particular edition of The Hustle also included a blurb about a startup (BrainBridge) that wants to transplant a human head onto a donor body within eight years. They plan to use high-speed robotic surgeons and AI algorithms to make it all work (of course there is AI!) The blurb links out to an article in the New York Post, so that’s something right there. I’d love to hear what actual neuroscientists think about the potential for this.

My buddy also shared that the edition mentioned that Firefox recently resolved a software defect that was opened in March 2000 for the Netscape Navigator product. I had a 15-year relationship with a software company once, but generally gave up on defect fixes once the requests hit the five-year mark. Kudos to the team for closing the loop on this one.

I’m back in the cicada zone this week, and I’d be lying if said I wasn’t eager for them to finish their life cycle and have the next generation burrow back into the ground. They are projected to decrease in my area in mid-June, but work travel will take me to places where they might continue well into July. I try to dodge them when I’m out for a walk or a run, but it’s amazing how loud it can be when one of them hits your windshield at high speed. Good luck, little critters, we’ll see you again in 13 years.

What is your cicada-palooza experience? Are you fascinated by it or ready to be done with it? Or tired of hearing the Eastern half of the US talk about it? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/23/24

I’m reporting this week from the AMIA Clinical Informatics Conference in beautiful downtown Minneapolis. Although I usually prefer to be in the great outdoors, I must say I’ve enjoyed being in the city and having zero cicadas flying in my face compared to what I’m used to at home. AMIA wins the best badge ribbons title hands down and has something to meet everyone’s needs for pop culture references.

The conference has been filled with great sessions and plenty of networking opportunities. It’s been nice to see people who I rarely see in person and to make new contacts. Of all the AMIA meetings, this one focuses the most on applied informatics. I’ve already jotted down several pages of helpful tips for upcoming projects. 

Speaking of jotting notes, I’m glad that the included AMIA pen writes smoothly, because it’s been a long time since I’ve taken notes by hand. I appreciate the workshop sessions that have had table setups because it makes it much easier to manage your notes or laptop as well as any snacks or drinks you might have with you.

I also heard some great quotes that were worth making note of. One of my favorites so far is, “People who are into tech aren’t always into communication.” This resonates with anyone who has encountered detailed instructions for electronic devices that don’t take into account the fact that end users aren’t necessarily engineers. Another quote in the patient safety realm was, “Pharmacists don’t break rules, so if they’re doing it, you know you’ve run off the rails.” I was also excited to hear two people at the poster session and reception discussing something they had read about in HIStalk, which always makes my day.

One conversation between sessions included anecdotal reports about what is going on inside Ascension hospitals during their ransomware-inflicted downtime. Someone with inside knowledge mentioned a situation where younger members of the staff were unable to read the cursive handwriting used by some clinicians. My local public schools stopped teaching cursive around 2008 or so, causing some entertaining moments at family birthday parties as the youngsters try to read their grandparents’ handwriting in greeting cards. Cursive or not, physician handwriting has been the butt of jokes for decades, and poor penmanship can result in significant medical errors. Something for hospital and healthcare delivery organization leaders to consider as they’re reviewing and revising their downtime plans.

Back to Ascension, the organization is providing updates on a state-specific basis. I noted these nuggets from the Wisconsin section: Ascension retail pharmacies remain unable to fill prescriptions and patients have been asked to “bring notes on symptoms and a list of current medications, including prescription numbers or bottles.”

Lawsuits related to potential HIPAA violations have been filed on behalf of Ascension patients in the US District Courts of the Northern District of Illinois, Western District of Texas, and Eastern District of Missouri. I couldn’t find information on the other two, but the one from Texas appears to be a class action. Buckle up, Ascension, it’s going to be a wild ride.

As far as cyberattacks and downtime are concerned, the Workgroup for Electronic Data Interchange (WEDI) sent an eight-page letter to the Department of Health and Human Services highlighting the vulnerability of the US healthcare system and the need for greater oversight and improved business continuity planning. It asks for a new Office of National Cybersecurity Policy led by a “Cyber Policy Czar” and a National Health Care Cyber Fire Drill Week. Regarding the latter, organizations would be charged to work not only with internal systems, but with “critical trading partners” to test systems and define contingency plans. I’m happy to dust off my high-visibility Incident Command vest for the occasion, I just need to find some snappy shoes to go with it.

From Hybrid Curmudgeon: “Re: Dell flagging employees that aren’t coming back to the office as much as they’re expected to. How degrading.” Apparently, Dell is aggregating the data from VPN usage and in-person badge swipes to assign color codes for employees to make it clear how much they are working in the office versus from a remote location. Workers are expected to be in-person for 39 days each quarter. Starting this month, workers will receive weekly updates via the company’s HR platform and will be assigned a color (green, yellow, or red) based on respective time in the office (regular, some, limited). Top performers with a consistent presence in the office will be flagged in blue. I’ve worked in organizations where a variety of indicators are used to identify employees to be placed on the block for the next round of cuts, and this is just one more piece of data to add to those matrices. Nine box talent grids, anyone?

Speaking of talent, one of the hot topics among CMIO types this week was the challenge of retaining talented clinical informatics staffers when they’re partnered with physicians who need to move across the country either for training or for improved job prospects. Allowing staff to work remotely would be an easy fix, but I understand the reluctance of health systems to want to deal with multi-state employment law and payroll regulations. I still find it humorous that these same systems will outsource their IT departments, sometimes outside the US, but won’t make accommodations to retain successful team members.

I also heard some discussion about the number of burned-out physicians who are trying to cross into clinical informatics as a “way out” and the political implications of having them appear in the hiring process. It sounds like some are claiming that they’re “in clinical informatics” because they’ve used an EHR in their career, despite the lack of deeper knowledge of healthcare information systems or the processes and governance needed to sustain them.

My outbound flight for the conference had a mechanical issue which led to a delay of about an hour. Although passengers weren’t thrilled, I didn’t hear a lot of people voicing concern about connections, so that’s a good thing. At least it wasn’t an issue like the one that occurred recently when a United flight from Zurich to Chicago had to divert when a passenger’s laptop was swallowed up by a business class seat. The crew was unable to retrieve it, and due to the risk of fire with lithium-ion batteries, the flight landed in Ireland. The ensuing chain of events, including the inability to access the laptop from anywhere but through the cargo hold, led to a crew time out and an overnight stay for passengers.

What’s the strangest maintenance delay you’ve experienced on a flight? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/20/24

We’ve all heard about so-called “quiet quitting” and other strategies that employees are using to try to cope with less than ideal workplaces. There is plenty of literature out there on organizational culture and time management, so I thought I would share a couple of the most intriguing things I’ve come across in the last few weeks.

One concept has been referred to as “intentional inflexibility,” which seems to be a fancier way of saying that you protect the time you need to get your work done and to perform your best. This could mean that you decline meeting requests if they are for your most productive times of the day, or that you refuse to be constantly accessible via email, messaging, app, or text. Maybe it’s letting emails sit for a couple of hours until someone else replies to them, or maybe it’s only checking your email twice a day and hoping that churn has already occurred before it gets to you (viewing your emails as a conversation is particularly effective for this approach).

One has to be careful of company culture when applying this approach, however, because an employee “having good boundaries” might be interpreted as not being a team player.

A related article was about having a sense of false urgency at work. I’ve been in situations where people text you to find out why you haven’t responded to their Slack message, when the overarching reason is that you’ve been on three hours of back-to-back calls dealing with acute issues. I was once hounded by a member of the marketing team about “what is your favorite movie” since that was part of a project around getting to know the executive team. He had sent it on a Saturday, I hadn’t responded by Monday afternoon, and he was on a deadline. Expecting turnaround on an item like that in under one business day definitely falls under the banner of false urgency.

As a member of senior leadership, I was happy to have a conversation with the marketing leader about realistic deadlines and the need to coach the team about how to interact with other members of the C-suite. Of course, this kind of issue could also have been avoided by having a communication policy that addressed how to identify urgent requests versus non-urgent requests and how to know what an appropriate turnaround time is for different types of interactions. One company I worked for had a policy that if you needed an answer within 24 hours, you had to call the person with your request. It made people think twice about how urgent a request might actually be before making their move.

Another idea I’ve been reading about is that of organizational drag, which is when teams lose productivity due to policies and processes, whether formal or informal, that waste effort and decrease output. This includes being required to attend meetings that should have been emails and spending time reading emails that shouldn’t have been sent in the first place. It can also refer to wasteful processes, such as time and attendance tracking that could be completed in more simplified ways.

I’ll never forget when one organization I worked with migrated to a well-known project management and time tracking platform. The build was so much more complicated than it needed to be and added hours each week to the tracking requirements for consultants. Consultants make money when they’re billing clients and not when they’re manually keying extraneous data. Despite the immediate negative impacts, it took over a year to get the system optimized.

I’m also re-reading “Out of Office: Unlocking the Power and Potential of Hybrid Work.” I know I’ve mentioned this one before, but after working a couple of consulting gigs in in health systems across the US, some of the content is resonating differently than when I first read it. In one of the early chapters, the book addresses how “just in time” staffing became the norm in organizations today, even though in reality it means relative understaffing, since you don’t have any surplus capacity if you’re taking that approach. When you’re understaffed, people are reluctant to take time off or to use their time off to its maximum, especially when they fear that teammates will have extra work dumped on them, or that they’ll have to do a mammoth clean-up effort when they return to the office.

Having managed large teams during my career and especially having managed teams whose time is billable, it’s important to understand what overhead goes into just being an employee. These are the nonproductive parts of a job and may include items like corporate compliance training (HIPAA and fraud, waste, and abuse anyone?), maintaining proficiency and certification on different software platforms, managing professional licensure, and learning the tools that are needed to perform your job, especially when your employer decides to rip and replace those tools while you’re still expected to be productive.

Particularly in organizations that are trying to be intentional about company culture, you have to bake that time into capacity management as well. If you’re having multiple monthly all-hands meetings, socials, and mixers that you expect people to attend, you need to account for those. All too often, I still see management teams overlooking how initiatives like this directly impact workers, especially if they are on teams that are hanging on by a thread.

I worked on one team where the manager planned to have a holiday party with the theme of decorating miniature Christmas trees. First off, there was no recognition of the fact that not all employees celebrated that particular holiday, and that even if they did, that decorating trees was part of their tradition. Then there was the fact that this gathering was set for an entire half day during the end-of-year push that many healthcare organizations feel if their fiscal year follows the calendar year.

There was a lot of grumbling about the event and the organizer was frustrated by the low level of RSVPs. Several of us staged an intervention and convinced her to call off the event and instead to have a post-holiday party to blow off steam after the year-end close was done. Rather than a gift exchange, employees were invited to bring a ridiculous item to swap, either something that they received as a gift or just had around the house and didn’t need or want, with any leftover items being taken to a charity drop-off site.

We all got a laugh out of the unlikely items, especially when someone actually wanted them, and people who wanted to de-clutter were thrilled to get rid of things. Did it end up 180 degrees from where it started? Yes, but it was exponentially more well received.

What trends are you seeing as far as how employees are trying to navigate ever-changing workplace conditions? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/16/24

I was back in the patient role this week, visiting a different hospital for my annual MRI. I was glad that the high-risk clinic at Big Academic Medical Center offered me the option to have it done at a branch hospital, which shaved 30 miles off my travel.

The hospital is relatively new. Each person coming in is greeted personally and their appointment is searched in the system to make sure that accurate wayfinding directions are provided. When I arrived at the radiology waiting room, there was a check-in line backed up due to a patient who was confused about whether he could go home or not.

Once the line cleared and I made it to the desk, I noticed that there was a sign inviting people to check in via the kiosk, but unfortunately the sign had been completely blocked by the long line of waiting patients. Additionally, looking at the situation with a process improvement eye, I noticed that the kiosks were on the back wall of the waiting room – functionally behind you as you came in – so you weren’t likely to see them.

Part of my check-in involved a paper MRI screening form on a clipboard, so I’m not sure the kiosk would have helped anyway. I haven’t gotten a pacemaker, deep brain stimulator, or other implants since yesterday when I completed my online check-in, so I’m not sure why those questions couldn’t have been formulated into a patient questionnaire that I could have completed while in my pajamas.

The study went smoothly and I slept through a big part of it, which is a plus considering how noisy an MRI can be. The noises were a little different than I’m used to because it’s a different machine, and the last sequence sounded a bit like the cicadas that have descended on my area.

When the technician returned to the room to free me from the scanner, she said she noticed on my chart that I’m a physician and asked where I practiced. I talked about my work in virtual healthcare, and that I work from home for the most part. She said she thought that was cool, but when I mentioned that it probably wasn’t applicable to working in radiology, she said I would be surprised.

She mentioned that since the scanner manufacturer is based in Germany. The process for scanning patients there has more physician involvement. They actually have protocols for remote scanning, where the physicians operating the machines work from either a control center or from their homes. This facility recently piloted it, and although results were good, it relied heavily on having a certain level of support staff at the bedside that doesn’t match up with how roles are defined in the US. Additionally, the hospital felt that there was too much liability for it to be successful in our current environment, so the pilot concluded with a determination that more investigation is needed.

I always enjoy having a serendipitous moment like this and learning something new. But as far as other opportunities discovered on this visit, if you’re a radiology director, you might want to visit your waiting rooms and assess the positioning of signage and kiosks. 

HIMSS has opened its call for proposals for the 2025 conference, encouraging potential presenters via email to “lead conversations and make waves.” One could have some marketing fun with the “make waves” idea if the conference were held somewhere near a large body of water, such as San Diego or New Orleans, which would be welcome additions to the venue rotation in my opinion. Instead, next year’s event is in the desert, which doesn’t really apply.

Regardless, the email prompted me to go ahead and make my hotel reservation since Las Vegas hotels are often disgustingly expensive. I usually stay at The Palazzo and was sad to discover that even 10 months in advance, not a single standard suite was available on the Wednesday of the conference. I tried different occupancy types to confirm and had no luck. It just seemed weird. Maybe they are saving all of those for exhibitors rather than attendees? Nonetheless, if you’d like to submit a presentation, you can do so through June 10 at 5 p.m. Central time. In the mean time, I’ll stick with the two queen beds and see if any of my friends want to cost share since the room wasn’t cheap.

I’m always on the lookout for practical applications of AI technology that cut through the hype that currently swirls everywhere. This write-up from Missouri S&T caught my attention, especially a photo caption that had an electrical engineering graduate student looking through a dermatoscope to learn more about skin cancer since his team was working on solutions to improve detection. Joe Stanley, PhD is a professor in computer engineering and recently received a $440,000 grant from the National Institutes of Health on a project that will tag existing skin photographs then employ machine learning to expand the usefulness of existing data.

Given the fact that the solution will be used by physicians, it’s critically important that those developing it understand what goes on in a medical office and how physicians use data and tools to care for patients. There are far too many solution development teams out there that don’t take this vital step, so kudos to this one for helping researchers better understand the field they’re trying to improve.

Another headline that caught my attention this week was about a hospital getting rid of passwords for nurses. Unfortunately, it was a mindless blurb about transitioning from passwords to a badge reader system on an innovation unit. I’m not sure how innovative or newsworthy that really was since we had that at my primary hospital sometime in the neighborhood of 2016 and I’m sure it was at other places before that. Must have been a slow news day at Becker’s, or maybe just a diligent placement effort by a solid marketing team.

I heard from a reader this week who has been forced to participate in his company’s Return to Office program despite the fact that none of his team works in the local office. Apparently the company is trying to promote “new, exciting offerings in the cafeteria” to reduce the sting of coming to the office three days each week. The day’s offering was heavy on salami, onions, and other aromatics that I’m sure would make people prefer to be on a video call afterwards than in an in-person meeting. The office also issued guidance on how employees should communicate with family when they’re stuck at work at the end of the day, encouraging them to just say that they are delayed without hinting that meetings are running late or that anything is less than perfect at the company. That’s just about the worst micromanagement I’ve seen, and I’ve seen a lot.

What’s the worst micromanaging tactic that you’ve experienced from an employer? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/13/24

I have friends who work for Ascension. The concerns coming out of their facilities, which are offline due to a ransomware attack, are quite serious. It sounds like they haven’t done adequate downtime preparation, let alone preparation for a multi-day incident that has taken nearly all of its systems out of commission.

Mr. H reported in the Monday Morning Update about a patient who left one facility because it had been two days and he still hadn’t been seen by a physician. This is completely unconscionable. I hope regulators step in immediately.

Any hospital leaders in any organizations who are not aware of the current ransomware and cyberattack landscape should be removed from their positions of authority immediately. Hospitals need to be drilling for the eventuality on a regular basis. Not annually, but monthly.

I’ve written about this before, but one of the most serious near-misses of my career, which to me will always be a full miss, occurred during an EHR downtime, when the environment in my facility can only be described as chaos. No one knew where the downtime forms were. They were reluctant to engage downtime procedures due to a misplaced fear of “having to fill out a bunch of paperwork” that is required when they formally call a downtime.

I was working in what was essentially a freestanding emergency department at the time, although it was licensed as an urgent care. Due to that licensing, we could have easily stopped taking new patients while we got things sorted. However, the fear of repercussions from management was too great. They continued to bring patients into the exam rooms, leaving the clinical teams scrambling.

Once I found out what was going on and that we were still taking new patients, I called the downtime and demanded we stop bringing in new patients. There’s no need to worry about diversion, EMTALA violations, or turning people away when you’re not licensed as an emergency facility. I’ve been around long enough and practiced in enough challenging environments, including in a tent and out in the field with no support, to know that sometimes you just have to take charge.

Shame on these facilities that are putting patients at risk through lack of planning, lack of leadership, and focusing on the bottom line instead of focusing on the patients who are in front of them. I hope they’re providing counseling for the clinical team members who are experiencing profound moral injury as they are expected to continue to just do their jobs in an untenable situation. One person who reached out to me described it as a “battlefield” situation.

For those of you who are in administrative positions, I urge you to walk to the front lines in various clinical departments in your facility and start asking questions about downtime. It’s not enough to simply trust the reports that are coming out of planning committees and safety assessment committees. My free consulting advice: you need to put your proverbial boots on the ground to find out whether people know what to do or not. It’s not enough to perform phishing tests and to look at the reports that show that people are becoming less likely to click on sketchy links or to visit dodgy websites. People have gotten really good at watching those cybersecurity videos and picking the correct answer on a bland, five-question test.

What you need to know, though, is that when push comes to shove and someone has taken control of your infrastructure, do your employees know how to see patients? Kind of like when you’re drilling for an inspection by The Joint Commission and you expect everyone to be able to explain the PASS acronym for how to use a fire extinguisher (Pull, Aim, Squeeze, and Sweep for those of you who might not be in the know) you need to ensure that everyone knows how to successfully execute a downtime.

Back to PASS, though. Knowing the acronym isn’t enough. Does your team even know where the fire extinguishers are? If a random person came up to them during a time when there was no inspection, could they verbalize where to find them? A downtime is no different. All staff should be able to articulate what are the conditions that require that a downtime be called, how to initiate a downtime, the various roles of the team during downtime, how to find the “downtime box” or whatever supplies they need to use, what the downtime communication plan is, and how to manage critical patient care tasks in the near-term while the entire downtime procedure is put into place. 

Every single healthcare facility needs to know how it will handle a multi-week downtime. News flash: no one is immune to this, and anyone who thinks otherwise needs to seriously reevaluate their leadership readiness. Our facilities need staffing plans to help workers cope with prolonged downtime, including adequate double-checks and safety procedures to account for the loss of systems we’ve all grown to rely on, such as bar code medication administration (BCMA), allergy and interaction checking, and electronic time-out checklists.

At this point, and especially after the Change Healthcare debacle, no one has any excuse for keeping their heads in the sand and thinking, “It couldn’t happen to me.”

This weekend marked the opportunity to cross something off my bucket list without having to leave my home state to do it. The raging Level 5 geomagnetic storms are the first to hit Earth since October 2003, which was a time when I was knee-deep in building my practice and didn’t know a solar cycle from the citric acid cycle. Being involved in amateur radio for the last several years has taught me quite a bit about the former, and every day that I move farther from medical school has allowed me to forget more details about metabolic cycles than I care to admit.

As a “science person,” I’m happy to see this month’s expanded Northern Lights phenomenon capture the attention of so many people. I personally learned that the aurora comes in all different colors besides the most-often featured green. I hope there are children being inspired by it and considering future careers that involve exploring our universe and all the fantastic phenomena around us. Kudos to my favorite college student for capturing this amazing pic.

Were you able to see the aurora, or do you still have a trip to the northern latitudes on your bucket list? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/9/24

The American Medical Informatics Association is working with the Patient ID Now Coalition to persuade members of Congress to reject language in Section 510 of a 2025 appropriations bill that continues to ban the US Department of Health and Human Services from investing money towards a national unique patient identifier.

Organizations are still using a hodgepodge of matching algorithms that often work, but sometimes don’t. There are particular challenges with pediatric patients when organizations include phone numbers in the algorithm. Infants who might not yet have a Social Security number are also at risk. I’ve seen EHR conversions that inadvertently combined a pair of infant twins due to inadequate matching algorithms, so I would very much like to see a unique patient identifier even if it’s voluntary and patients have to opt in. The risks to patient safety remain great and I want my care teams to have access to all of my data.

Also in Congress, the House Ways and Means Committee is entertaining a two-year extension of Medicare telehealth rules that have improved reimbursement since the COVID-19 pandemic. There are multiple bills under consideration, including the CONNECT for Health Act and the Telehealth Modernization Act. Without an extension, the rules will expire at the end of this year. Primary care docs are leaving my state’s rural areas in droves, and increased coverage would allow patients to have visits with physicians in other areas of the state without driving for multiple hours.

I’m so used to working in high-reliability organizations that it shocks me when I encounter an organization that probably should be more high-reliability than it is. I was at a large regional post office this morning, and apparently they had experienced a power outage and the electricity had just come back on. There was one customer at the counter and two in line, so the postal employee announced what had happened and asked for our patience as they rebooted the systems. It took a few minutes for her station to come back up, and when the customer was ready to check out, apparently the credit card machine didn’t work. She was sending several registered mail items, so went out to her car to rummage for cash or a checkbook.

The employee suspended her transaction and called me to the window, making an announcement to the dozen or so people that had accumulated in line that the credit/debit machine was down and that they could only take cash or check. Everyone behind me turned and left, and I was grateful that I had my friend Andrew Jackson in my wallet, although I haven’t carried a checkbook in decades. One would think that the US Postal Service would be critical infrastructure and have at least some level of UPS backup (uninterruptible power supply of course, not the competition) with generator backup. They can deliver despite rain, heat, and gloom of night, but a power outage is going to put a dent in things.

I’ve been a panelist for several Women in STEM events and am always on the lookout for ways to increase the number of girls interested in healthcare and technology careers. During a recent talk, one of my co-panelists talked about “The Scully Effect,”  which shows that women who watched “The X-Files” were more likely to pursue careers in STEM-related fields. According to 2017 data, 63% of study respondents who were familiar with the Dana Scully character admitted an increased their beliefs in the importance of STEM.

Many of the young women I work with weren’t alive when Gillian Anderson began playing Dana Scully in 1993, so it will be interesting to see who will be STEM role models for newer generations. Media popularity now seems to be centered on TikTok and various social media influencers, many of whom share unscientific and downright dangerous content. I’d love to see a campaign to raise awareness about the roles available to women in healthcare IT, since I’ve run across multiple medical students who didn’t have a clue that it was a career path.

Federal regulators in the US are taking a greater interest in the issue of organizational consolidation in healthcare. They’ve opened comments looking to understand “the effects of transactions involving health care providers (including providers of home- and community-based services for people with disabilities), facilities, or ancillary products or services, conducted by private equity funds or alternative asset managers, health systems, or private payers.” You can browse the submitted comments (1,400 so far) and see how frustrated patients, physicians, and other providers are with our healthcare non-system. Hot topics in the comments I screened include lack of competition, greed, hospitals requiring pre-operative labs to be done in-house at a higher cost than competitive labs, the negative effects of companies like CVS expanding their scope of business, and compromised patient care. All the talking heads in healthcare should have to understand comments like this one from Lindy:

I am a retired home health caregiver, as well as an American citizen who lives below the poverty line financially. It has been a lifelong struggle for me to access good healthcare, and it is only getting worse. Corporations are by design intended to maximize profit, and in the health care field, this translates into sacrificing the good of a human being for the profits of a corporation. Every human being should be prioritized over profit, failing that is to put money over humanity which degrades us all. How can it be that dollars are more important than a mother, a father, a child who is suffering and in need? It is cruel, heartless, and inhumane on every level. It is time to put the genie back in the bottle, prioritize human beings over dollar signs, and prevent moneychangers from having the ability to dictate who lives or who dies because of money. America must be better than that, and corporations must be kept in line with humanitarian priorities.

It’s National Nurses Week, so here’s a shout-out to all the nurses out there who are caring for patients day in and day out. Special props to my nurse informaticist colleagues, who have taught me so much about thinking about systems from different points of view.

Of course, there are still hospital executives behaving badly as they attempt to show gratitude to the people that make their facilities run. One example of a tone deaf gift choice was sent to me by a nurse in the Midwest. The hospital gave nurses lunch boxes, which felt particularly insulting to night shift workers since the facility removed all hot food service for them. They also require workers to use self-checkout for prepackaged items on the night shift. The only overnight worker is a cook who is doing prep work for daytime workers, who still have full food service, including salad bar.

It sounds like managers suspected that the gift wasn’t going to be well received and provided these adorable badge reels plus breakfast out of their own pockets.

What’s the most irritating thank you gift you’ve received from leadership? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/6/24

I volunteer as an instructor at an outdoor school every few months, but I ended up missing a full year of sessions due to schedule conflicts. This weekend, I was back at it. It was a welcome detour from my usual days of back-to-back conference calls and endless client-related fire drills.

There was a threat of rain for the weekend, but all of our participants were reminded of the need to be prepared for anything that nature might throw at them. Part of my responsibility for the weekend was monitoring the weather, and when you consider what can happen during spring in the Midwest, that can be its own challenge.

I usually keep my camping gear packed so that I can be ready for adventure at a moment’s notice, but I apparently moved some items from one backpack to another without replacing them. I ended up arriving without a headlamp and had to make use of my backup flashlight, which was truly terrible. Fortunately, the daylight hours are longer and I wasn’t called out of bed in the middle of the night for a medical emergency or a facilities crisis, so I was OK.

I’ll admit that I was also counting on the fact that if someone had to find me for an emergency in the middle of the night, they would likely have a better flashlight than my backup. It’s always nice when you’re surrounded by people that you trust and that you know will have your back if you need help.

I also forgot a key piece of my outdoor school wardrobe. I was pleasantly surprised that no one gave me grief about not having it. The people with whom I serve on staff know that I have my stuff together greater than 95% of the time, so maybe that had something to do with it. I’m grateful to be able to work with people who trust me and know that if I’m not running at my usual level of performance, there’s probably a good reason for it, and I’ll make up for it if I can.

I admit that I was running around crazy on Friday with some work in the morning that took longer than it needed to. I was dealing with a sex discrimination situation and needed to make sure it was escalated as far as I could take it before I left town, trusting that others would pick it up and continue to act on it in my absence.

It’s disheartening to know that this kind of thing continues to happen in 2024. This particular situation is particularly egregious, with various regional teams deliberately violating a nationwide company’s policy in their attempts to keep women from participating in certain activities, citing “safety” as the reason. The roots of this issue go back several years, and those of us who have been working for decades to have women included in technical or other typically male-oriented fields are simply tired of it.

I wasn’t about to stand by while women were bullied because they are new to the organization and others were afraid to advocate for them for fear of retaliation. That’s when it’s nice to be a consultant, because other than my own work, I have nothing to lose in this situation. Fortunately, the individuals who I escalated to were in agreement that what had been going on was inappropriate, so I doubt I’m going to get kicked off the project any time soon.

We’ve all been the new person on a team, and it can be difficult. It’s important that existing members of the team are willing to support new members and make sure that they are treated fairly. I’ve been on teams where leadership does more bullying than leading, and in those situations, it’s tempting to just keep your head down and try not to become a target yourself. Unfortunately, that approach sometimes emboldens the bully, and it certainly doesn’t help the situation go away.

If we look out for each other, it strengthens the team. Eventually we can arrive at that magical place where the team is fully tuned in to each other and can really start to achieve its goals. It’s not always easy to be an upstander, but as we’re working to build workplace culture, it’s a necessity.

I enjoyed working with my assigned teams this weekend, which included a hospital pharmacist, several paramedics, a chaplain, and more than a couple of IT folks. It was interesting to see people leave their typical roles and focus on new challenges, such as lighting cooking fires in the middle of a rainstorm and figuring out how to safely use axes, saws, and other things they aren’t exposed to in their daily lives. I think our students learned a lot about how they react to new situations, how they can better work with people who may not be like them, and how to “embrace the suck” when things don’t remotely go as planned.

As many times as I’ve done this, I even learned a thing or two. One such lesson was that I shouldn’t have bothered to bring my laptop, because despite the work that needed to be done, I wasn’t going to have time to even power it up. The small amount of free time that I did have was taken up by a delightful power nap under a gazebo while the students were with another instructor.

Another lesson was that even though I was executing a plan I had done dozens of times in the past, I probably needed to check my preparations more thoroughly than I did. One could argue that the corollary to that one is “never take anything out of your go-bag,” and I think I learned that one as well. Last, I was reminded of the fact that even in challenging situations, sometimes you just have to make an attempt to do your best and be OK with that.

I have the dates for the next two outdoor school sessions on my calendar, so barring any urgent work travel or family emergencies, I should be able to stay in the groove. My backpack is restocked and my headlamp has fresh batteries. I’m ready for whatever gets thrown at me next. In the mean time, I’ve learned how to make campfire cannoli with crescent rolls, a stick, and pudding – and let me tell you, when it’s 90% humidity and you’re tired and your feet hurt, one of those is a great pick-me-up.

What’s your favorite dessert for camping? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/2/24

The hot topic in the virtual physician lounge this week was that another company has decided that delivering healthcare is more difficult than it thought.

Across the board, members of a primary care discussion group felt vindicated that Walmart plans to close all 51 of its Walmart Health centers as well as its Walmart Health Virtual Care telehealth offering, citing rising costs and “the challenging reimbursement environment.” These are the same struggles that physicians are facing, usually without any kind of corporate subsidy.

The health centers locations by state are Florida (23), Georgia (17), Texas (7), Arkansas (3), and Illinois (1). Non-provider associates are eligible to transfer to other Walmart or Sam’s Club locations, otherwise they’ll be paid for 90 days and then receive severance benefits. Providers will be paid “through their respective employers” for 90 days and then will receive transition payments. Walmart Health is an Epic client, making me curious as to what breaking that contract looks like.

I’m a fanatic about scheduling my next dental appointment before I leave my current appointment, so I was surprised recently when I started receiving reminder text messages that my appointment was due and I needed to schedule. I called the office and they confirmed that my appointment had disappeared from the system, but offered me the “recently opened spot” that was actually my original appointment. It turns out that they migrated their electronic dental record to a different system and apparently some appointments became casualties. I’ve done enough practice management system conversions in my career to know that sometimes things happen, but it sounds like they may not have had as rigorous of a QA plan as they needed since they said other appointments had disappeared as well.

On the Saturday morning prior to my appointment, I received a text message to fill out some forms. I was busy doing other things and didn’t do it, only remembering as I was in the car on the way to the appointment. I had some extra time in the parking lot and tried to fill them, out but discovered that the web app wasn’t really configured for a mobile device and the fonts were too small to read. I couldn’t figure out how to make the fonts any bigger, so gave up and went into the office. They tried to send me the text again to have me complete the forms on my phone. I explained the problem with the font size and they had no suggestions other than to hand me an old fashioned clipboard. They mentioned that “none of the information from the old system came into the new one,” which made my informaticist heart shudder.

The paper forms were a sorry lot, with the first page having been printed without all the desired data elements on it, so someone had gone through and written “Emergency Contact Name and Number” blanks by hand. I zoomed through to the medical history form, and only after answering the first question did I realize that the format made no sense at all. I made my best interpretation at what they were wanting and handed back my clipboard as quickly as possible.

It’s embarrassing that professionals think these kinds of forms are OK. I secretly wanted to offer some clinical consulting services. I mentioned my confusion about the form to the dentist, who reassured me that my records had indeed been migrated into the new system, showing my chart on the in-room display. He said that he would follow up with the front desk to find out why they’re making people fill out a full history, so at least that’s something. I’m not sure who the vendor was on the electronic dental record, but if you work for one and are reading this, please check your mobile app to make sure it’s accessible to those of us who are experiencing the visual changes that come with age.

An ”Inside Story” feature in JAMA Internal Medicine tells the story of what resident physicians feel like when the EHR goes down unexpectedly. The resident describes an “unexpected fatal error to the system that the IT department was working to resolve.” There is no mention of a downtime solution, with the author stating that “samples for the morning laboratory tests could not be collected because the phlebotomy team did not know which patient needed which tests.”

The resident arrived at the “simple answer” of asking patients about their conditions and talking to the nurses who had most recently cared for them. They changed to a “minimum laboratory testing approach” after realizing that it was likely that patients had been undergoing tests that weren’t necessary, but rather were ordered simply as a result of order set use.

The author notes that “the EMR downtime made me realize that while the system seems to make our clinical routine convenient, it may not result in increased efficiency or better patient care.” Patients continue to receive daily labs that are part of an admission order set and those caring for them aren’t asking each day whether those orders are necessary or appropriate. They mention that “I look unprepared to my team when I do not know my patients’ latest basic metabolic panel and complete blood count values during rounds, but no one would ask me how much time I spent talking to my patients.” The author also enjoyed actually talking to members of the care team rather than communicating through the EHR, closing by saying that “our patient care on that day was the most patient-centered and most collaborative than ever in my 2 ½ years of residency.” Only one comment has been left on the piece so far, but I’ve got my popcorn and am sticking around.

It’s time to update those health maintenance settings in the EHR, now that the US Preventive Services Task Force (USPSTF) has issued an updated Recommendation Statement on breast cancer screening. Women aged 40 to 74 are recommended to have screening mammography every two years. The previous recommendation that was last updated in 2016 called for women to begin screening mammograms at age 50 and that women aged 40 to 49 should engage in individualized decision-making to determine a screening plan.

In a situation where we don’t have enough physicians who have the time to truly do health-related counseling during their visits, individualized decision-making can be problematic. Patients are reluctant to schedule a dedicated appointment to discuss screening, so it becomes one more thing that has to be crammed into a well woman or other preventive visit. I wonder how quickly people will be updating the recommendations in their EHRs and how organizations plan to educate physicians and care teams.

What is your organization’s plan to roll out the new USPSTF recommendation? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/29/24

Following my recent piece on bro culture, a number of people reached out to me to share their opinions about culture changes in healthcare and healthcare IT over the years. One of them, who I’ll call Nurse Elaine, had some commentary that was absolutely spot on. We ended up having a lengthy back-and-forth correspondence, which is always fun when you’re an anonymous blogger and still can’t believe at times that people are willing to pour their hearts out to you.

“For most millennials (or later) growing up, healthcare wasn’t typically viewed as a field ripe for entrepreneurial breakthroughs, where one could establish a privately owned billion-dollar unicorn enterprise. Becoming a clinician was a stable career path, often seen as a gateway to a comfortable life with dinner-table respect. Professionals in the 1990s, especially those deeply entrenched in healthcare, didn’t speak of any foreseen disruption looming over the healthcare landscape. The sixth graders of 1994 (today’s professionals) marveled at their first encounters with computers, explored the groundbreaking wonders of Microsoft Paint, and navigated the Oregon Trail. Innovation seemed far removed from the realm of healthcare. However, technological promises have increasingly become intertwined with care delivery with each passing era. For better or worse, it’s interesting when you consider how we got here, to a healthcare landscape filled with unicorn promises, some fulfilled but most not.”

Elaine had some amazing commentary about how enthusiasm for healthcare grew out of the dot-com bubble and talked about companies such as Theranos, Outcome Health, Amwell, and Teladoc that “emerged as darlings of the venture capital world, armed with ambitious plans to clear their consciences and revolutionize healthcare delivery with visions aimed to simplify care processes, address complexities, alleviate fears, and enhance accessibility.” Her next comment had me doing a combination cry/laugh: “Sound familiar? Twenty years in, and we’re still marketing to the same problems.” She went on to describe some of the players as “a wave of powerful novices … who eagerly entered this domain despite their lack of profound understanding of clinical care delivery, wearing glasses tinted with the allure of returns.”

She noted that while sexy startups were expanding their funding sources and building infrastructure, the founder generation of EHR companies was “patiently laying the groundwork for documentation process disruption,” which as a nurse, she sees as some of the only true disruption the industry has seen. Companies like Epic and Cerner were ready to reap the rewards of economic stimuli such as the American Recovery and Reinvestment Act and HITECH, which led to Meaningful Use and a record $35 billion flowing to incentivize EHR adoption. (Spoiler alert: it worked.) We had some great conversation around the rise of the chief information officer role within care delivery organizations and the fact that the role continues to be held largely by men over the age of 50. Sure, we’ve seen some amazing newcomers and some bold women, but for most health systems the balance of power hasn’t shifted tremendously.

I always love conversing with readers who have spent time in the trenches, especially those who have served in an informatics capacity, and Elaine definitely had the “been there, done that” vibe, recapping some of the negatives that had come out of the HITECH Act and Meaningful Use that we’re still facing today: “poorly designed user interfaces, coding issues, burdensome documentation, disconnected quality reporting, inaccessible vendor roadmaps, data sharing without meaningful context” and more. Although vendor quality issues have improved at some companies, others in the same sector remain plagued by it, and other than a handful of companies who have gotten it right, vendor roadmaps are often no better than a pirate-inspired treasure map that may or may not lead to what you seek.

From there we fast-forwarded to 2014 with the rise of Theranos and all that brought to the industry. Elaine reminded me that Elizabeth Holmes was the world’s youngest self-made billionaire, but we know now that it was all sizzle and no steak. That segued into a conversation about the 2016 US presidential election and the impact it had on healthcare, as well as women in leadership. She made some great points about the role of women in decision-making roles at venture capital firms (17%) and the fact that so-called femtech funds established by women “tend to be small due to the perceptions of women as investors – smaller ventures can only offer smaller check sizes that typically do not secure a board seat or significant decision-making power within portfolio companies, which lessens the impact on care delivery and investment strategy.”

She brought up some great points about there being “abundant evidence indicating that women primarily make healthcare decisions within their households and that nurses, predominantly female, form the backbone of clinical care delivery, but corporate boards are often dominated by men.” She went on to say that “this gender disparity fosters decision-making based on a camaraderie mentality rather than merit” as well as failing to consider what’s best for care delivery. I pointed out that some of the decisions I’ve seen also leave out the people for whom this entire industry is designed to exist – the patients, and that unfortunately some people in the industry still act like patients are somehow pesky or some kind of a nuisance. She closed on that train of thought by noting that “while healthcare may not be intentionally anti-woman, it is unmistakably pro-bro.”

By this time, I had learned that Elaine has been in the startup space for much longer than I have, and I wish I had someone like her to bounce ideas off of when I first began working with startups. She captured the most recent decade of investment in healthcare technology as “a frenzied gold rush” with a focus on disruption for its own sake rather than as a method to improve care delivery. She pointed out that investor funding has surged since 2016, growing from $4 billion that year to more than $29 billion in 2021. She had me spitting Diet Coke on my keyboard when I read her comments about “flashy conferences headlined not by expert clinicians but by D-list celebrities” and the “sea of investors swarming in puffer vests,” and looking back at some pictures and conference write-ups from the time period, she’s not incorrect in her assessment.

We talked about Theranos, and she gave me a summary of the billion-dollar fraud at Outcome Health, which somehow I had put out of my memory (the Department of Justice write-up on the incident reads like a bad soap opera plot if you’re interested). The short version involves things many in the industry have seen, misleading investors by inflating performance metrics and exaggerating market penetration. Oh yeah, there was also the part about overbilling customers.

By this point, Elaine and I had been emailing back and forth a couple of times a day, and we had finally reached 2020 and the arrival of the COVID-19 pandemic. This is where I really enjoyed hearing her impressions as a nurse, because it’s always good to commiserate with someone who knows what it feels like when your job decides that you’re expendable and not worth the $5 a day in personal protective equipment that might literally save your life. She talked about some companies that she was exposed to in her work that “emphasized flashy growth rather than gaining a profound understanding of clinical care delivery” and what it felt like to see outsiders showing up at her institution via Zoom call to offer solutions where “the well-established best practices and protocols in healthcare, developed over hears of research and learned from the challenging experiences of malpractice suits and undesirable patient outcomes clashed with the breakneck speed of ventures trying to meet their inflated valuations.”

Clinical leaders had to figure out how to cope with what she describes as “aggressive marketing tactics” and “massive ROI promises” and solutions that had the risk of worsening the pressure on clinicians. Some of these vendors in turn delivered lackluster solutions and shared some information about vendor employees she had gotten to know through her role that reported toxic work environments where teams were tasked with keeping customers quiet about defects so that the company could achieve a unicorn valuation – resembling “the cutthroat world of investment banking more than a mission-driven service sector focused on building sustainable, effective businesses.” She went on to say that “somewhere in this whirlwind, the essence of care delivery to patients and the dedication of clinicians who invested their education, finances, and daily lives into their work became lost amid the pursuit of profit.”

From there, we segued into the bursting bubble that was health tech in 2022 and 2023, with the inability of companies to raise funds among “rising inflation rates, unfulfilled growth, and frivolous spending” and the collapse of Silicon Valley Bank following a classing bank run by frightened companies. Of course, US taxpayers funded yet another bailout. She had me laughing with her advice to the industry: “Going forward, lessons must be well understood to collect $200 and move past go.” She pointed out the need for solution consolidation, the abundance of competitors, and market saturation in certain healthcare technology areas. She had some great stories about vendors who failed to understand the difficulty of selling into large health systems, including lengthy sales cycles and the need to be able to trust your vendors when you’re focused on clinical care and human health. Many healthcare leaders find the traditional tech mantra of “move fast and break things” to be not only ineffective, but at times frightening, and plenty of vendors fail to understand that.

We both shared excitement for the increase in the number of clinician innovators moving into the space. Some of these are coming from innovation groups at established care delivery organizations. In contrast to the disruptor generation, these individuals have personal knowledge of healthcare delivery and operations and understand the highly regulated industry that they’re working in. However, they’re going to have to work hard to compete with the flash and sizzle that’s out there. In my career, some of my biggest wins have been with solutions that aren’t sexy, but they get the job done and don’t increase burden to patients or their care teams. Elaine hopes that venture capital firms, which will continue to be an essential part of the industry, start taking a more sophisticated approach to innovation with attention to experts in the field and clinicians who understand the industry and its end users, including patients.

Ultimately all of us need healthcare and its associated technology to not only work, but to work well. Most of us will end up in a hospital at least once in our lifetime, whether it’s in childbirth, following an accident, for surgery, or for management of a serious illness. When we get there, we’re not going to care about the sizzle. We’re going to want the care delivery equivalent of a four-course meal and we’re going to want it done safely, respectfully, and ethically.

What do you think about the state of healthcare information technology, how we got here, and where we need to go? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/25/24

The CMS Innovation Center has announced its proposed Transforming Episode Accountability Model (TEAM), which will incentivize coordination during surgical procedures and for the 30 days following the procedure. The model is expected to improve care quality including reducing readmission rates and decreasing recovery time. It is also projected to reduce Medicare expenditures and create more equitable outcomes. The model will initially focus on lower extremity joint replacement, hip and femur fractures, spinal fusions, cardiac bypass procedures, and major bowel surgeries. Participating hospitals will receive a global payment to cover all expenditures during the procedure and follow up period in exchange for requirements that they coordinate with primary care teams to promote long-term health outcomes. The model also includes coordination around therapy and rehabilitative services, home health, medications, and hospice services related to included procedures. The model is included in the FY 2025 Inpatient and Long-Term Care Hospital Prospective Payment Systems Rule for those of you who need some light bedtime reading.

Low tech but cool: Michigan Medicine is incorporating Barbie into virtual visits for pediatric rehabilitation to help patients understand how they should be moving. Physicians can use the doll to illustrate how their joints should move as they complete various portions of a virtual examination. A recent study showed that Barbie-enabled mock visits required less verbal prompting and led to an improved understanding of the physicians’ directions without any increase in the time needed for appointments.

Violence against healthcare workers continues to be on the rise, often in ways you might not expect. The Vermont State Police arrested a 27-year old man after he destroyed property with a chainsaw and assaulted staff at Northeastern Vermont Regional Hospital. At the time of his arrest, troopers noted he was “in the parking lot actively assaulting staff.” Vermont classifies “Assault on a Law Enforcement Officer/Health Care Worker” into a single violation. I’m glad to see crimes against health professionals receiving the same visibility as those against members of law enforcement.

Sometimes the combination of items in my inbox tells a greater story than any of them on their own. Two subject lines fell into that category this week: “AI’s Influence on Provider Verification, Credentialing and Enrollment” followed by “The credentialing game is a joke! It is easier to buy a gun than to get a job.” I have empathy for the physician making the latter statement in a comment on an article about credentialing. I’m now at the six-month mark waiting to be credentialed to work for a care delivery organization, and at least in my current state of residence, I could walk into any sporting goods store and walk out with a firearm. I have a clean clinical record without malpractice claims, reports to the state medical board, or shady resignations. Anyone who works with physicians and wants to understand another way in which we might be frustrated should check out the article and its comments. If AI can help solve the problem, I’m all for it. Unfortunately, the email about that led to registration for a webinar that will happen while I’m on a plane, so I’ll have to wait to see how that solution might pan out.

Another interesting inbox item discussed research looking at how to use a smartphone compass to measure things like blood glucose. It leverages the magnetometer properties of the compass in conjunction with magnetic-hydrogel composites that are responsive to different analytes. The authors used glucose-specific hydrogels as part of a proof-of-concept experiment that measured glucose in one of my favorite substances – wine. They compared levels in sangria, pinot grigio, and champagne. For those not inclined to drink wine, they also measured pH levels of coffee, orange juice, and root beer. It’s an interesting way to avoid the additional processes needed when using human subjects. The authors agree that additional work using biological fluids is needed. Having spent some time recently in California wine country, I can suggest a few additional non-biological substances to sample.

A friend of mine whose company is developing a technology solution reached out to me today to make sure his demo script was believable before putting it in front of prospective clients. I gave him a bit of a talking-to about his company’s approach to development, because if you’re doing the process well, you should have examples of customer use cases that were gathered prior to the creation of the solution in the first place. Those can easily be employed for testing purposes as well as the creation of demo scripts. Unfortunately, that wasn’t the situation here, where they built the solution based on an idea and never really obtained the voice of the customer. Sometimes we refer to that as crafting a solution that’s in search of a problem. I’m guessing that having tens of millions of dollars of someone else’s money to spend might have something to do with their approach.

It certainly doesn’t qualify as healthcare technology news, but the ongoing saga of the Voyager 1 spacecraft has captivated me for the last several months. In short, the 46-year old spacecraft, which is 15 billion miles away from Earth, had been steadily sending back data until late last year, when it started sending back nonsense. For those of us who look at things through a clinical diagnostician’s lens, it sounded like the system had the technology equivalent of a stroke. Scientists have been painstakingly working with the craft, sending various messages and commands that take 22 hours to reach it and the same time to return. Fast forward to last week, when NASA announced that it had identified the problem and was working to solve it. Apparently a single chip in the spacecraft’s Flight Data Subsystem had failed, and there wasn’t enough space anywhere else to move the code that resided there. They split the code into four pieces and moved it elsewhere and are in the process of making other code adjustments to help the system route data appropriately to ultimately restore normal communications.

It’s remarkable that the craft is even functioning at all, given its exposure to the hazards of space. The Voyager support teams have performed the ultimate remote surgery to try to get as much life out of it as possible. I probably have more computing power in my wristwatch than Voyager has on board, which is simply amazing to think about. Other notable happenings in 1977 include the release of the original “Star Wars” movie, initial operation of the Trans-Alaska pipeline, and the introduction of Radio Shack’s TRS-80 computer.

What other technology from the 1970s has stood the test of time? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/22/24

I recently spent some time in Silicon Valley, meeting with both existing and potential new clients. I have to say, this is the greenest landscape I’ve seen in this part of the world in a long time. The area has had a lot of rain in recent months and the vistas look very different when they’re not painted in shades of brown. I’ve worked with a number of startups over the years, some of which are headquartered here and others in other tech-heavy parts of the country including Austin, Atlanta, and Las Vegas. It’s been interesting to see how the places have changed and the nature of the business has evolved in recent years. Some of the players, however, don’t seem to have evolved much.

When I first became involved with healthcare technology, it was definitely male dominated. My health system had one or two women analysts, but none in IT management or executive positions. Our ambulatory EHR project was led and managed entirely by women who had a reputation for taking charge – especially since we were the organization’s first technology project that was run by the customer rather than by IT. We opted to lease IT resources from the organization rather than having them run things, since we had several years’ experience with ambulatory EHRs and practice management systems and they had none. Even though we had a bit of friction due to that project structure, everyone was professional, and we were able to get an amazing amount of work done.

Our vendor had a bit more of a boys’ club vibe, with nearly all executive functions held by men. There were a few women in management positions, mostly in more supportive departments like training and accounting. This was my first exposure to what we now call “bro culture,” but at the time, the bros were more outliers and it seemed like executive leadership humored them because they drove results, but only to a point. The guy who took clients to a strip club disappeared from the company shortly after the incident, and people who made inappropriate comments were quickly sidelined. Fast forward half a decade and I was introduced to my first real “bros” – who espoused not only the culture but who somehow brought leadership under their spell and convinced them to spend millions of dollars on projects with questionable merit and even more questionable management. It was the first time I saw people throwing money around with abandon and marginalizing the people who were actually experts in the field and who were doing the work but who didn’t buy in to the culture.

Over the years, we’ve seen the rise of tech bros and pharma bros, and lots of bros behaving badly. Especially after my recent travels, it’s clear that bro culture is still going strong. There are numerous articles out there about the phenomenon, including in the human resources literature. There are some common features seen as people define the issue – including a culture that places winning (and hustling) above all and that excuses the bad behavior that often happens along the way. Bro culture often includes excessive partying, bullying, and harassment of colleagues who don’t play along. If you’ve been in an environment where coworkers make comments because you’re not drinking alcohol or not drinking as much as everyone else, you might be in a bro culture. If you’re hearing snide comments about parental leave, blocked time for breastfeeding, or colleagues being “no fun,” you might be in a bro culture.

I find the phenomenon interesting, because some of the most hustling, winning people I’ve ever worked with are distinctly not bros. At one company, the teetotaling sales reps who were eager to get home to their families did some of the best work, closing deals all over the place. They won by understanding the voice of the customer, prioritizing customer and prospect needs, and valuing the people who worked with them. When working in those environments, I never experienced the level of malicious gossip, toxic commentary, or foul language that I’ve seen in recent times. Don’t get me wrong, I’m not afraid to drop the F-bomb when it’s warranted, but it’s all about knowing your audience and the situation. But if you’re in a situation where inappropriate comments are the norm and not the exception, you might be in a bro culture.

In some organizations I’ve worked with, investors play a role in supporting the bro culture. The New York Times ran an article about this back in 2017, and there are many things about this that haven’t changed. The piece noted that change will only come “… if the people in charge of Silicon Valley – venture capitalists, who control the money – start to realize that the real problem with tech bros is not just that they’re boorish jerks. It’s that they’re boorish jerks who don’t know how to run companies.” I felt validated when I read other comments in the Times piece. As a physician, I’m often one of the only “licensed” people working with a company – the other area being legal. Physicians working in clinical informatics are highly attuned to regulatory and legal requirements and use that knowledge to keep stakeholders out of trouble. If you’re working with people that push you to ignore regulations, you might be in a bro culture. Recent settlements between the Department of Justice and various tech vendors tell that story.

The Times piece uses Uber circa 2017 to make many of its points, with some of those being that “toxic workplace culture and rotten financial performance often go hand-in-hand” and that “bros do best when they hire seasoned executives to help them out.” The author referred to “adult supervision” and “institutional restraints” as essential to avoid a situation where bro “vices end up infecting the culture of the workplaces they control.” One thing not mentioned in any of the articles I found but that I’ve heard about from a couple of people is what we might call the “girl bro.” She definitely has bro tendencies but also functions as an enabler for bad culture and sometimes as a “fixer” trying to clean up messes as they occur. Most of the girl bros I’ve heard of have been in sales roles, but I’ve also heard of them filling an HR function, and if you identify one of the latter rare creatures in the wild, you’re definitely in a bro culture.

I agree with the Times piece that sometimes it takes the business cratering before you start to see a change. That’s unfortunate for the people who work at those companies and who are just trying to get by. Especially in healthcare technology, it’s important to remember that not only are workers there because they’re trying to support their families, but also because they’re often “true believers” who want to do the right thing for patients and their loved ones. I think for those types of individuals it’s especially difficult to be in a bro culture and they often vote with their feet.

What do you think about bro culture in healthcare, and in healthcare technology in particular? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/18/24

It’s long been known that women make many healthcare decisions for their families, if not the majority of healthcare decisions. A study published last month in JAMA Network Open shows that patients who are female or who have chronic illnesses are more likely to use telehealth. The data in question is from 2002 and was part of a cross-sectional study of 5,400 adults where 43% had telehealth visits during that year. Video visits were less common among patients aged 65 to 74 and those without Internet. The authors found no differences when patients were segmented by education, race/ethnicity, or income. Other interesting tidbits included the fact that nearly 20% of patients reported technical difficulties and that 30% of telehealth visits were conducted using only audio connections.

From Doomsday Prepper: “It’s not just the bulging cans anymore. Did you see this writeup about the CDC investigating counterfeit Botox that’s giving people botulism?” I have to admit I don’t spend as much time in the epidemiology literature as I once did, but it looks like patients in the pursuit of youthful appearances may be turning to low-cost or unlicensed providers who are placing them at risk of serious illness. The Centers for Disease Control announced that it is looking into incidents in nine states where 19 people have reported serious illnesses following botulinum toxin injections. Affected patients may have visual changes, trouble swallowing, or even breathing problems. Symptoms were severe enough in 60% of the patients to warrant hospitalization. Patients can protect themselves by asking if providers are licensed and trained to administer the injections, and whether they’re using FDA-approved products obtained from a reliable source.

I’ve spent more than a decade working with organizations that span multiple time zones, so I’ve had to be continuously conscious about how I schedule meetings. Ideally, employees will specify their working hours in the organization’s calendar application, but I’ve seen several articles recently about whether “8 am meetings” should be done away with. The phrase implies that the time would be 8am for the majority of employees, but in a distributed organization 8 am on the east coast could be 5 am on the west coast, or even earlier for employees in Hawaii. Early morning meetings can make for difficult childcare arrangements – as someone who used to have to round at 6:30 am, I feel that pain acutely. Although healthcare organizations run 24×7, I’ve seen more of them opting to avoid early morning or late afternoon meetings in order to create more flexibility for employees.

Although I’m supportive of making team operating agreements around meeting hours (and even banning meetings at certain times, like Friday afternoons, when everyone’s out of brain cells) I think it’s even more important to make sure meetings are necessary, well-planned, and well-executed. One of my favorite organizations to work with has questions people have to walk through before scheduling meetings. For example, if there are multiple people from the same team invited, do they all have to be there, or can one person represent the team? Is there an agenda that includes expected discussion points and anticipated outcomes? Who will document minutes and action items so that those who are not in attendance know what happened? It seems simple, but the majority of organizations I work with have little to no framework for productive meetings. That same organization has also implemented a policy where meetings are scheduled in 20- or 50-minute increments, allowing people to check email, take care of personal needs, or just decompress when they’re subjected to back-to-back meetings. With those breaks in place, there’s an expectation that meetings start and end on time, which I’m sure everyone appreciates.

In the spirit of “what goes around comes around,” telehealth company Cerebral gets hit by the Federal Trade Commission with a multimillion dollar fine for deceptive practices around data sharing, security, and cancellation policies. In addition to the fine, Cerebral will be prohibited from using health information for advertising purposes. Cerebral is widely regarded by physicians as having contributed to overprescribing of ADD and ADHD medications and a subsequent shortage of those medications for patient use. Although they’re not getting the smackdown for that, they are being penalized for providing sensitive information to third parties including patient demographics, medical and prescription histories, IP addresses, and more.

They were also cited for mailing postcards to patients that included language revealing diagnosis and treatment information for anyone to see, allowing former employees to continue to access health records, allowing non-providers to inappropriately access patient records, and having a faulty single sign-on process that allowed patients to see the sensitive health information of other patients during simultaneous logins to the company’s patient portal. The company will pay $5 million for consumer refunds, a $10 million civil penalty, and a $2 million penalty due to inability to pay the full amount. The company will also have to place notices on its website about the allegations and its ongoing mitigation plans. It feels a little like putting Al Capone in jail for tax evasion rather than other crimes, but given the damage this company has caused to patients and their families, we’ll take it.

The American Medical Informatics Association is conducting a survey on documentation burden among health professionals. The AMIA website lists the primary goal of the survey as being “to capture perceptions of excessive documentation burden across various healthcare disciplines frequently (e.g., every six months) to trend changes over time.” The survey is open through April 26 and will reopen in August. Licensed and unlicensed health professionals who provide patient care and document in an EHR are invited to participate. The survey took less than two minutes to complete.

I didn’t know much about public health informatics until I began to prepare for the initial Clinical Informatics certification exam more than a decade ago. As I read a couple of textbooks that covered the field, I found myself fascinated by the ability to use data to drive health outcomes. Fast forward a few years and we found ourselves living in a public health research project, and informatics efforts in the field accelerated dramatically. The CDC recently updated its Public Health Data Strategy to include addressing gaps in public health data and to reduce the complexity of public health data exchange. Although we’re seeing improved funding for public health informatics efforts at the federal level, it’s still a patchwork when you look across the states. Some of the state-level efforts in public health are pathetic, which is a sad commentary on how those states value the individuals living and working within their boundaries.

What is your community doing to support public health? Leave a comment or email me.

Email Dr. Jayne.