EPtalk by Dr. Jayne 4/11/24

I recently saw an article talking about the creation of chief AI officer roles at several organizations. Artificial Intelligence is here to stay and we need to be proactive about its consequences. Politico ran a great article recently that looked at the intersection of AI and medical malpractice. It cites comments from AMA President Jesse Ehrenfeld, who says that lawsuits are already being filed about the use of AI in healthcare. In speaking with some of my friends who are attorneys, they noted that there will be some interesting case law created over the coming years. Tech vendors will be pointing fingers at the clinical end users who leverage AI in patient care, and those practitioners will be pointing their fingers right back at the AI technology’s creators. Physicians are already left holding the bag for a variety of things, including patients who refuse recommended care and patients who get caught in the crossfire when insurers won’t cover recommended care. What’s one more point of liability?

From Madge in HR: “Thanks for mentioning employee handbooks last week. I think the majority of people just sign them blindly and don’t read them. It’s always interesting to me when a company deploys a new policy to the wild, but especially so when you know that the policy is the result of a recent event. My company just announced our new ‘Professional Behavior Policy.’ While it’s shocking to me that we need such a policy in place, it’s reassuring to know that the company values professionalism and is willing to require it of every employee. The prohibited behaviors that stuck out to me included: slamming doors; refusal to communicate or communicating dishonestly about business matters; obstructing, undermining, or preventing another employee’s work performance; and possession of objects that are sexual in nature. Long story short: Be nice to each other. Don’t throw a tantrum. Don’t lie. Don’t keep others down. And for the love of all that’s good and right, keep your bedroom toys out of view when you’re on a Teams meeting.” Although I agree with the intent behind these, I don’t envy those that have to handle complaints on some of the more subjective issues. Most of us have at least some experience at companies where people stretch the truth to varying degrees and where politics and blocking are a daily event. It’s sad given the fact that we’re all in an industry where the ultimate use case is about helping people.

The US Food and Drug Administration has cleared its first AI tool for sepsis detection. Developed by Prenosis, the Sepsis ImmunoScore tool was approved through the FDA’s De Novo pathway. Sepsis is a serious health condition, leading to more than 350,000 deaths annually. The tool looks at more than 20 clinical parameters including vital signs and laboratory results to help identify sepsis risk. Although other organizations, including Johns Hopkins University and Epic have built sepsis detection systems, this is the first one to receive FDA approval. The Prenosis tool sorts patients into four different risk categories but is not considered an alert system. Testing was performed on a dataset that included more than 25,000 patients.

Having spent a good chunk of my career working in emergency department and urgent care settings, a recent article about “rat snacking” really resonated with me. Although the headline was mostly about physicians, the piece applies to anyone whose work schedules disrupt traditional mealtimes. The authors define “rat snacking” as when “people consume whatever type of food they can scavenge.” Anyone who has ever subsisted on graham crackers and apple juice swiped from a hospital unit’s floor stock feels this in their bones. A local hospital recently curtailed the availability of what one nurse describes as “real food” on the night shift, citing cost control measures. Maybe they should be more aware of the literature that shows that disordered eating can lead to nutritional deficits and excess consumption. Of course, the answer is planning ahead and packing your own food, but that only goes so far when your eight-hour shift suddenly becomes 12 or 14.

The Change Healthcare ransomware debacle continues to be a thorn in the side of many physicians, as they await claims and payments to catch up. Several of my local colleagues have had to take out lines of credit or personal loans to cover office payroll and they’re eager to eventually reach resolution with their revenue cycles. Change Healthcare’s parent company, Optum, isn’t winning any friends with recent headlines about practice acquisitions that leave patients without physicians as theirs jump ship. This particular story includes a vignette of a patient who has been part of the practice for more than two decades but cannot be accommodated after the departure of his physician. The patient panels carried by primary care providers these days are more than twice the size of those that existed when I was in a traditional family medicine practice, and those bloated panels make it difficult to recruit replacement physicians.

The happenings going on at this particular organization, Oregon Medical Group, have led to the introduction of legislation designed to slow the influx of corporations into healthcare in the state. The reality of the entry of these parties into the healthcare ecosystem is that their goals are not the same as the owners they replace – often physicians. Where physician-owned organizations will generally continue to participate with low-paying payers, such as Medicaid, many corporate entities move quickly to try to push those patients out of the practice. Non-physician owners that have shareholders are motivated primarily to deliver profit to those shareholders, which can increase provider burnout and place patients at risk.

Given the challenges facing primary care physicians, I was surprised to see the number of medical students who requested to participate in my local medical society’s “Coffee with a Doc” program. I took a first-year medical student to lunch and was surprised to learn that her school is incorporating classes on “the business of medicine” as early as year one. She had some good questions about RVUs and physician payment, and I introduced her to the concept of Direct Primary Care, which apparently wasn’t included in her curriculum. I’m seeing increasing numbers of my family medicine colleagues moving in this direction, so I’m glad the topic came up. Kudos to her school for adding information to the curriculum that can help students learn more specifics about what they’re getting themselves into.

From Stage Mom: “Given your previous comments about health systems sponsoring stadiums and other facilities, I thought you would appreciate this article about a $5.4 million theater naming deal.” BayCare Health System, based in Clearwater, FL, will pay the amount over a 10-year period in exchange for naming rights at the BayCare Sound amphitheater. The agreement has an option for a 10-year renewal in 2034. BayCare also has a ballpark under its belt. According to ChatGPT, that amount of money would pay for more than a quarter million influenza vaccines, or more than a hundred thousand cervical cancer screening tests, or more than 36,000 mammograms. I wonder which the community would rather have?

Will health systems keep slapping their name on everything, or will they start to put their non-profit profits to better use? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/8/24

I found myself working this weekend in the path of totality for the solar eclipse. I’m glad I booked my travel almost a year in advance because standard rental cars aren’t available from the usual national brands. Rates for the remaining luxury vehicles are upwards of $400 per day, so I was glad to have locked in at $47 when I did.

My conference-rate hotel was also locked in at $104 per night and my hotel is sold out. I’m fairly certain they are not used to having so many guests, because they don’t have enough towels to restock the guest rooms in real time. They’re picking up towels in the morning, laundering them, and replacing them around dinner time. Management has been extremely apologetic, and I feel for them having to staff around a conference that always happens during this particular timeframe and then having an eclipse thrown on top of it.

It’s been interesting to hear people in the hotel restaurant talk about it. This morning, I sat next to someone who traveled 1,700 miles to experience a total solar eclipse. Based on the weather forecasts, there’s a good chance it will be cloudy on Monday, but even if you can’t see the sun, the eclipse will still happen. I was in the path of totality in 2017 as well, and it was pretty wild to feel the temperature drop and hear the bird song disappear, only to be replaced by the sound of crickets.

The pinhole viewer that I built worked well despite the fact that I made it from a cereal box and aluminum foil. Since I’m traveling this year I plan to just stick with a pair of certified eclipse viewing glasses. A recall has been issued for certain glasses that were sold at convenience stores in the area, which is sad as well as potentially devastating that someone would create counterfeit glasses that could lead to serious eye damage.

In anticipation of everyone wanting to go outside for the minutes of full totality, I made sure we have a gap in the agenda to accommodate it. I did something similar in 2018 when the first SpaceX Falcon Heavy rocket was launched, taking advantage of a high-end conference room projection system to see it live. For the people who were paying my salary back then, don’t worry, I worked it into the change management seminar I was presenting. I guarantee that people walked away with lessons in teamwork and diversity as well as having experienced history being made.

With respect to this year’s eclipse, several governors have made emergency or disaster declarations in advance of the arrival of throngs of people to their states. When people question why they might do that, I explain that it’s all about scarce resources and disruption of processes. I’m in an area that’s not exactly a tourist mecca and I guarantee that people will be pulling over on the interstate tomorrow, creating increased risk for first responders and ambulance traffic around the regional medical center. I’m sure there will be fender-benders as well if people are driving distracted.

It’s going to be in the 80s here tomorrow, which is unseasonably warm for this area, and that will increase the risk of heat-related illness. I met a traveler whose medications were in a piece of checked luggage that went missing, so they are going to need to get a replacement prescription and possibly need to visit an urgent care if their physician doesn’t manage the request on a weekend. I also chatted with some adults who were chaperoning a school trip to see the eclipse. They mentioned that so many teachers requested time off to experience it with their families that they didn’t have enough substitutes to fill the gaps, so the school decided to cancel for the day. They were planning on spending Sunday visiting some sites that were important to the Civil Rights Movement in the 1950s, so learning will going on that goes beyond just science.

A lively discussion is underway in one of the American Medical Informatics Association forums about the use of Microsoft Teams as a clinical communication platform. Many people have chimed in about their experiences with various types of messaging, including EHR-based secure chat, third party solutions, and use of old-school telephones and pagers. An article from the Journal of Medical Internet Research that was mentioned looked at use of an integrated EHR-based secure chat in a large Midwestern health system. Data was collected from July 2022 to January 2023 and analyzed with regard to message volumes, response times, message characteristics, user roles, work settings, and messages sent and received by users.

Researchers identified 9.6 million messages that were sent by 33,000 users. Nurses sent 40% of them, followed by physicians at 25% and medical assistants at 12%. Many users interacted with 20 more more messages per day, leading the authors to raise concerns that short message response times (average 2.4 minutes) and high volumes “highlight the interruptive nature of secure messaging, raising questions about its potentially harmful effects on clinician workflow, cognition, and errors.”

We hear a lot about workflow and the burdens that are associated with increasing message volumes, but I don’t see a lot of people talking about the impact on thought process and errors. Research has shown that true multitasking is a myth, and we’ve all seen the negative impacts of trying to do too many things at one time without enough focus.

The always-on nature of communication these days tends to make many clinicians I know feel edgy, like they can never turn off their workday. In my online forums, I routinely see questions from clinicians on how to disable messaging during non-work hours. One physician resorted to getting a separate work phone and having her spouse lock it in a drawer during her off times because she couldn’t help but check it all the time, fearful of missing something. Hopefully, that’s an outlier scenario, but it illustrates how caregivers are being impacted by technology.

The study also found that across 14 hospitals and 250 outpatient clinics, weekly message volume grew by 31% in a six-month period. It had some limitations, one of which was that they were unable to link the data with work schedules or to identify when messaging was being conducted during non-working hours.

The authors noted that additional work is needed to better understand whether secure messaging is replacing other methods of communicating, such as phone calls, or whether it is “simply increasing the overall burden of communication.” They also cited concerns on whether secure messaging is less efficient than other real-time modalities and whether the asynchronous nature of messaging increases the time to resolution of patient issues, since messaging conversations had a median duration of 25 minutes compared to what would likely have been a much shorter phone call.

Notwithstanding the need for additional research, it’s important to make sure that healthcare delivery organizations have their systems configured correctly so that the right people are receiving messages at the right time. Clinicians shouldn’t be expected to respond to secure messages 24×7 unless they are on call. Being able to have true downtime is essential to healthy functioning, whether people realize it or not. Clinicians should also be well-educated in how to set their accounts as “away” or similar so that other users don’t simply fire messages into the ether and hope for the best. From the virtual water cooler, it sounds like there are some opportunities in setup and education.

How does your health system handle secure messaging? Is it a helpful tool or an electronic tether that clinicians feel they can’t escape? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/4/24

As usual, Epic put smiles on peoples’ faces with its annual April Fools’ Day webpage, stating that “the newest building on Epic’s campus will have the coolest theme, like, ever: Barbie Dream House.” It went on to say that the fictional building would include a pool slide and conference rooms named Beach, Girls’ Night, and Mojo Dojo Casa House.

The page also joked that Epic had been selected by television network ABC as the official EHR of “Grey’s Anatomy” to add more medical realism to the series. It wrapped up with a discussion of MyHeart: Epic’s New Dating Portal that “runs advanced searches to find patients near you who might be a good match based on hundreds of criteria, including your problem list, allergies, medications, and more.” Well played folks, well played.

I’m in the middle of an onboarding process for a new position, and although I was dreading the experience, it’s one of the better ones I’ve been through. As a consulting CMIO, I’ve worked with dozens of health systems and care delivery organizations and have gone through either full onboarding processes (when I’m an employee) or through modified onboarding (when I’m a contractor.) The experiences have varied dramatically. One of the worst processes I’ve ever seen involved demands to sign documents attesting to the fact that I had received and read policies that didn’t exist, which I only found out after asking to see them. I wonder how many of their regular employees just signed blindly? Some of the better processes have a clear onboarding checklist to ensure that you’re doing everything in the right order, and the best have that plus the ability to ask questions real time.

I’ve been through dozens of HIPAA training courses, as well as education on fraud, waste, and abuse, to the point where I could probably teach the curriculum. For this position, even though the role is technically non-clinical, I had to go through training on proper lifting, ergonomics, and the importance of non-skid footwear, none of which I’ve gone through for patient care despite the fact that they would have been useful. If you’re looking for an example of training that will engage people rather than make them snooze, I highly recommend Skip, the workplace safety superhero. It will be interesting working in an actual office again. Even though I’ve done patient care in person, this will be a different type of environment, and I’m excited that it doesn’t require navigating a TSA checkpoint or wondering whether my rental car will be there when I arrive. It’s time to dust off my trusty lunchbox and pack my Thermos for what I’m sure will yield many good stories.

From Jimmy the Greek: “Re: telecommuting. I’m a fan, but also recognize that with privileges come responsibilities. Now that I’m fully entrenched in a hybrid model where employees within a one-hour commute of an office are required to be in the office three days per week, it’s been interesting to see how our remote employees still enjoy a certain relaxed atmosphere in their home offices. The company I work for has a strict tobacco-free policy on all company campuses, but it also covers remote work, where employees are prohibited from ‘smoking or using tobacco products’ while visible on a web conference. It was a bit jarring, therefore, when one of my fully remote co-workers stepped onto her front porch to enjoy a smoke while fully visible on a Zoom meeting. I don’t smoke, but if I did, seeing someone light up a Marlboro while I was stuck in a conference room almost a kilometer away from an area where I could smoke without fear of disciplinary action would definitely reduce my overall job satisfaction.” I’ve read a number of employee handbooks in my career and this is one place where the devil might be in the details and sentence structure is everything. The use of the phrase “prohibited from smoking or using tobacco products” implies that they are only blocked from smoking tobacco cigarettes and not others. Vaping, which is certainly as distracting as smoking cigarettes, isn’t mentioned, nor are marijuana cigarettes. Perhaps the human resources department might want to consider more specific language that includes all the different things one can smoke as well as vaping and/or use of other tobacco-containing products. For the employee in question, a refresher on learning how to operate camera controls might be in order.

I was excited to see that the Department of Veterans Affairs is implementing some solid use cases for artificial intelligence. One model called REACH-VET is designed to help identify veterans who are at highest risk for suicide. Another uses natural language processing to flag patient feedback for comments that suggest homelessness or other issues where human intervention might be appropriate. A third model looks as veterans with prostate cancer to differentiate those who will do well after initial treatment from those who need more frequent follow-up. Congressional subcommittee members responsible for VA oversight want to ensure that safeguards are in place when AI is used, with Technology Modernization Subcommittee Chair Matt Rosendale pushing the VA to make veterans aware of instances where their data is being used in AI models.

I was also pleased to see the US Senate looking into whether emergency department care delivery has been harmed by the involvement of private equity firms. The inquiry follows interviews with emergency physicians who are concerned about patient safety issues related to aggressive cost control activities. The most recent investigation falls under the Homeland Security and Governmental Affairs Committee and follows one that is already in progress by the Budget Committee that is looking at hospital systems that are associated with private equity.

I’ve worked for some of the companies that are part of the investigation, and based on my experiences, I don’t think the Senate is going to like some of the things they uncover. It’s no secret that what are considered the most cost-effective ways of delivering emergency care often involve the least-trained and least-experienced clinicians. When things get wild, there is no substitute for a seasoned emergency department physician with decades of experience under their belt, but organizations are certainly eager to replace them strictly on cost alone.

How do you feel about the rise of private equity in healthcare? Have you seen examples of where it’s helping or hurting? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/1/24

I’ve spent the last couple of weeks catching up on some reading, after my library “hold” list went rogue. I typically keep several dozen books on hold but in a frozen status so that I sit at the top of the wait list and can release them when I’m ready.

For some reason, a cluster of them released unexpectedly, dropping on top of my already planned reading. Unfortunately, at my library there isn’t a way to send a book back to the hold list once it’s in transit, unless you want to start over at the end of the line. I dutifully picked up my books and dug in for some intense reading, since you can’t renew them if others have them on hold and I wanted to make sure I was able to read them all. One of the books was “The Chaos Machine: The Inside Story of How Social Media Rewired Our Minds and Our World” by Max Fisher.

Being in healthcare and taking care of adolescents, teenagers, and young adults, I’m acutely aware of the impacts social media has had on these groups in recent years. Even before the societal disruptions of the COVID pandemic, research tied use of social media to sleep issues, which are in turn associated with depression, memory issues, and poor school performance. As we became physically isolated during the pandemic, many young people turned to social media to fill the void, with varying results. In many communities, cyberbullying has been on the rise, and concerns about social media have increased to the point where the US Congress is stepping in.

“The Chaos Machine” is full of meticulous details, many of which are pulled from interviews with Silicon Valley executives, social media experts, gaming experts, academics, and those who have been negatively impacted by social media. It references scholarly works, court records, and other primary sources that tell a story that most of us can’t even fathom. Given the subtitle, I expected it to dig heavily into the physical and psychological impacts on individuals with the concept of world impact as an abstract. I’ve read about the impacts on social media on US politics but wasn’t aware of many of the details the book provides about how the technology has directly impacted other countries, such as Myanmar and Brazil.

Parts of the book are difficult to read, including descriptions of online mobs threatening whistleblowers with violence ranging from swatting to rape or murder. Even more difficult to read are the descriptions of indifference by social media executives when confronted with evidence that their products are causing harm. Surprise, surprise, internal Facebook documents from 2018 reveal that systems were intentionally designed to deliver “more and more divisive content in an effort to gain user attention & increase time on the platform.” The book covers the rise of medical misinformation on social media and some of its harms, but having been a frontline physician, it doesn’t really explain the magnitudes of harm that we see when people use social media for medical advice.

Especially interesting was the description of the growth of Silicon Valley, comparing it to the Galapagos Islands as far as providing a unique evolutionary environment for technology development. However, instead of the isolation leading to the development of unique animal species, it led to “peculiar conditions” that “produced ways of doing business and of seeing the world that could not have flourished anywhere else – and led ultimately to Facebook, YouTube, and Twitter.” I see some of the same conditions in healthcare IT, where people still believe that you can just throw money at problems and somehow they’ll get solved, and where the people calling the shots often have only a rudimentary understanding of how healthcare is delivered in the US.

The book takes a walk down memory lane, talking about strife that took place in 2006 as Facebook introduced its News Feed. It was one of the first documented episodes of internet outrage becoming action, complete with protesters and the side outcome of dramatically expanding user engagement. “The Chaos Machine” covers the so-called casino effect, where social media platforms use the human dopamine system to hook users with intermittent variable reinforcement. It chronicles the rise of social media “like” buttons, which provide additional reinforcement through validation from other users.

I don’t’ want to give away the rest of the book, but I think it’s worth the read. I would recommend it for anyone who is trying to raise children in this crazy world and who thinks it’s OK to just let them play on a parent’s phone or that it’s a good idea to help a child falsify their age to obtain a social media account.

I met a new neighbor whose children attend a Waldorf school, which holds the philosophy that “exposing children to computer technology before they are ready (around 7th grade) can hamper their ability to fully develop strong bodies, healthy habits of discipline and self-control, fluency with creative and artistic expression, and flexible and agile minds.” In thinking about adolescent patients, I’m supportive of this stance, although I know that for parents it’s a nearly impossible battle unless the rest of the “village” around your child is similarly aligned. In thinking about some of the adults I know, it might have been a good idea to keep them away from social media even longer because they’re apt to behave badly even though they’re of age and should know better.

The book was a fairly quick read, as well as something different from my recent binge reading of murder mysteries and detective novels. Next on the list are two novels from Stacy Abrams, followed by chef Iliana Regan’s memoir “Burn the Place.” I enjoy reading about strong and determined women who have made their mark in industries that aren’t supportive. If it’s a good read, her second book “Fieldwork: A Forager’s Memoir” also threw itself out of my rogue hold queue. After that will be “Symphony of Secrets” by Brendan Slocumb, which I’m auditioning for a potential book club selection. If you’re in a book club with a sassy CMIO, you might want to hold on reading that one for now just in case.

What kind of books do you read when you have free time? Or do you accumulate a list or stack that you might never make it through? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/28/24

I attended a recent online forum focused on a telehealth topic. I was surprised to find that some of the participants really didn’t understand the idea of a virtual-first practice. The only way they could conceptualize it was as part of a brick and mortar organization. When I started talking about ordering labs from services that would come to the patient’s home or using patient-provided data from connected devices, I got some blank stares.

The participants were from large health systems and other well-established organizations. I wonder if they’re outliers in their organizations or whether there is really a lack of interest in trying to deliver care outside of traditional office-based settings. Being able to offer services like that isn’t just about convenience. It’s also about serving patients in remote areas and helping those who have other reasons they can’t leave their homes. I hope they take the ideas back to their organizations for discussion.

I receive a ton of marketing emails and spammy-sounding connection requests on LinkedIn. It’s guaranteed that I won’t accept your request if you use made-up words to try to sound cutesy about the serious problems facing physicians today. Case in point: one vendor positioned their product as “the cure for documentitis and physician burnout.” It went on to further define “documentitis” as “inflammation caused by burdensome documentation requirements imposed by EMRs, billing systems, etc.” I’m sure their marketing folks thought it was amusing, but it shows a complete lack of regard for the true causes of documentation fatigue, including out of control regulatory requirements, expanding quality measurement, and lack of regard for the professionals in the system. As someone making purchasing decisions, this kind of messaging takes a company to the bottom of my round file.

Another one of my pet peeves seemed to be everywhere this week — the presence of large microphones in front of the participants on conference calls. I sympathize with the need to have clear audio and to want to use nice equipment, but when you’re a healthcare professional communicating with other healthcare professionals, it’s important to remember that you’re not a DJ and this is not a podcast. The majority of people I take calls with use integrated laptop microphones, earbuds, or something higher tech but unobtrusive, and they sound just fine. I’m hoping this was just a freak occurrence this week and it’s not a new trend. However, as a licensed amateur radio operator, I’ve got some solid options to put into play if it does become the hot new thing.

One of my favorite readers sent me an article about AI nurses, referring to the idea as “cray-cray.” The phrase has been added to the Oxford Dictionary, so I’m not afraid to quote it. The premise on AI nurses is that they’re designed to deliver non-diagnostic nursing care, such as education, which would help mitigate the ongoing nationwide nursing shortage. The idea was dissected recently in The Hustle, which offered some interesting commentary, including the fact that the hardware needed to run such an offering isn’t cheap.

I would add to that the fact that nursing is regulated by the states and licensure is required, so it’s going to be a hard sell that this is actually nursing care versus something else. Organizations will have to look closely at quality metrics that have been shown to be improved through effective nursing education, such as readmission rates, and understand whether AI-delivered education will meet the mark or cause other downstream consequences.

Speaking of potential unintended consequences, I was glad to see a recent article that looked at whether the hospital at home movement could be a double-edged sword. Although positive outcomes have been reported in the literature, such as reduced costs and improved patient experience, some areas haven’t been fully researched. I’ve talked about some of these in the past, including equity and the fact that patients with lower socioeconomic status might not have a caregiver in the home or a safe home environment compared to those in higher socioeconomic categories. The article brings up the idea of safe storage of medications, availability of food particularly in areas that are food deserts, and the ability to safely store meals that may be delivered in advance. Reliable and cost-effective utilities may also be an issue in some situations, as is the presence of broadband for communications and device connectivity.

The comments section on the article brings up additional points. One commenter who used RN in her name described it as “just a fancy earlier discharge scenario. We already have post-ops shoved out the door half awake, unable to dress themselves and throwing up the whole way home. What a crazy, cruel system we have created.” Another referred to the concept as “quite the pipe dream given today’s realities and limited resources.” Another commenter with experience as a home health RN noted, “I have been in extremely low income homes that were kept in immaculate condition and were exceptionally clean and have been in other homes that were in extremely well to do neighborhoods that were so dirty on the inside that I had concerns with even placing my bag on the floor.” That’s an interesting point and creates an additional burden on organizations to ensure suitability of the environment regardless of its ZIP code or other identifiers. I’d be interested to hear from organizations who are already managing hospital at home to understand how they assess potential care environments and what percentage of candidates are deemed suitable once there is a deeper dive.

I’ve always been interested in public health, so I was glad to see the US Food and Drug Administration publish information on egg safety for those who celebrate spring religious holidays such as Easter and Passover. Salmonella is always a concern where eggs are involved, and the press release offers tips on safe handling, cooking, and storage. Deviled eggs are a staple for family gatherings in our family, but I do enjoy the holiday clearance aisle at Target for all my post-Easter cravings.

What’s your favorite springtime food? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/25/24

This weekend was targeted on catching up on some journal articles and making a continuing education plan for the next couple of months. I’ve got some new projects I’m working on that are a little bit outside my comfort zone. I know from experience that unless I make a formal plan to dig into the topics and stick to their plan, there’s a high likelihood that I’ll get pulled into firefighting projects for my clients and will never get done with the reading I feel I need.

Part of today’s effort was to read through all the articles that I’ve bookmarked in the last couple of weeks because I find them interesting, clearing them off the digital reading pile. It was a good cross section of topics and I think readers might find it interesting to see what’s on the reading list of a free-range clinical informaticist.

There were several articles from the Journal of the American Medical Informatics Association, with most of the ones I found interesting arriving in the most recent issue. The first addressed “Using artificial intelligence to promote equitable care for inpatients with language barriers and complex medical needs.” This topic resonated with me since I spent a good chunk of my training at an academic medical center in a city that served a particular refugee population that grew dramatically in the span of a few years.

The authors hypothesized that in-person interpreters are “particularly beneficial for these patients” but underused, and set out to use predictive analytics to identify the patients who should be prioritized for interpreter services. They performed semi-structured interviews with stakeholders to understand what those caring for patients thought about the idea.

I’m a big fan of qualitative research. Although one can gather a lot of information from surveys that elicit specific data points, some of the best understanding I’ve gained on complex issues has come from direct conversations with those who are involved in the issue. Stakeholder analysis is frequently overlooked when organizations are scoping large complex projects, and my feeling is that organizations neglect it at their own peril since it’s an excellent way to identify those who will support your project and those who are likely to block it. The key is having interviewers who are neutral and trusted, and making sure that people feel comfortable sharing their perspectives.

The authors conducted 49 stakeholder interviews and identified significant risks that would need to be addressed, including accuracy, privacy, and supply / demand issues. They also identified benefits including the ability to overcome clinician bias and to empower interpreters. Those are sentiments that you can’t always ascertain from a checkbox.

Another article that caught my attention also dealt with machine learning, this time looking at ethical perspectives on algorithm development for healthcare. The study also included qualitative research, interviewing 10 machine learning researchers on the topic. The participants were unanimous in identifying the ethical significance of algorithm development, which is good.

Not surprisingly, they identified areas where ethics may need to play a larger role, including around “standards related to scientific integrity, beneficence, and justice that may be higher in medicine compared to other industries engaged in ML innovation.” I haven’t read a truer sentence in some time, and it resonated with me after being at HIMSS and hearing some of the things that vendors were saying about artificial intelligence and machine learning. It’s amazing that companies still think that solving the healthcare problem can be done in the same ways that they have solved various problems in other industries. The last two decades have been littered with companies that thought that they had all the answers, but ended up exiting the healthcare space quickly.

A third article looked at whether patients who read visit notes have a higher rate of so-called “closing the loop” on recommended testing and referrals. The authors set out to look at “the relationship between patient portal registration with/without note reading and test/referral completion in primary care.”

For those of you who haven’t spent time in the primary care trenches, the primary care physician is essentially on the hook to make sure that patients complete every recommendation and referral that they are given. Even if the patient says “no” and state that they have no intention of completing a recommended action, the fact that they don’t is reflected in various clinical quality measures and also can come back around and bite the physician in the event the patient has a poor outcome.

I’ve been involved in medico-legal cases where the physician clearly recommended a test and the patient clearly refused it, but fast forward to when the patient has a preventable harm and the usual allegation is that the physician should have tried harder to get the patient to comply.

The article looked specifically at colonoscopies, which are of course recommended for early detection of colorectal cancer. They also looked at dermatology referrals for suspicious skin lesions and cardiac stress tests. They looked at whether patients who used the patient portal and who had read at least one visit note had more timely completion of the tests compared to patients who had portal accounts but didn’t read notes and compared to patients without portal access.

The authors found that compared to patients who had no portal access, those who had accounts had 20% higher chance of closing the loop on recommended tests. When patients had accounts and read at least one note, the odds were 40% higher. The authors controlled for various social, demographic, and clinical factors, but concluded that there are still gaps that must be addressed when recommendations are left incomplete. They recommend increasing efforts to promote patients accessing their notes, as well as other patient engagement strategies to ensure that patients complete recommended diagnostic and preventive steps.

Having done a fair amount of work in the space, the latter is certainly a lofty goal. There are so many reasons that patients may not complete recommended testing. These include but are not limited to: perception of the importance of the test; insurance coverage for and/or the cost of the test; time needed to be off of work or to secure childcare; understanding of the preparation needed for the test; difficulties in scheduling; and transportation issues. The list goes on and on.

I’ve worked on campaigns to address the issue through patient portal messages, texting with chatbots, integrated voice response systems, old-school 1:1 phone calls, postcards, letters, community outreach, health fairs, and more. Each little bit drives the needle, but there is still much work to be done.

I still have a stack of articles to read, but I felt like I at least made a little progress today. What’s on your list for continuing education topics? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/21/24

I’ve seen several recent mentions of Vale Health, which promises to be a “national health marketplace that serves communities through trusted health system relationships and leading health and wellness solutions.” That’s certainly a mouthful.

The company was founded by former Froedtert Health executive Mike Anderes and is designed to be a consumer-facing platform. The company lists 15 founding health system members who have membership on platform advisory boards that “set guidelines for choosing quality solutions, ensure careful treatment of consumer privacy, guide our product development priorities, and create the optimal engagement experience for people they serve.”

The majority of the company’s website is still under development, with only “better sleep” having listed products. Optimal weight, healthy pregnancy, healthy skin, mental wellness, and digestive health are all listed as coming soon.

Under the sleep products page, the site promotes a phone app, smartwatch, cooling sleep blanket, and melatonin tablets. Selecting “learn more” about the products linked me out to the app’s website and Amazon for the rest of the items. The site promises to “curate the highest quality, most respected products and services to address the health needs and wellness goals of the tens of millions engaging with their providers each year.”

Given the fact that the site promotes specific branded products with sales links that clearly indicate that the company may earn a commission, this just feels icky. It reminds me of when the American Medical Association entered into an ill-fated relationship with home appliance maker Sunbeam for product promotion.

As a clinician, I’d love to see the guidelines created by the advisory boards. What led them to choose a Fitbit product as opposed to one from Garmin? What about using Nature Made melatonin versus other brands, not to mention that the use of melatonin for sleep is controversial when you read the medical literature – it’s recommended in very specific situations, which of course aren’t mentioned on the site.

If you dig deep into one of the linked pages, it says that products are chosen using product review websites, information from manufacturers, user opinion, and online research into safety certifications, etc. They “do not conduct physical assessments of the products” and apparently they also don’t post information about the relevance of the products to the current standard of care for any diagnosed condition.

I spoke to someone in the know at one of the partner organizations. They voiced concerns that it feels like the company is “the Goop of healthcare” and I don’t disagree. I’m always suspicious when organizations promote the nebulous “wellness” concept and talk about the vague “health” of a body system, which is a pretty key indicator that nothing that’s about to be presented is FDA-approved or proven in high-quality, peer-reviewed literature. It’s not surprising that when you look at the company’s board of directors, there are venture capitalists. Just one more thing that makes this feel like a money grab rather than anything else.

Speaking of money grabs, the White House is launching new efforts to address healthcare costs. A task force is being formed and will include representatives from the Justice Department, the Federal Trade Commission, and the Department of Health and Human Services. Drug and provider costs will be at the top of the list of items to address.

I’ll be interested to follow the formation of this task force and would love to see the inclusion of other types of representatives. Let’s add some patient advocates, some “average” primary care physicians struggling to keep their doors open, and while we’re at it, let’s also include real-life patients who are fighting the system daily and struggling to pay their bills. I’ve long said there’s more than enough money spent on healthcare in the US that every one of us should have high quality care at a reasonable cost. Unfortunately, a good chunk of it goes to profits and also to fraud, waste, and abuse. This is why we can’t have nice things.

The best medical article I read this week was one in JAMA Network Open that looked at the effects of tai chi versus aerobic exercise on the systolic blood pressure readings of prehypertensive patients. It summarizes a randomized clinical trial that was performed in China. Although the study was small at 342 participants, it showed that blood pressure reductions at the 12-month point were greater in the tai chi group than with group that performed aerobic exercise. A little more than half of the study participants were women, and the mean age was 49.3 years in a range of 18 to 65. The participants had to either be untreated (no western or traditional Chinese medicine treatments) or to have been off of treatment for at least two weeks. Patients were excluded if they had diabetes, coronary artery disease, chronic kidney disease, current pregnancy, or breastfeeding.

Each intervention included supervised sessions, both in person and via video, that were conducted four times per week. They involved a 10-minute warmup, 40 minutes of core training, and a 10-minute cooldown. The tai chi component included 24 standard movements of Yang-style tai chi, where the aerobic component included stair climbing, jogging, brisk walking, and cycling. The sessions were conducted between July 2019 and January 2022, which is interesting given the span across the start of the COVID-19 pandemic. Blood pressures were measured at baseline, six months, and 12 months. Researchers also looked at lipid profile, fasting glucose, kidney function, weight, body mass index, and adverse events occurring during the study, although there were no differences in the parameters between those two groups. More than 82% of participants completed the study.

I’ve been working to keep myself out of the hypertension range since having episodes of mind-blowingly high blood pressures during the COVID pandemic. It turns out that when I’m exposed to the stress of a busy emergency department or urgent care, I’ll hang out with a systolic blood pressure in the 180s. If I’m at my primary care office or any other healthcare facility, 150 isn’t unheard of. I’ve come to accept that as part of the traumatic anxiety of caring for thousands of COVID patients. At home, I’m occasionally in the prehypertension range, but that has become better in the last couple of years as I avoid salt and exercise more. I’ve never tried tai chi given the limited options where I live, but maybe I’ll have to find some online resources and see if that brings it down any further.

What’s your ideal exercise? Do you like trail running, beach walking, swimming, or something more exotic? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/18/24

My inbox seemed to explode while I was at HIMSS. I’ll be trying to tunnel out for at least the next week, I would bet.

One of the interesting articles I found was about the clinicians at telehealth provider Bicycle Health and the fact that they have filed with the National Labor Relations Board to unionize. A press release from the Union of American Physicians & Dentists notes that physicians, physician assistants, and nurse practitioners have experienced “a shift in company culture where we as providers feel increasingly overworked, undervalued, and our feedback is regularly ignored. In order to continue providing the best care for our patients struggling with opioid addiction, we knew we needed to come together.”

I’ve worked as a telehealth clinician for several different companies. It’s more likely than not that they have treated their telehealth providers as expendable despite the fact that patients can’t be seen if there aren’t licensed providers to see them. Even working for organizations that also had a brick and mortar presence, it’s clear that administrators thought telehealth providers are replaceable.

That may be true, given that a lot of telehealth providers only work on an as needed basis and are paid accordingly. As such, they are treated more like Uber drivers than knowledgeable professionals. It will be interesting to see how this shakes out over the coming months.

I spent a fair amount of time at HIMSS contemplating the marketing efforts of various companies. Some have clear and well-reasoned strategies, while others are a little bit more of what we might describe as all over the place.

Nothing says marketing drama than NYU Langone Health System suing Northwell Health over allegations of trademark infringement. Earlier this month, a federal judge dismissed the suit, citing the variability of shades of purple, intermittent use of sentence case as well as all-capital phrases in white, and other factors in the failure to prove infringement. The judge dismissed some of the claims without prejudice, which will permit NYU Langone to amend its complaint in the future.

I love some of the quotes from Northwell Health’s chief marketing and communications officer, who stated that NYU Langone has “no filed claim to the color purple” and that “If it truly is a trademark right of theirs, then they should protect the asset.” He went on to say that Northwell uses 16 colored triangles in its main logo, representing the diversity of the health system, and that continued pursuit of action is a “waste of time and resources.”

Speaking of lawsuits, I also had a blurb in my inbox about New York City (including New York City School District and New York City Health and Hospitals Corporation) suing social media companies in relation to the growing youth mental health crisis. The lawsuit was filed in the Superior Court of California, with named defendants including Meta / Facebook / Instagram, Snap, TikTok, and Google / YouTube. The complaint is 311 pages long and parts of it are a truly fascinating read. It starts with factual allegations against all defendants and then moves to specifics. Among the general allegations:

• Social media’s core market includes school-aged children, who are “uniquely susceptible” to harm from the platforms.
• The platforms are designed to addict youth who use the platforms with minimal parental oversight.
• Millions of children use the platforms compulsively, including during school hours.

Specific claims include algorithms that are designed to promote compulsive use, gambling-inspired features that create cravings for likes as a reward, and tailored advertisements. Plaintiffs are asking for an order that the defendants’ conduct “constitutes a public nuisance” that requires abatement along with funding for prevention efforts, mental health treatment, actual damages, and punitive damages. I see plenty of children, teens, and adults who are addicted to social media and who can barely function without a phone in their hand.

At the same time, Florida Governor Ron DeSantis vetoed legislation that included social media restrictions for minors. Politico noted that the governor had indicated well in advance that he wasn’t supportive of the measures. Legislators immediately scrambled to try to create replacement legislation. The vetoed legislation would have prohibited creation of accounts by those under age 16 and would have required third-party age verification and would have prevented parents from helping their children bypass the restrictions. Watered-down replacement language would allow parental consent.

During my career as a physician, I’ve seen plenty of parents make bad decisions on behalf of their children, most recently because they fear the peer pressure that might ensue if their children don’t get exactly what they want. Physicians saw an uptick in skin issues in January from parents who bought their children certain TikTok-promoted skincare products for Christmas, not understanding that powerful anti-aging chemicals would be harmful. As of the time of this writing, DeSantis plans to sign the revised bill.

Although I enjoyed the warmth of Orlando and being able to enjoy some sunshine, I certainly don’t miss the traffic or the cranky children and frustrated parents. It was 20 degrees cooler when I landed at home and that was followed by severe weather and a significant temperature drop that was accompanied by golf ball-sized hail. We’re headed back below freezing tonight, so it’s time to get out the fuzzy slippers and flannel lounge pants in preparation for a full day of conference calls tomorrow.

I must say that when I travel, it feels a little strange to wear dressy clothes on both top and bottom after several years of virtual work in a hybrid wardrobe. My clinical shifts don’t count as wearing real clothes since all of my scrubs are well worn and are softer than most of my pajamas.

I’m looking forward to slipping back into my usual routine and seeing what the healthcare IT universe throws at me next. What do you enjoy most about being away at a conference? And what are the best parts of coming home? Leave a comment or email me. 

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/11/24

Mr. H reported on this last week, but I’m still struggling with the story about Guam Memorial Hospital spending $5 million on an EHR that isn’t fit for purpose. As someone who used to do consulting work to help healthcare organizations with EHR system selection needs, it’s just baffling that this hospital’s project has reached this point.

You can try to blame the fact that there was a pandemic that caused delays, but that feels like a convenient excuse to try to cover problems that range from incompetence to willful neglect. There’s also the question on who will profit from the $20 to $60 million that it will take to replace the current system with one that will actually get the job done.

The system has been in place since October 2022. An administrator has stated that leadership determined it “really wasn’t built for an acute care hospital landscape” and would be more suitable for a behavioral health application. Because there isn’t funding to address the issues, caregivers are essentially stuck with it for the time being.

It feels like the basic tasks involved in system selection were somehow skipped: demonstrations, reference checks, and site visits with peer organizations that were currently using the system. This isn’t a magical new process for buying an EHR. I’ve done it at least a dozen times in the last two decades, and it’s pretty straightforward. Even if you claimed that the pandemic prevented site visits, you could still address a number of needs through a virtual site visit. In my experience, physicians rarely lie about the capabilities of an EHR unless they are being bribed.

I can’t throw the vendor under the proverbial bus without all the facts. It’s not entirely clear with of the vendor’s modules were actually purchased and how they were implemented.

I’ve personally been involved with EHR implementations where health systems did some pretty silly things, such as “forgetting” to include laboratory interfaces in their original Request for Proposal document, and grossly underestimating the volume of patient data that would need to be converted in order for physicians to work efficiently and for patients to be safe.

On the other hand, it feels like the facility might have skimped out on certain implementation steps as well as system selection steps, including elements such as workflow design, inclusion of patient safety and quality reporting features, and a little thing called user acceptance testing. Maybe issues were raised and leadership just plowed on through, though – I’ve certainly seen that happen a number of times.

As for the complicity of the vendor in this situation, I did a quick glance at its website, which may not at all resemble what the hospital had access to as it was selecting the system. There are plenty of areas of the website that channel language specific to behavioral health inpatient applications. There are consistent mentions of using DSM 5 to capture diagnoses in the chart rather than using ICD-10. There are also several mentions of the ability to document group visit notes, which typically don’t occur in the standard medical / surgical inpatient setting. The vendor does list a number of component products, however, and it looks like there may have been some mergers or acquisitions along the way, so that might be part of the issue too.

The news article notes that management is busy preparing a new RFP and therefore couldn’t offer additional comments on the downstream operations and billing impacts caused by the situation. I suspect they can’t offer comments because they’re actually preparing updates to their resumes as they consider pursuing other opportunities. The hospital is tied into a subscription-based contract, so they’re stuck with it until they can get a replacement live.

Hospital IT projects don’t happen overnight, and if the same leadership team remains in place, I’m sure it won’t be an efficient rip-and-replace at all. Even in the best of situations, you’re looking at an 18-month lead time to install a hospital system, just due to the sheer number of decisions that have to be made, the workflows that have to be mapped, the clinical data that has to be converted, and of course the ever-hellish hospital contracting process. That’s not allowing additional time for lots of questions to be asked, since the facility has already bought a lemon and stakeholders probably don’t want to buy another one.

Reading through the article, the organization has dealt with a number of technology problems in the past, including concerns logged during site visits from the Centers for Medicare & Medicaid Services (CMS). Those citations focused blame on the hospital’s previous EHR, which has since been discontinued. CMS cited the facility for failure to systematically track medical errors.

The administrator speaking to the media for the article noted that the new system had been recommended by the previous vendor. That’s problematic in my book, because when I have a vendor that’s failing to meet expectations, the last thing I want to do is to take their recommendation for a replacement. Apparently the two vendors were somehow affiliated, but trying to figure that out is beyond the scope of my investigative reporting motivation at this point. Apparently it was a no-bid contract situation, and that’s enough information for me. I can’t help but feel concern for and outrage on behalf of the patients who are now stuck receiving care in this environment, and the clinicians who have to try to make do with something that is clearly incapable of supporting them.

There are only a handful of comments on the article, and I wonder if any of them are from clinicians. If I had inside knowledge of the situation, I’d certainly be spilling it. I’m curious if we have any readers who work with the vendor in question or who have inside knowledge on the situation and would be happy to help you share your thoughts anonymously. Inquiring minds want to know: How do situations like this happen? Is there more to this story than meets the eye? Or is it simply a case of rampant incompetence? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 3/7/24

I was hanging out with some medical friends the other night, and as it happens when adult beverages are involved, the conversation was all over the place. We were talking about patient education, and one of my colleagues who is fairly new at working directly with patients admitted to having used ChatGPT to help him formulate an answer to the question of “What is a placenta?” while keeping the answer at the level a 12-year old could understand.

It points out the importance of answering questions in language that patients can comprehend, especially when medical folks are used to using larger words and entirely too many Latin phrases. Patient education is important as are communication skills, but both tend to be undervalued in healthcare today. As a side note, following that conversation I decided it would be cool to be able to peek behind the curtain of the commercially available generative AI solutions to see the kinds of questions that are being asked by the general public.

Other hot topics include a local hospital tasked with cutting 10% of its frontline nursing staff to help balance the books. Although I understand the slim margins that most hospitals operate under, I doubt that cutting nursing staff is going to be a positive as far as patient safety, nurse-to-patient ratios, or patient and family satisfaction. They’ve already gotten rid of their weight management program, which doesn’t make sense given the obesity epidemic and people’s willingness to pay cash out of pocket for obesity drugs. In addition, they’ve eliminated a number of physicians and service lines related to women’s and children’s health. I’m sure if the community knew what was going on there would be an outcry, but the hospital has been keeping it pretty hush-hush.

From Burned Out PCP: “Re: AI. What do you think about this article that looks at AI as the solution to the primary care physician shortage? I’m hanging up my stethoscope because I can’t take it any more. Thankfully, my ability to do clinical informatics work is serving as a lifeboat.” The article does a nice job summarizing some of the statistics, including the staggering savings the US could realize ($67 billion) if everyone had a primary care provider, as well as the projected primary care physician shortage ballparked in the neighborhood of 40,000 physicians by 2034. The author summarizes some of the factors contributing to primary care physician burnout, such as the fact that “most doctors enter the profession because they want to build trusting, long-term relationships with patients and see them get healthier. Instead, primary care has increasingly become short-term and transactional.”

I agree with this statement. It has been difficult to watch the erosion of respect for primary care practice since I graduated from residency training. Generational values have shifted and it feels like patients no longer value those relationships. Healthcare costs and economic realities have pushed patients to select convenience over comprehensiveness and low-cost over longitudinal relationships.

The author lists the likely suspects for AI tools to assist physicians, including digital scribing and documentation. They also include the ability to digest information from physician notes, laboratory and imaging reports, and other documents to create a more useful view of the patient and to identify potential gaps in care or recommendations for changes to the treatment plan. I don’t feel like the author really added much to the current understanding of the role of AI, and assumed it was a generic op ed piece until I got to the author info at the bottom which identified the writer as the chief medical officer for Amazon Health Services. I think I would have expected a bit more from someone in that role, especially with an article that appeared in Fortune, but that’s just me.

The US Food and Drug Administration has authorized a “first of its kind” feature for the Samsung Galaxy Watch, intended to assist with management of sleep apnea. The feature allows users over the age of 22 who have not been previously diagnosed with the condition to conduct a two-night monitoring period. I know from my experiences tent camping at a variety of locations that there are plenty of people with sleep apnea out there. Of course, some of them are likely diagnosed but haven’t figured out the logistics of bringing a CPAP machine to the woods, but I suspect a number of them are undiagnosed. Perhaps I need to start dropping hints to my camping friends who are on team Android.

The US Department of Health & Human Services (HHS) has recently published a notice in the Federal Register that explains changes to the data required for providers to obtain and keep a National Provider Identifier. The National Plan and Provider Enumeration System (NPPES) will now permit providers to list a post office box as a practice location when the provider doesn’t have an office location other than their home. It also expands reportable gender values to include X for “Unspecified or another gender identity” and U for “Undisclosed” beyond the usual M and F for male and female. The system will begin collecting these new values next month. If you love the Federal Register or just need supplemental reading material before bedtime, details on the changes can be found here.

Like many people, I’m getting ready for HIMSS and appreciate having HIStalk’s Guide to HIMSS24 to help me find booth numbers without having to use the annoying HIMSS exhibition website. The list feels a little shorter this year than it has been in the past, but it’s unclear if people didn’t submit a blurb for inclusion or if they’re simply not submitting. Based on the friends I’ve reached out to in order to determine if they’re attending, it feels like I may be at HIMSS by myself and surrounded by tumbleweed.

On the other hand, I just was “uninvited” from a HIMSS-sponsored lunch and learn session after previously being confirmed, so maybe there are plenty of cool kids going. This is the first year that I don’t have multiple party choices for the evenings, so I might be making an early night of it. If you’re looking for anonymous but sassy reporting on your event, you know where to send the invite.

A friend of mine reached out about the recent Oracle Health reduction in force, which apparently was conducted in sync with National Employee Appreciation Day. Nothing says appreciation like a layoff, so here’s a jeer to the people who decided on the timing. What does your organization do to make employees feel appreciated? Anything different they should be doing instead? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 3/4/24

A number of my physician friends still work for independent medical practices, which is a bit surprising given recent market forces that have been challenging even for the most well run of them. Now that the Change Healthcare ransomware attack is approaching the two-week point, many are concerned that they are going to be in financial straits.

The first quarter of the year can be difficult for medical practices, especially if they have a large percentage of patients that are covered by high-deductible health plans. Those patients often avoid care until they reach their deductibles, which means volumes can be down in the practice. This tends to pick up towards the end of the calendar year, when patients have met those deductibles and are trying to squeeze in visits before the new year rolls around. 

Several of my friends were chatting about the inability to send claims to insurance companies and are worried about cash flow. I asked whether their business continuity insurance policies would cover the disruption and was surprised that more than half of them didn’t know if their practices even have that kind of insurance coverage. One would think that after coming out of a pandemic that significantly disrupted practices’ ability to function, groups would have looked into that if they didn’t already have coverage. Maybe the reliance on federal pandemic funds made them think they didn’t need to worry about it, but they are now wishing they did.

For those that outsource their revenue cycle management functions, they have been surprised by the lack of communication about the situation and what the third parties are doing to try to switch to other vendors. Some are wondering how they’re going to be able to make payroll and are trying to get short term loans to cover practice expenses. I’ve heard that a couple of local banks are stepping up to help out, but it sounds like national banks are less excited to be doing so. For lack of a better description, everyone is just scrambling at this point.

My current clinical practice pays me on a per-visit basis, regardless of a patient’s ability to pay or what insurance they might or might not have. That provides me a bit of a buffer from the Change Healthcare situation, although I know that the organization I work with is nervous about the situation. They’re committed to caring for patients and have a decent financial reserve, however, and I feel reassured that I’m unlikely to be benched like I was during the pandemic.

I’m exclusively seeing patients via telehealth these days, partly due to volume demands and partly due to my computer skills. I think my employers enjoy having someone who can power through visits, understands the need to set up their own favorites and defaults, and doesn’t complain about the EHR.

Patients have grown to rely on telehealth. The fact that we don’t know for sure what will happen with telehealth reimbursement is making a lot of organizations nervous. A little more than a week ago, 200 organizations signed on to a letter that asked the US Congress to take action to ensure that virtual care payments that were modified during the pandemic remain favorable. A couple dozen of these organizations were health systems, but among the rest were professional societies, patient advocacy organizations, virtual care companies, and tech giants such as Amazon. Big names signing on included Ascension, Intermountain Health, Johns Hopkins Medicine, Mass General Brigham, Michigan Medicine, Trinity Health, and UPMC.

The signers encourage Congress to take action now so that patients and care delivery organizations can plan and budget, rather than leaving them hanging until the eleventh hour as Congress tends to do. Organizations can be confident when they make investments in virtual and hybrid care models, which will be essential in managing workforce challenges. They also note the need for employers to be able to plan ahead for their health plan offerings for the coming year, which they can’t do if decisions aren’t made well before the traditional open enrollment periods that most employers have in November. Additional points made in the letter include:

• Patients have come to rely on telehealth, and ending payments will be detrimental to established care relationships.
• Safety net organizations have used telehealth to extend care, including community health centers and rural health clinics.
• Continued provision of mental health services via virtual care is essential.

I’m now in my seventh year as a practicing telehealth clinician, which is hard to believe when you think about it like that. It’s a skill that physicians of my training generation certainly weren’t trained to do, but we adapted quickly to it when our organizations decided to roll out programs. Those of us who were already seasoned definitely had an easier time during the pandemic. I was fortunate to be able to use a mature platform that hadn’t been cobbled together with Zoom, duct tape, and leftover Cat 5 cable.

I still chafe having to wear a white coat to perform telehealth visits, as required by my organization, but the annoyance of the scratchy polyester is outweighed by the fact that patients genuinely appreciate the flexibility of care even when I’m just providing advice and not sending out prescriptions.

I can’t think of any physicians I know who still perform house calls, but in many ways telehealth visits have become the house calls of the future. Especially when you can add technology like connected blood pressure cuffs, scales, and imaging devices, it goes along way towards what you could say was almost like being there. Now we just need to break down the payment barriers, and while we’re at it, I’d love to see our federal government find a way to break down the patchwork licensing restrictions in the US that keep me from seeing patients who live a couple dozen miles away from me but who are figuratively in a different world as far as me being able to care for them. My standard of care isn’t going to be different just because of where the patients live, but state medical boards sure try to convince people that it’s a real risk. It’s time for licensure reciprocity or a federal license.

I’m realistic enough to know that probably won’t happen before I retire, but a girl can dream.

What are the biggest priorities that our legislators should be tackling where healthcare is concerned? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/29/24

Lots of folks around the virtual water cooler are talking about the ransomware attack that has brought Change Healthcare to its knees. In addition to negatively impacting financial transaction, the trickledown effects are preventing patients from getting needed medication refills at the pharmacy.

The BlackCat gang claims that they took 6 TB of data, including clinical, payment, and claims files as well as patient demographic data. This includes data on active US military personnel. Spokespeople for parent company UnitedHealth Group have stated that 90% of affected pharmacies have switched to new processes to get the prescriptions moving. You can follow along on a dedicated status page.

From Phi Beta: “Re: healthcare financial departments. Are in full battle mode with claims authorizations and eligibility all off line due to Change Healthcare / Optum cyberattack. I’m hearing Duke Medicine cannot send out any claims. The financial costs for US healthcare entities are going to be massive. No one seems to be telling that story.” Now that the outage has gone as long as it has, I think people are starting to have those conversations. The impact of this will be staggering and cause everything from tsunami-size waves to ripples through revenue cycle processes for the next year.

Several people have sent me fun and sassy pics from ViVE, which were much appreciated since I’m hanging out at home in chilly weather rather than partying it up in LA. Roving reporters indicated that the Billy Idol concert was “shockingly good.” I did get annoyed by the repeated emails from ViVE asking if I had “FOMO.” By definition, can you still have “fear of missing out” when you are actually missing out? Inquiring minds want to know.

Even though many of us in the industry have followed the VA and US Department of Defense IT projects closely due to their sheer size and visibility, the fact that I have active duty military personnel in my family makes it even more interesting to me. I was intrigued by the reports that the EHR transition had slowed down recruiting and onboarding and wanted to know exactly why. Having used both systems in the past, it didn’t make sense to me that switching from one system to the other would have made such a huge difference in workflow or click counts that it would delay entry. Additionally, there were reports that after the new system went live, twice as many recruits were disqualified. That didn’t make sense at all, unless the new system had totally different parameters than the old one.

After doing some digging, reading a lot of articles, and confirming with military personnel, I finally understand. Although the EHR is involved, it’s really not the cause. It’s the sheer volume of records that reviewers are now having to address compared to what they had before. In the legacy workflow, reviewers had access self-reported patient histories coupled with a relatively small number of medical records for each recruit. In the new system, health information exchange technology is used to pull much larger volumes of data about individuals. Although some branches of the military have refused to comment on it, an Air Force spokesperson did provide information to National Review, which confirmed that higher numbers of records are revealing more disqualifying conditions, which then need to be investigated and evaluated.

Previously, 81% of all Air Force applicants passed on their initial screening during fiscal year 2021, but after reviewers had greater access to patient data, that number dropped to 69% in 2022 and eventually to 58% in 2023. Increased access to data led to increased time needed for review, and until additional reviewers were added to help catch up, there was a lag. I’m not sure how failure to staff up in the face of a significant increase in workload can be attributed to the EHR rather than to lack of understanding of the time needed to review records coupled with poor capacity management. It’s always easier to blame the technology than it is to hold management accountable, I suppose.

A UK coroner’s classification of a young woman’s death as “preventable” has landed the EHR in trouble. The 31-year-old patient died from a pulmonary embolism after presenting the day before at the hospital. The coroner’s inquest confirmed that staff identified the diagnosis, but there were “errors and delays” in administering the correct treatment on an appropriate timeline. The hospital’s new emergency department EHR was named as a contributor, noting that it lacked clear and color-coded indicators for patients who needed urgent care, which had been present in the legacy system. Instead, the Cerner system has symbols next to patient names that had to be clicked to indicate the acuity of care rather than the acuity being immediately apparent. The coroner noted that there had been clinician complaints that went unresolved after the transition to the new system. The hospital has 56 days to respond to a demand for action. When we implement healthcare technology, we have user acceptance testing for a reason. Let this be a warning to people who don’t listen to the users or overrule their findings.

From Less-than-happy Hybrid: “Re: return to work. I feel like a ping pong ball going back and forth between the annoyances of working in the office and my Zen home office setup. In the office, my entire group was moved to a different floor that is nothing but cubes. I can’t even see if other people are here, and since none of us have actual cube assignments I don’t know where to find people if I wanted to collaborate. There are no lockers or storage cabinets. so I’m stuck hauling my stuff home at the end of every day, which isn’t an employee satisfier. There’s also a cheapo battery-powered clock on the wall whose ticking is making me crazy. It may not survive the morning. I also just heard a very distinctive sound coming from across the aisle and confirmed that some guy was brushing his teeth. At his desk. I’m so glad we’re building all this culture.” Other readers have weighed in with annoyances with remote colleagues, including attendees who are consistently doing school drop-offs or pickups during standing calls, yet will not admit that the call is scheduled at a bad time and should be moved. I’ve worked with people like that and it’s maddening since you know that they are not paying attention and are possibly placing themselves and their children at risk driving while on calls. One reader shared some photos of backgrounds they’ve seen on calls, including messy unmade beds, sinks piled high with dishes, and inappropriate artwork in the background. I use a lot of platforms and every one of them has an option to use digital backgrounds or at least blur the background, so there’s no excuse for appearing to be in an unprofessional environment even if you are indeed in the middle of one.

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Curbside Consult with Dr. Jayne 2/26/24

In the US, our love of technology often overtakes our trust of people’s knowledge and expertise. I encountered this on a regular basis in the urgent care setting, where patients demanded testing for conditions that were well-suited to the use of clinical decision support rules. In other countries, clinical decision support rules are accepted – and even expected – as a way of helping patients avoid unnecessary testing and healthcare costs. Some of the most useful and validated CDS rules are those around probability of strep throat, ankle fractures, and pediatric head injuries. However, testing has become a proxy for caring, and if physicians don’t order tests for patients with applicable conditions, those physicians are likely to wind up on the receiving end of low patient satisfaction scores or even hostile online reviews.

I had been thinking about this when I stumbled across a recent article in the Journal of the American Medical Informatics Association that looked at whether explainable artificial intelligence (XAI) could be used to optimize CDS. The authors looked at alerts generated in the EHR at Vanderbilt University Medical Center from January 2019 to December 2020. The goal was to develop machine learning models that could be applied to predict user behavior when those alerts surfaced. AI was used to generate both global and local explanations, and the authors compared those explanations to historical data for alert management. When suggestions were aligned with clinically correct responses, they were marked as helpful. Ultimately, they found that 9% of the alerts could have been eliminated.

In this case, the results of using XAI to generate suggestions to improve alert criteria was two-fold. The process could be used to identify improvements that might be missed or that might take too long to find in a manual review. The study also showed that using AI could improve quality through identification of situations where CDS was not accepted due to issues with workflow, training, and staffing. In digging deeper into the paper, the authors make some very important points. First, that despite the focus of federal requirements on CDS, the alerts that are live in the field have low acceptance rates (in the neighborhood of 10%), which causes so-called “alert fatigue” and makes users more likely to ignore alerts even if they’re of higher importance. Alerts are also often found in the wrong place on the care continuum – they cite the examples of a weight-loss alert firing during a resuscitation event and a cholesterol screening alert on a hospice patient.

They note that alerts are often built on limited facts – such as screening patients of a certain age who haven’t had a given test in a certain amount of time. While helpful in some situations, these need to include additional facts in order to be truly useful; for example, excluding hospice patients from cholesterol screenings. I’d personally note that expanding criteria that underlie alerts would not only make them more useful but would avoid hurtful alerts – for example, sending boilerplate mammogram reminders to patients who have had mastectomies and the like. I’ve written about this before, having personally received reminders that were not only unhelpful but led to additional work on my part to ensure that my scheduled screenings had not been lost somewhere in the registration system. There’s also the element of emotional distress when patients receive unhelpful (and possibly hurtful) care reminders. Can you imagine how the family of a hospice patient feels when they receive a cholesterol screening message? They feel like their care team has no idea what is going on and isn’t communicating with each other.

The authors also summarized previous research about how users respond to alerts, which can differ based on users’ training, experience, role, complexity of the work they’re doing, and the presence of repetitive alerts. Bringing AI into play to help process the vast trove of EHR data around alerts and user behavior should theoretically be helpful, if it can successfully create recommendations for which alerts should be targeted. The authors prescreened alerts by excluding those that fired less than 100 times, as well as those that were accepted less than 10 times during the study period. They then categorized the remaining alerts depending on whether they were accepted or not, then going further to look at features of alerts that were not accepted including patient age, diagnoses, lab results, and more before beginning the XAI magic.

Once suggestions were generated, they were evaluated against change logs that showed whether the alerts in question had been modified during the study period. They also interviewed stakeholders to understand whether proposed alert changes were helpful. The authors found that 76 of the suggestions matched (at least to some degree) changes that had already been made to the system, which is great for showing that the suggestions were valid. The stakeholder process yielded an additional 20 helpful suggestions. Together, those 96 suggestions were tied to 18 alerts; doing the math revealed that 9% could have been eliminated by incorporating the suggestions. For those interested in the specific alerts and suggestions made, they’re included in a table within the article.

In the Discussion part of the article, the authors address the idea of whether their work can be applied at other institutions. From a clinical standpoint, they address conditions and findings that are seen across the board. However, if an organization hasn’t yet built an alert around a given condition, there might not be anything to try to refine. They do note that the institution where the study was performed has a robust alert review process that has been in place for a number of years – a factor that might actually underestimate the effectiveness of the XAI approach. For institutions that aren’t looking closely at alerts, there might be many more found that could be eliminated. The institution also has strong governance of its CDS technology, which isn’t the case everywhere. The authors also note that due to the nature of the study, its impact on patient outcomes and user behavior isn’t defined.

As is with most studies, the authors conclude that more research is needed. In particular, findings need to be explored at a number of organizations or by using a multi-center setup. It would also be helpful to those responsible for maintaining CDS to have a user-friendly way to visualize the suggestions coming out of the model as they’re rendered. It will be interesting to see if the EHR vendors that already have alert management tools will embrace the idea of incorporating AI to make those tools better or whether they’ll choose to leverage AI in other more predictable ways.

Is your organization looking closely at alerts, and trying to minimize fatigue? Have users noticed a difference in their daily work? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/22/24

Many parts of the US are starting to emerge from winter weather, and the healthcare IT folks are starting to emerge from their relative slumber to head into spring conference season. ViVE kicks off in Los Angeles this weekend, and if you didn’t register as an early bird you’ll be shelling out $2,995 for registration. Compared to that, HIMSS looks like a bargain at $1,675, although the ViVE people will remind you that their registration also includes breakfast and lunch plus its “Industry Night” celebration, although I haven’t yet seen mention of the headliner for that event.

Conferences have gotten expensive, and even the non-flashy ones will cost you a decent chunk of change. I’ll be attending a more academic/professional-focused conference later this spring, and when you add up all the costs – registration, travel, lodging, and meals – I’ll be spending at least $2,500 to attend, not to mention the cost of the time away from work. Sure, I’ll be getting some continuing medical education credits, catching up with friends, and doing some networking, but even if your employer is willing to subsidize your attendance at conferences, it’s hard for physician leaders to justify going to more than one per year. One of my local health systems still has a so-called “travel ban” in place, mostly due to finances rather than concern about infection control or staffing. Seems to me like just one more thing being attributed to the “new normal” post-COVID.

Nearly everyone around the virtual water cooler today was talking about Teladoc Health’s stock tanking Wednesday. The company released its financial results after the close of the market Tuesday, and the market provided its answer as the stock slipped lower. Like every company, Teladoc has had its ups and downs, but growth has slowed over the last three years despite a rise in consumer demand for virtual care services. As is the case with many companies, the combination of bad investments and bad management are difficult to overcome. Telehealth is a tough business to be in, especially when you’re trying to meet not only the regulations of 50+ US states and territories but also those of an international market. We’ll just have to see what the next couple of quarters brings for this company and whether its future can be salvaged.

For organizations participating in the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS) Quality Payment Program (QPP), the data submission portal is now open for the 2023 performance year. Eligible clinicians have until April 1 at 8pm ET to submit their data via the Quality Payment Program sign-in page. If you don’t already have your login information, I’d recommend starting that process now even if you don’t have your data ready for submission, as it can take a couple of weeks to get access sorted out. For those of you submitting, I’d be interested to hear how the process of data preparation is going. If you’re relying on vendors to help you get the data ready, when do they project you’ll have it? Or are you having to do the entire lift yourself? Feel free to send your anonymous feedback about the process and we’ll share it with readers.

A movie that has stuck with me over time is “Up In the Air” starring George Clooney. For those who may not have seen it, Clooney’s character Ryan Bingham works for an organization that helps companies outsource corporate layoffs. He has a variety of ways to help label what is happening to impacted employees, along the lines of “making you available to the workforce.” A reader shared a couple of examples from recent layoffs: Citi recently referred to the loss of 20,000 jobs as helping to create “a simplified operating model” and UPS described 12,000 layoffs as trying to “fit our organization to our strategy.” Other bad phrases I’ve heard include “involuntary career event” and of course the dreaded “rightsizing.” The worst I heard recently was when American Airlines labeled their January call center layoff as a way to “better serve our customers.” Anyone who has ever waited in the interminable phone queue understands what an oxymoron that is.

Here’s another solution in search of a problem: The American Board of Family Medicine has created a new Digital Credential program, designed to provide physicians with a way to share their board certification status “through a live online platform” targeted for social media, email signatures, websites, and more. It also offers the option to add the credential to mobile wallets, “allowing you to quickly share your board-certified status on the go.” The number of times that anyone other than a Credentials Verification Organization has requested proof of my board certification is zero, so I’m not sure physicians were clamoring for this. I tried to use the system’s functionality to automatically add the credential to LinkedIn, only to have it try to add my board certification with today’s date rather than the actual issuance date many years ago. I’m still shaking my head and wonder how much our professional organization spent on this.

Baptist Health South Florida is using the fact that February is American Heart Month to offer “special pricing” on CT Calcium Scoring tests. Patients without insurance (or those who have insurance that does not consider the test a covered service) can have the test for $49 as long as they have a physician order. For those of you who have insurance and have not met your deductible, you’re on your own to figure out how much it will cost. I’m in favor of making healthcare accessible to all, but I don’t like the idea of a hospital organization using this as a loss leader to attract patients who might potentially need more costly services. These are people’s lives – not a rack of rotisserie chickens at Costco.

Many of the patients I see are struggling financially, so I’m always looking for free resources that will help support their health goals. I stumbled upon this video from the National Health Service in the UK and was immediately drawn in since it promotes belly dancing as an aerobic workout that can help improve flexibility and core strength. It also advertises mood-building benefits through music and exercise. If you’ve got 45 minutes to spend on your health, it’s worth checking out. The video does include a disclaimer that the program is “suitable for most people in good health with a reasonable level of fitness” and that you should get advice from a healthcare professional before trying it if you’re not sure about your current level of fitness or if you’ve had recent injuries or health conditions such as a heart attack or operation.

What’s the best you’ve seen as far as free tools for health promotion? Is belly dancing your new breaktime activity? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/19/24

For the past 20 years or so, I’ve volunteered to work on Super Bowl Sunday so that my colleagues who are die-hard football fans or longstanding party hosts can do their thing. If I’m working in a low-acuity emergency department or in an urgent care, the day is usually slow, although more patients present as soon as the game ends. Back when I was doing my training, I spent one Super Bowl Sunday covering a busy Labor and Delivery unit. It was eerily slow until the end of the half time show, and then things became wild as women headed in after realizing that sheer will power wasn’t going to keep their babies from arriving. Sometimes it’s slow enough to catch at least some of the commercials, but usually I end up reading after the fact about which ones caused the most conversation.

This year, I was surprised to see how many people were talking about healthcare-related commercials. Although most of them were local or regional, at least one ran nationally and received plenty of coverage. Patient advocacy organization Power to the Patients aired a public service announcement featuring rapper Jelly Roll, country performer Lainey Wilson, and singer-songwriter Valerie June. It called for healthcare price transparency and specifically called upon the US Congress to pass laws to support it. Points made during the ad include that 100 million people in the US are “drowning in medical debt” and that the greed of hospitals and insurers is “destroying the American dream.” Reports indicated that the campaign also had planes flying banners through the skies above Las Vegas.

Other organizations making a Super Bowl spend included:

• Connecticut’s Hartford HealthCare and Yale New Haven Health with competing ads.
• New York’s Roswell Park Comprehensive Cancer Center.
• Wisconsin’s Bellin Health.
• Tennessee’s Niswonger Children’s Network (part of Ballad Health) and St. Jude Children’s Research Hospital.
• Pennsylvania’s OSS Health.

I understand how organizations want to toot their own proverbial horn, but even the cheapest Super Bowl ad represents a lot of dollars that could be used to do things like provide patient care, support staff, improve facilities, and more. The reality is that organizations spend a tremendous amount of money on advertising. Case in point: A recent article noted that Atrium Health is paying $1.5 million over five years for naming rights at an amphitheater in Macon, GA, stating that “music is a great way to bring people together, and we know that strong social relationships have been associated with improved physical and mental health.” Atrium also paid to name a local minor league stadium in Kannapolis, NC, after the health system. They’re four years into a 10-year deal, so I wonder what kind of return they’re getting on their investment. It seems like an enduring presence at a local facility will get more attention than a fleeting Super Bowl ad.

Hospitals weren’t the only healthcare players getting in on the advertising game. Pfizer had an ad featuring the music of Queen that focused on its vision for the future of cancer care. Astellas Pharma promoted a menopause treatment that retails for $660 per month. MangoRx added an ad for its erectile dysfunction treatments to round out the health-related content. The United States is one of the only developed nations where direct-to-consumer advertising is allowed, and most physicians I talk to wish such campaigns would go away. In my experience, nearly all of the patients who follow the advice to “ask your doctor if drug X is right for you” would benefit from other (usually less expensive) treatments than the one that was featured in a glitzy marketing campaign.

I would be interested to see some industry data that shows how much the average hospital or health system is spending on marketing efforts and what they believe is their return on that investment. For example, we’ve all seen so many renaming and rebranding efforts that it feels like it’s impossible to remember who is who. One of our local hospitals spent a ridiculous amount of money putting a new light-up sign on the top floor of the hospital, replacing the existing light-up sign. This one is 50-percent larger and is borderline distracting when you’re on the freeway, and offers no other redeeming value – not even a conversion to more energy efficient LED lighting.

I continue to see hospitals that are penny wise but pound foolish. One local facility has a significant problem with employee turnover. Nurses are jumping ship because pay isn’t keeping up with local competitors. Instead, nurses are bouncing from hospital to hospital every 12 to 18 months in search of better pay and benefits. The lowest-paying hospital is losing tons of money due to the turnover costs, not to mention the loss of institutional knowledge and community reputation as nurses don’t hesitate to tell friends and family how “cheap” hospital administration is. Sure, administrators have controlled salary costs in the short term, but at what long-term cost? It seems that doesn’t really matter, since there is churn at the administrator level as well and people leave when there are too many questions. Still, the hospital supports various local sports teams, but it’s a sad day when it can’t prioritize reduction in nursing turnover. Another local hospital ended hot food service for overnight workers, which I suspect isn’t going to be a real satisfier for those who are on the night shift.

I’d be interested to hear from anyone who works for one of the institutions who made a Super Bowl ad purchase, or who is a consumer of healthcare in their region. Are you proud that your organization showcased its expertise or are you left scratching your head because you know they’re claiming financial hardships that should exclude a Super Bowl ad from the budget? Even if you don’t have an institutional connection, what do you think about healthcare organizations advertising in general? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 2/15/24

I’m always amazed when people want to use EHRs to drive non-EHR behavior, almost forgetting the concept of free will. A friend reached out to me to ask if I knew how to configure Epic EHR tools to help her track how much time she spends using the EHR on her days off, which includes work done during weekends, holidays, and when on vacation. She said she felt “blown off” by the IT team after opening a help desk ticket since they are only tracking so-called “pajama time” on scheduled clinic days. She feels that tracking the data on weekends and non-clinic days would help motivate her to work less. I explained how IT teams manage their work and how they typically focus on system enhancements that would benefit large numbers of users and explained that she’s essentially asking for a one-off behavior modification program. I offered some options for free time-tracking software on her phone, which I think would be even better, since she will have to consciously decide that she’s going to start her timer and use the EHR versus “just popping in for a moment” as she has become used to doing.

In talking through it, she never thought about using any other way to track her time – such as an old-school notebook or even a time-tracking app. I also mentioned the importance of tracking other time-sucking ways she spends her day, including social media, random internet surfing, online shopping, and more. Sometimes we just need to take responsibility for our own choices, and it’s not always the IT team’s job to figure it out or the EHR’s responsibility to track it. Of course, I know that EHRs have a way of wasting a lot of clinician time, especially if their organizations don’t have policies and procedures in place that allow clinicians to work at the top level of their licensure. However, this particular physician also admits she brings her own laptop to work so she can do things that aren’t allowed on the office computers, so I suspect the problem is much larger than her ending up doing work on the weekends.

I recently took over a new volunteer position and was given access to a shared drive full of documents and files with the advice that “everything you need is in there.” The extremely painful process of going through the folders reminded me of how spoiled I have become working for high-performing organizations where version control information is required to be clearly present on every document. Sure, you can access that information electronically from within the applications, but for long-standing documents, that can require a lot of digging. It’s also helpful to see who authored the document, the business reason for its creation, and a high-level overview of key changes that have happened along the way. You can bet that when I hand off the materials to the next person, the documentation will be a little stronger. I’m trying to dig through them with a glass of wine in hand, but I’m afraid my cellar will be empty before I get through all of the documentation.

Happy 30^th birthday to the Journal of the American Medical Informatics Association. The publication launched in 1994 and has had significant growth during its lifespan. The journal’s 2023 statistics: 1574 submissions received with 254 accepted for publication. Here’s to the next decade of quality clinical informatics literature.

From Cube Dweller: “Jayne, I appreciate your ongoing coverage of the return to office situation. I’m one of those people who has enjoyed being in the office all along, mostly to get away from my children and have a bit of peace and quiet. Now that all these hybrid people are being forced back to the office, our management is making us have all kinds of forced fun to welcome them back. I wish they’d take a page from this article about how to not make it feel like a bad middle school mixer.” I appreciated the content of the article, which shared one company’s idea of a better way to get employees to connect. The employer profiled is Verkada, which provides security equipment. CFO Kameron Rezai created what they call the “3-3-3 program,” which offers a reimbursement of up to $30 each for employees who meet at local businesses in groups of three or more after 3pm. Rezai cited autonomy as one of the goals of the program, stating, “We trusted our employees to go out and make their own connections.”

Since the program’s inception in April 2023, the company has had good uptake, spending more than a half-million dollars from a fund that formerly paid for structured events. As someone who has felt the pressure of trying to plan workplace events that have something for everyone, this feels like a win-win. Want to go hike with your coworkers and get a beer afterwards? Check. Want to visit a local tearoom or coffee shop? Check. Chill at the local gelato shop after a long day of meetings? Check. Staffers do have to post event snapshots before they file their expense reports, which I think would be great for helping others generate ideas. This would also potentially scale to remote workers, who could arrange delivery of snacks and drinks then hop on a virtual meet and greet together. Local businesses also benefit, so that’s another plus.

I’m mentoring a young clinical informaticist, and we have a lot of conversations about study-related concepts such as statistical power, correlation, and causation. There are so many studies out there that “link” different concepts or events together, which may have a tangled web of causes. My mentee brought up a recent Epic Research study that noted that for patients in the emergency department, there was a correlation between providers having access to outside records and a reduced risk of a “code blue” event. The article notes that previous research has shown a link between the presence of outside medical records information and patient outcomes such as visit length, tests and diagnostics that are ordered, admission rates, and even charges.

As someone who has spent a long time working in the emergency department, I understand that piece – having more information helps you better understand a patient’s current state and how their various health conditions have progressed. You can also see if they had recent testing that would reduce what you need to order today, or the presence of data can make a comparison easier. From a code blue standpoint, my experience is that those events are most closely tied to the patient’s current presenting problem: major trauma, heart attack, respiratory failure, etc., and are less closely tied to chronic conditions. As a scientist, it’s fun to find things that correspond, but the best studies are those that generate actionable data that can be used to improve patient outcomes. Maybe I’m missing something here, so if you’re seeing what I’m not, please clue me in.

My mentee is also working on a public health project that looks at foodborne illness and came across what can only be described as an attention-grabbing title: The Great Michigan Pizza Funeral. The “ceremonial disposal” of nearly 30,000 frozen pizzas occurred in Ossineke, Michigan on March 5, 1973, following a recall due to concerns about botulism-causing bacteria in mushrooms used to top the pizzas. The pizzas were placed in an 18-foot deep grave with the governor of Michigan in attendance. Later testing revealed that the mushrooms were not indeed contaminated, and that laboratory mice found dead during the initial testing suffered from an unrelated infection.

What kind of pizza would you never eat, unless it was the only food left to sustain you? Which is best – thin crust, thick, or pan? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 2/12/24

Several of good friends from medical school hold significant physician leadership roles. I always enjoy catching up with them and hearing what is going on at their hospitals, as well as trading ideas for solving the different kinds of challenges our organizations are facing. Sometimes one of us has already been through an issue and there’s no sense in reinventing the proverbial wheel when you don’t have to.

Although my colleagues are knowledgeable about their own departments as well as those that they have to work with closely, they don’t always have the broad view of hospital operations that I have as an informatics leader. I think that when working with large enterprise EHR implementations, clinical informatics leaders are just conditioned to make sure that we are thinking about every part of the hospital as well as systems that aren’t even under our roofs, such as emergency medical services, transfer infrastructure, and more.

Regardless of region or state, everyone is facing hospital overcrowding. When there aren’t enough inpatient beds available, patients start backing up into the emergency department. The root cause of the inpatient bed shortage is multifactorial. Sometimes physical beds are lacking, and sometimes there are actual beds open but the shortage is one of staffed beds. There just aren’t enough personnel to keep a unit open.

Although many disciplines are in short supply, including respiratory therapy, the major issue I see in my region is still a nursing shortage. Hospitals in our area are still playing games with nurse compensation and have instituted staffing policies that negatively impact nurses and their families. Of my friends who are nurses, all have left hospital care except one, and I guarantee if she worked on a medical/surgical unit, she would leave, too.

Unless people are actually impacted by these shortages, they don’t tend to get engaged around the policy work that is needed to solve the problems. I was excited to see NBC News bring some of these issues to light this week, as it reported on the potential end of funding for Hospital at Home programs at the end of this year and how that end might worsen already tragic emergency department (ED) overcrowding.

CMS created the program, which is officially called Acute Hospital Care at Home, in 2020. The program allows hospitals to deliver high-acuity care to patients in their homes, where they receive visits from community paramedics and are connected via technologies such as video visits and home-based monitoring systems. The programs can help boost ED throughput by admitting patients back to their homes rather than potentially having to board them in the ED while they wait for a physical hospital bed.

Although more than 130 health systems have been approved to participate, it’s difficult to understand how many are truly bought in or what level of resources are being dedicated to program initiatives. Even if they are participating, hospitals may be left dangling at the end of the year unless Congress votes to extend funding for the program. Although some private payers are participating, CMS still provides the majority of funding for programs.

Even for those organizations that have embraced Hospital at Home programs, their impact is incremental. Atrium Health, for example, is treating 60 patients per day in its program in North Carolina and hopes to ramp that up to 100 patients per day by the end of 2024, which is a fraction of its total count of inpatients. If Hospital at Home programs are sunset, patients who might have been referred to them are instead going to need regular inpatient beds, which will further worsen the situation in systems where those programs had been successfully making a difference.

Policymakers need to look at other causes of ED overcrowding. In addition to the shortage of staffed beds on medical/surgical units, there are fewer beds available in nursing homes, psychiatric units, and rehabilitation facilities. Mental health services are in short supply everywhere, with families sometimes bringing loved ones to the emergency department because they feel they have nowhere else to turn. Telehealth solutions can help mitigate this to some degree, identifying patients who might qualify for outpatient management or who need help navigating the system, such as obtaining medication refills or finding a new provider for ongoing care. Progressive states are looking at the upstream causes of the mental health crisis and are allocating money to community programs, but other states seem to be just looking the other way.

The report also mentioned other pitfalls of our state-by-state patchwork of healthcare solutions. It looked at data from Massachusetts hospitals, including data on patients who are boarded in the emergency department while they wait for beds in the hospital. It profiled the venerable Massachusetts General Hospital, which has been boarding at least 45 patients at a time for more than a year, and in January of this year hit a count of 103 boarders with 220 people across the state in the same situation. The hospital considers this to be a “capacity disaster” and has asked the state to approve additional beds to help the situation.

They have also instituted a Hospital at Home program and have created a Discharge Lounge to help speed patient departures from the hospital building. Patients can wait there for their caregivers to pick them up, rather than remaining in a standard hospital room. That intervention helps 125 patients per month leave more than 60 minutes earlier, which will add up over time and as the program is expanded. The hospital is also providing transportation services to help patients leave when they don’t have reliable transportation.

Other solutions that can help make beds more available include virtual nursing care, where offsite nurses can work with patients and families to deliver patient education and discharge teaching, freeing up bedside nurses to deliver care that must be rendered by an in-person nurse. Virtual nursing programs in my community are keeping nurses that have been placed on light-duty restrictions active in patient care, rather than sidelining them. The technologies can also be used as a “phone-a-friend” solution for early career nurses to bring in a second set of nursing eyes to evaluate a particular patient. Having been a newly minted intern, I appreciate the idea of using technology to consult dedicated virtual resources rather than having to interrupt colleagues who are already knee-deep in patient care of their own.

The NBC News report goes on to note that Massachusetts is “unique” in the way that it keeps statistics on emergency department boarding, and that many states are lacking high-quality data on the problem. I know my own state doesn’t do a good job of tracking it, let alone communicating it, which means that citizens in our communities have no idea there’s as big of a problem as there actually is. The majority of my neighbors and friends in the community think that because COVID is “over” and there aren’t daily stories on the news about how bad things are at the hospitals, that everything is fine. That is, until a loved one sits for 17 hours in the waiting room before they see a physician. But it’s unclear if those experiences translate to actions, such as lobbying one’s legislators.

Demographics are shifting in the US, with increasing numbers of elderly patients and more of us who are living with chronic conditions. We are not spending enough money on preventive care, health promotion, or disease prevention, so the problem is likely to get worse before it gets better. Let’s hope that stories like this help to raise awareness and generate change so that we don’t continue in the downward spiral in which many of us feel trapped.

Does your organization support Hospital at Home activities, and how are they going? Leave a comment or email me.

Email Dr. Jayne.