EPtalk by Dr. Jayne 6/6/24

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

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

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 6/3/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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EPtalk by Dr. Jayne 5/30/24

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/23/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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Curbside Consult with Dr. Jayne 5/20/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/16/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/13/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/9/24

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 5/6/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 5/2/24

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/29/24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/25/24

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/22/24

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

EPtalk by Dr. Jayne 4/18/24

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

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

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

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

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

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

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

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

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

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 4/15/24

I spent this weekend at a class reunion for my medical school. They host a reunion event every year, but the attendees are only invited in five-year increments. It was interesting to see the breakdown of registrations. No one attended from the class of 2019, which seems expected since those physicians are likely still busy with training or are in their first few years of practice and might have trouble getting away. The class of 2009 also had no attendees, but many of the other classes had about a dozen members in attendance. The class of 1974 knocked it out of the park with 31 attendees. The oldest representatives were from the classes of 1954 and 1959, which each had one representative. My class is distinctive because we were the first one to have more women than men. I was speaking with a woman who graduated five years before me (and who happened to be one of my chief residents when I was on clinical clerkship rotations) and she mentioned that she was one of only 20 women in her class. It’s amazing that the university was able to shift the demographic that dramatically in only five years.

The weekend was full of educational events, campus tours, city tours, and several social events. One of the highlights of the week was a scholarship dinner, attended by some of the scholarship recipients as well as those who had donated to class gift funds that provide scholarships. I had three students at my table – one was in his first year of medical school, and the other two were in their third years and were knee-deep in clinical rotations. It was interesting to hear about the specialties they find most interesting and what they might plan to pursue as a career and why. Primary care is at the bottom of the list, at least among the students I talked to throughout the weekend, despite the university moving towards a “zero debt” financial aid program that is supposed to allow students to “follow their dreams without fear of student loans.” It became apparent in other conversations that the university is really pushing for students to go into academic medical careers, which are historically lower-paying than those in private practice.

Although the members of my immediate graduating class know what I do for a living, nearly everyone else I spoke to started the conversation with “Where do you practice?” and I had to explain my career as a clinical informaticist. None of the people I talked to outside of my classmates knew that clinical informatics was a board-certified subspecialty or that you could make a career out of it. Upon learning what I do, several attendees went into some pretty serious rants about how electronic health records have destroyed the practice of medicine. Fortunately, most of the social events allowed me to keep a gin and tonic in hand so that those conversations went more smoothly than they might have otherwise.

Of the members of my class attending, only two are still in full time clinical practice. The rest are either in academic positions where they only see patients one or two days per week, or they are in pharmaceutical or other industry roles where they no longer perform patient care. As someone who is trained in primary care, I’ve had plenty of times in my career where I’ve felt bad about not being in full-time clinical practice – that I’m part of the physician shortage problem. However, looking at what my colleagues are doing, I don’t feel so bad. Even when I’m not seeing patients, I’m generally working on projects that are directly applicable to patient care and helping those on the front lines be able to deliver it in a more seamless way with less burnout.

Speaking of burnout, I wasn’t surprised to learn that the most burned out member of our class is in emergency medicine. She was talking about working during the worst parts of the COVID pandemic and about not having appropriate personal protective equipment. Her comments immediately took me back to being in that same position four years ago. Others in the conversation acted like it was their first time hearing about such things, and it sounds like most of them spent the pandemic doing administrative tasks, performing research, or seeing patients via telehealth. She mentioned the push of private equity organizations into the emergency medicine staffing space and the fact that it’s driving people out of practice. Fortunately, one other class member who happens to be in a specialty heavily impacted by private equity acquisitions (dermatology) took up that charge and spoke about how that transition has nearly destroyed practices in his city. His private practice is a holdout and continues to do well, although he admits they did consider being acquired but felt it would be a bait-and-switch situation.

Our class was about 50/50 with medical versus nonmedical spouses, and in contrast to previous years, only a couple of spouses showed up to all the events. I guess by this point in their lives they figured that listening to their spouses reminisce about graduate school wasn’t the most exciting way to spend an evening, especially when a ticket purchase was required. It will be interesting to see who is still in clinical practice when we meet again in five years, and who has decided to hang up their white coats for good. Speaking of white coats, our school’s students now receive theirs during the first month of school as part of a professional initiation ceremony, complete with the class writing its own oath of professionalism and with many family members in attendance. The students I had dinner with were surprised to learn that we received ours folded up in plastic wrappers from the bookstore, only a couple of days before we went to our clinical rotations. We certainly didn’t have luxurious coats embroidered with our names and “Prominent School of Medicine” logos.

I’m glad those in charge have improved things in the intervening years, but a bit sad that they hadn’t figured it out back in my day. Our alma mater has completely revised its curriculum, integrating clinical experiences very early in the first year and encouraging students to take elective courses in areas they find interesting. Compensation has improved for those teaching, which hopefully means fewer professors that act like it’s a chore. The facilities are top notch, and I wish we had access to advanced simulation labs rather than having to practice certain skills on each other or even patients. It’s nice to see things changing for the better and I wish these up and coming students the best.

What do you think about the future of your profession? How can we do better for the coming generations? Leave a comment or email me.

Email Dr. Jayne.

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.