EPtalk by Dr. Jayne 12/7/23

Researchers at Brigham and Women’s Hospital, Massachusetts Institute of Technology, Celero Systems, and West Virginia University have created a new ingestible device that can monitor vital signs such as respiratory rate and heart rate. The so-called Vitals Monitoring Pill uses an accelerometer to pick up small movements in the digestive system that occur each time the patient’s heart beats or they take a breath.

The device was initially validated in an animal model, then used for humans as part of a sleep study trial. Although the study was small with only 10 patients, researchers found that the data the device collected was comparable to that collected using standardized monitoring equipment. The study was also limited by the fact that participants were either sleeping or resting in a bed and the authors note there is the need to evaluate it in a more natural environment.

Researchers plan to focus on modifications that could keep the device in the digestive system for up to a week and to develop systems that could release medication in response to certain readings. They propose to be able to use it to detect opioid overdoses and treat them without external intervention.

From ShowMe: “Re: the state of Missouri. The last one in the nation to get on board with a prescription drug monitoring program (PDMP). For several years, in the absence of a state solution, the St. Louis County PDMP has been the de facto solution and other counties participated. Missouri is finally rolling out their solution next week, but users have been warned that they’ll have less functionality with the new solution. Way to go, technology.” I reviewed the materials forwarded by ShowMe and it looks like providers will lose the interstate sharing options they previously had through St. Louis County’s PDMP. Instead, they’ll have to separately register for access to neighboring states and use those individual state PDMPs to perform queries. Illinois requires that registrants of their PDMP have an Illinois controlled substance license, which many Missouri physicians may not have, so drug-seeking patients may be able to exploit the data gap. Additionally, not all counties have agreed to transfer their historical data from the St. Louis County solution to the state solution, so gaps will exist there as well. Physicians have been asked to “please keep this in mind when making clinical decisions. As a result, co-prescribing of naloxone with opioid prescriptions is recommended.” Technology is supposed to support clinicians rather than cause new issues, but I guess it’s to be expected when a state is dead last at doing the right thing. Missouri was one of the last states to bring up an immunization registry, if I recall correctly.

From Jimmy the Greek: “Re: return to office. My organization’s leadership has asked us to ‘practice’ working in the office. Having spent more than half of my career in an office, the idea that I need to practice coming to the office before I do it for real is insulting.” Jimmy’s screenshots made my head spin. Although I appreciate the company’s sentiment, there are ways to offer the same information without being patronizing. Despite this being a team of IT professionals, they were encouraged to come to the office for a “dry run” to test the wi-fi, headsets, and desks as well as to experience the parking arrangements and practice booking a conference room and eating in the company cafeteria. Additionally, employees were told to test their commute to evaluate travel time and traffic considerations, but gave no mention of the fact that hundreds of employees returning to the office are going to totally change the traffic patterns around the facility. As someone who has been a people manager in both remote and in-person situations, I’d like to think that managers know their people well enough to know who has worked in an office setting before and who might be at risk for issues or might require extra support. At a minimum, the organization could have offered a free meal to help entice employees back.

The Joint Commission has unveiled a new certification which will become available starting January 1. The Responsible Use of Health Data certification will evaluate hospitals across key areas including deidentification, data controls, data use, algorithm validation, patient transparency regarding deidentified data, and oversight structure for use of deidentified data. It will be interesting to see how organizations prepare their employees for this certification and whether clinicians will discover that there is so much more to using health data than they realize. I recently was in a spirited discussion with a clinician who had been ignoring a patient’s request for an amendment to their medical record. When the chair of the compliance committee and I informed the clinician that this was a violation under HIPAA, she said we were “full of crap, because no patient information was shared.” It had never occurred to her that HIPAA covers much more than information sharing, because the organization’s training had a narrow focus. A follow up survey to other clinicians revealed that 90% of them didn’t know patients had a right to request an amendment and 12% thought it was acceptable to just ignore patient portal messages. It looks like this organization has some work to do, not only in education, but also in fostering professionalism.

NorthShore-Edward-Elmhurst Health has rebranded itself as Endeavor Health as a follow up to the $5.3 billion merger that was responsible for its creation. The transition effort will include new names for its hospitals as well as updated employee uniforms, websites, and of course a social media campaign. Statements from leadership were around the “inspirational and aspirational” nature of the name, but when I hear it, I only think of the similarly named PBS program. I wonder how the cost of a health system rebrand compares with filming a gritty period drama, but suspect the latter has a better return on investment.

After considerable good-natured cajoling by younger colleagues, this blog marks my first attempt at trying to stop using two spaces after a period. As someone who is in my fourth decade of touch typing and who learned on the venerable IBM Selectric, I can attest that it’s hard to learn new tricks. Objectively, the process change added frustration and reduced my typing speed significantly, but I found the mental overhead to be the worst. I think I’ll go back to the old ways that will die with me, along with the use of handwritten thank you notes, formal invitations, and knowing how to set a table to accommodate a five-course meal.

One space or two? Is it worth it to try to eliminate the extraneous keystroke? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 12/4/23

I was invited to yet another retirement party this week. It was again for a primary care physician who is leaving medicine at an age that is decidedly less than the oft-discussed 65.

Burnout played a role in every retirement gathering I’ve attended over the last couple of years. It’s sad to see so much knowledge and experience leaving the field. More than half of these physicians would have been interested in continuing to practice part time, but it sounds like their corporate employers weren’t terribly interested in trying to make that happen. The practices they left continue to be slammed and have wait lists for new patient appointments that are several months long.

Most of my local primary care physician peers are a number of years away from being able to retire. I struggle to think of one colleague who isn’t suffering from some degree of burnout.

When asked what might help the dumpster fire that is healthcare in the US, quite a few cite artificial intelligence as the answer. Just use ChatGPT to write your prior auth letters! Or insurance appeals! Or letters for emotional support animals, educational modifications for school-aged patients, Family and Medical Leave Act documents, and more! The enthusiasm that people voice about these solutions seems to be contagious, but it’s rare that those who are using it fully understand the risks of feeding protected health information into different solutions, or that they can be liable if they’re allowing staff to use AI solutions for patient management but aren’t doing 100% review of the output.

With this in mind, I was excited to read a special communication in last week’s Journal of the American Medical Association titled “Will Generative Artificial Intelligence Deliver on Its Promise in Health Care?” If the title alone wasn’t enough to catch my attention, seeing Dr. Robert Wachter listed as the first author definitely helped.

Wachter and his co-author Erik Brynjolfsson note that historically, it usually takes many years for technologies to deliver promised benefits. Because healthcare is such a complex environment, this can make the incorporation of new technologies even more challenging. They go on to say that generative AI is different, though, and has “unique properties that may shorten the usual lag between implementation and productivity and/or quality gains in health care.” They also note that not only are health organizations more receptive to the technology, but that many “are poised to implement the complementary innovations in culture, leadership, workforce, and workflow often needed for digital innovations to flourish.”

The latter is an interesting point, especially since I’m often working with organizations that struggle to implement “innovations” that are more than a decade old. These solutions may not be heavy on technology, but are often fairly straightforward people and process adjustments that have the potential to improve patient care, reduce staff and clinician frustration, and create more efficient interactions in the healthcare system. Often they are relatively inexpensive to implement, but require the sometimes elusive stakeholder alignment in order to bring them to fruition.

Given all the buzz around AI-related solutions, I’m starting to wonder whether we can slap a label on them that says “AI-driven” and use that as a way to convince people to take some steps towards making their organizations run more efficiently.

Turning back to the JAMA article, some interesting facts jump out. First, nearly one-third of the $4.3 trillion that is spent in the US each year adds little to no value. I’ve seen that first hand in the urgent care trenches, where patient demand for testing and imaging studies often overshadows the physician’s judgment, particularly when an organization places a high value on patient satisfaction scores. Clinicians are trained to use a variety of clinical decision support rules to determine whether someone needs an x-ray after injuring their ankle, or whether a child needs an imaging study when they fall off their bed. However, insistent patients or parents may push or escalate, resulting in thousands of dollars in healthcare spending that could have been avoided.

It feels like we’re rarely able to make clinical diagnoses anymore, relying on the history, exam, and our education and training. Instead, we have to perform laboratories to prove ourselves sometimes, even when the answer is very straightforward. One organization I worked at pushed clinicians to order unneeded medications that could even be harmful, in the guise of “patient satisfaction.” Needless to say, I frequently wound up on the wrong side of that organization’s quality reports, but at least I had my integrity.

Second, preventable harms are still a major problem in the US, with tens of thousands of deaths happening each year due to situations that could have been mitigated. These range from simple medical errors that might be prevented with the application of basic technology (such as allergy warnings that appear when medications are prescribed) or complex errors that result from multiple failures along the way. Those can be particularly hard to work through as a clinician, since there are often many steps where the problem could have been prevented, but the system failed regardless. Electronic health records were initially seen as a solution to these difficult situations, but some days it feels like they have created two new problems for every one that they solved.

The article goes in depth to describe “the productivity paradox of information technology,” where technologies fail to deliver value. One main reason for this is the flawed nature of many early versions of technologies and the need to have multiple iterations before a successful tool is achieved. The second reason, which the authors view as more important, revolves around “the processes, structure, and culture of the workplace.” I felt validated when reading that sentence since I’ve lived it so often while trying to help organizations with their clinical transformation initiatives. The authors note the need to often have multiple complimentary innovations to overcome the productivity paradox. It’s another way of saying that no silver bullet exists for solving a difficult problem.

They go on to explain some of the “particular challenges” of implementing technology in healthcare. These are the factors that so many companies fail to understand as they promise to fix healthcare or revolutionize the patient experience. These challenges include the highly regulated nature of healthcare, differing opinions on data ownership, the need to protect patient privacy, and the fact that all these factors at times interfere with each other.

They go on to list other challenges, including the fact that the EHR market is highly concentrated with only a few major players left. In contrast, parts of healthcare have a plethora of players, including clinicians, care delivery organizations, payers, employers, pharma, device vendors, government, and more. As such, new technologies are likely to progress when they can make improvements for multiple stakeholders rather than for just one subset of players in the industry.

Other challenges that they list include the fact that healthcare data can be messy depending on where it comes from (billing, clinical documentation, compliance) and that healthcare is constantly evolving, often through research and changes in practice. As such, AI tools that are based on historical patient data may not be applicable in the present and in fact might be dangerous.

Last, they note that healthcare is high stakes, with the very real impact on patients making it potentially harmful to do the “fail fast and iterate” approach that happens in other technology environments. We’ve all seen innovations that harm patients, whether it’s an inadequately studied drug, a faulty medical device, or an improperly implemented clinical decision support tool.

Despite the fact that previous AI technologies haven’t delivered, (IBM Watson, anyone?) the authors see several factors that may lead to improved solutions this time around. They cite the relative ease of use of generative AI as a positive, along with the fact that the technology can be delivered to users easily through devices they’re already using. The ability to interact with new solutions via application programming interfaces (APIs) is also a plus, as is the speed of evolution of the generative AI solutions themselves.

The authors believe that healthcare leaders are better prepared to consider workflow redesign than their predecessors, in part due to the presence of clinical informaticists (yay!) and those with experience in user-centered design. They feel that leaders have learned from past failures as well. They mention the irony that many of the problems that were created by prior digital innovations – such as documentation burden and the EHR inbox – may be addressed by new generative AI powered tools, which would be a lovely thing for all of us.

It will be interesting to revisit the premises of this article after we’re six months or a year down the road. Maybe by the time generative AI reaches its second birthday, we’ll be living in a world of smoother patient care, streamlined communications, and improved clinical quality, all thanks to the wonders of artificial intelligence. It’s more likely, though, that major improvements will still take years, but at least that will be faster than the decades of inertia we’ve all been living in.

The authors call on AI developers to address elements such as bias, safety, cost, and hallucinations. They note that regulators need to develop standards that promote innovation as well as safety. They state that most important is for healthcare leaders to “prioritize the areas where genAI can create the greatest benefits for their organizations, paying close attention to those complementary innovations that remain necessary and striving to mitigate the known problems with genAI and any unanticipated consequences that emerge.”

What do you think about the role of generative AI in coming years? Are we on the cusp of greatness, or heading down the road to ruin? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/30/23

We’ve made it past some of the early fall holidays, and those of us on the front lines are waiting to see if they will cause a spike in respiratory illnesses.

Heading into Thanksgiving, many parts of the US were feeling the pressure already. Respiratory Syncytial Virus (RSV), COVID, and influenza are leading the pack. At one point, all of the pediatric hospital beds in the Dallas-Fort Worth area were full, which should ring alarm bells for those who care about children.

My colleagues at Cook Children’s in Fort Worth mentioned that they were seeing up to 500 patients daily in the emergency department and were boarding critically ill patients in the emergency department because there were no ICU beds. New vaccines for RSV are in short supply in some regions, which will likely add to the problem later in the season.

This week, I ran across a couple of articles that talked about the fact that ChatGPT has only been around for a year or so. Headlines included phrases such as “ChatGPT scared the heck out of us,” and there was a lot of retrospective thought about whether its launch opened as big of a Pandora’s box as everyone thought it might.

Generative AI has certainly matured over the last year. There’s still a lot of hype about how it’s going to transform the way people work. One suggested that managers use AI to help define ambitious deadlines for projects that are underway, or that they can use it to create motivating speeches for their teams. It went on to say that AI could help identify ways to make the workplace more exciting.

Another gave the idea that AI could be used to create employee satisfaction surveys and to process results to determine how employees want to be incentivized. I kind of like this one since I’ve worked for several employers that totally disregarded employee sentiments. Maybe because AI is such a darling, they’ll pay attention to those results just because they were processed using a tool versus a basic employee survey. One article brought up an interesting tidbit about OpenAI’s GPT-4, namely that certain restrictions can be bypassed by using less-common languages such as Gaelic or Zulu. That’s definitely interesting, and you can bet I’ll be playing around with that idea.

Just a few days prior to the Veterans Day holiday in the US, the Department of Veterans Affairs (VA) met its goal of enrolling one million veterans in its genetic database, aptly named the Million Veteran Program. The database is unique because it links genetic information with electronic health records and also includes information on diet and environmental exposures. Researchers have been working for 12 years to reach the goal. Compared to other genetic databases in Europe, this one represents a more diverse population. The data is only available to physicians and scientists at VA facilities. Veterans can continue to enroll either through the link above or by calling 866.441.6075 to make an appointment at a VA facility.

Although the VA’s EHR project certainly gets a lot of press, there is so much more that the organization is doing to support veterans. It’s a vast organization, with locations from coast to coast. This year, the Veterans Health Administration delivered 116 million patient appointments at 1,300 facilities, beating the previous record by 3 million. It’s not only a care provider, but manages benefits applications and compensation programs, which necessitates maintaining a different staffing profile than other healthcare organizations. It’s also responsible for delivering services around those parts of its business. To give you an idea of scale, its Health and Benefits App reached 1 million downloads this year.

The VA is also actively investing in the artificial intelligence space, working on tools to reduce employee burnout. It plans to launch an AI-related contest that features $1 million in prize money for teams that create the best solutions in speech-to-text for medical appointments and in document processing as non-VA medical records are added to the patient’s VA chart.

Several of the physician groups that I follow on Facebook have had an overwhelming number of posts about cybersecurity incidents. Since organizations tend to take their entire network down when there is an incident, that means that physicians have no access to downtime solutions such as disaster recovery servers or third-party information archives. Although the health systems in question typically put out press releases that state that patient care is being delivered safely and effectively, comments from the trenches seem to reflect an environment that is anything but:

• No ability to look up labs.
• No way to access history and physical forms for surgical procedures.
• Hand writing operative reports.
• Clinicians who are relatively new grads have never charted on paper.
• Systems haven’t practiced for downtime events, resulting in mass chaos.

One clinician whose system recently went through a cybersecurity event but is back online noted that she recommends keeping copies of all handwritten notes. Apparently, many were lost during the event and were not scanned or otherwise added to the system, resulting in requests for her to redo documentation weeks after the event. Another reported that his hospital was down for over a month, which as a clinician, I can’t even imagine. Hackers are a reality and organizations that think it couldn’t happen to them are mistaken. I challenge all the CIOs and CMIOs out there to ensure their organizations have adequate supports in place and that they’re practicing for a potential event.

I dropped by my primary care office this week to get a vaccine booster. Despite having just had my photo ID scanned at another office in the same system last week, I had to again present photo ID to be scanned as opposed to just being verified. I could see the previous scan of my photo ID on the receptionist’s screen, since there was no privacy filter on the monitor. I could also see my photo on my patient chart, which matched the already-scanned ID. I understand she was likely just following an office policy, but this is where I challenge people to make sure that the policies in place make sense and/or provide value or whether they’re just process for process sake.

I was also greeted with a 2020-esque COVID interrogation, including being asked if I had traveled internationally in the last six months (yes), whether I had been around sick people (yes), whether I had traveled internationally in the last 30 days (yes), and whether I had any respiratory symptoms (no). There were no follow-up questions to any of the positive responses.

As I sat waiting to be called back, another couple came in, and when asked the question about sick people, they asked, “What do you mean by sick?” It was clarified to be “measles, mumps, or chicken pox.” I suppose I should have been a “no” on that one then. They weren’t asked the question about symptoms. The couple was already wearing medical masks, so I’m guessing the receptionist made an assumption if the intent of the questioning was to determine if patients should have masks. Respiratory season is upon us and it will be interesting to see if the questionnaires morph as the season progresses.

The good thing that came out of that visit is that they pointed out that I had an open order for follow-up testing, which was interesting because the test had been allegedly scheduled during the in-person visit at another office last week. Apparently it hadn’t been scheduled properly, and had I not gone for that vaccine, I wouldn’t have had a clue. Four phone calls later, I finally had it scheduled, and I must say the patient experience component of the entire process has been lacking. At no point during any of the conversations did anyone apologize for the dropped ball, not even a lukewarm “I’m sorry you’re feeling frustrated by this.” It’s not an experience I want for my patients either, which is making me rethink my referral patterns. Where’s a patient satisfaction survey when you need one?

Does your organization actively work to stamp out non-value-added processes, or is it content with simply doing things the way they’ve always been done? Have they shifted processes to put more of the burden on the patient? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/27/23

We’ve made it past the Thanksgiving holiday, and hopefully people were able to spend time with their loved ones and then have a little time on their own to de-stress before heading back to work.

Historically, this time of year brings out all kinds of family drama. Looking at the data from one of the practices I work with, over the past couple of years there have been upticks in the number of visits for anxiety and depression between mid-November and mid-January.

Although I avoided dinner time conversations about Medicare, one family gathering involved a conversation about hospital-affiliated primary care practices that are charging facility fees. Another covered the move of private equity organizations into the local care ecosystem, leading to decreased access as they cut providers from their rosters following acquisition. US healthcare is certainly in a dark spot, and patients are paying the price as they find it more difficult and more expensive to get the care they need.

Local pharmacies have been eager to step into this gap. However, one elderly relative discovered that it wasn’t as easy to get appropriate care as it should have been. She’s in her 80s and has multiple risk factors for severe disease from RSV infection, so she tried to make an appointment for the recently approved vaccine. She walked into a location of a nationwide retail pharmacy chain and was told she couldn’t get the vaccine without an appointment. However, per her recollection of the story, they wouldn’t make an appointment for her, instead telling her to call for one. She called and wound up in a phone tree system, which kept prompting her to choose a location despite the fact that she was standing in one. When she selected the prompt to speak to a representative, it continued to ring, but no one answered.

She went to another location, which refused to administer the vaccine because she didn’t have a prescription. I’m not sure if this was because the pharmacy didn’t have the appropriate standing order in place from their medical director, or if it was some kind of insurance issue, or if they didn’t want to do the counseling since the vaccine isn’t strictly recommended based on age but rather as a part of a shared clinical decision-making process.

Either way, she left without her vaccine and instead spoke to her primary care physician. It sounds like the primary physician isn’t keeping up with the literature, because he told her she didn’t need the vaccine because she “isn’t around babies,” which has nothing to do with the indications for the vaccine. It’s designed to reduce the burden for a disease that hospitalizes more than 60,000 older adults each year and results in up to 10,000 deaths among retirement-age adults each year.

I’m hoping that the EHR team at her primary care physician’s office ensures that the vaccine is added to health maintenance dashboards so that physicians who aren’t keeping current might be prompted to address the condition with their patients. Hopefully that hospital-affiliated organization will also be providing continuing education to ensure physicians are aware of current recommendations, since it’s foolish to assume that technology alone can solve a clinician knowledge gap.

But in the mean time, thinking about my family members, I was tempted to dig out a prescription pad and just write the order myself. I don’t practice medicine like that, though, so I provided some coaching to hopefully help the patient have a better conversation with her physician. In the mean time, I’ll be calling a couple of pharmacies to see if they have standing orders in place that would allow her to get the vaccine.

Is this a place where telehealth-only organizations might help patients that can’t get what they need? Probably not, since many of them won’t allow their clinicians to order injectable medications even if they are low risk, like vaccinations. At one telehealth organization where I worked during the height of the COVID pandemic, we weren’t even allowed to write letters that would have explained that patients were high risk and could receive priority vaccinations. Even though providers on those networks are usually independent contractors, they’re often constrained by group policies that prevent them from doing things that might otherwise be straightforward in a traditional medical practice.

Speaking of telehealth, a recent article in JAMA Network Open looked at how patients complete tests and referrals when those services are ordered as part of a telehealth visit compared to those ordered during in-person visits. The telehealth visits were delivered by providers at a large hospital-affiliated primary care practice and community health center in Boston during the time period between March 1, 2020 and December 31, 2021. The authors looked at colonoscopy orders, dermatology referrals for suspicious skin findings, and cardiac stress tests. They found that only 43% of orders placed during a telehealth visit were likely to be completed, compared to 58% of orders placed during in-person visits. Interestingly, 57% percent of orders placed without a visit (perhaps as a result of a non-visit telephone call, or a patient portal message) were completed.

The authors suspect that one reason for the discrepancy might be the absence of schedulers or medical assistants to help patients during telehealth visits, or the lack of follow up communications encouraging patients to close the loop on their orders. That doesn’t explain why the non-visit orders were completed as frequently as they were, however, unless schedulers were assisting those patients. I would be curious to look at completion rates for orders from third-party telehealth organizations. Some of them won’t even generate orders for patients because they have no way to get those orders to a performing facility near the patient. Others limit their orders to those that can be done as part of an employer wellness program, such as diabetes screening tests or cholesterol testing. Third parties are often worried about liability, and given the transactional nature of many visits, there isn’t a mechanism to follow up on abnormal test results or to easily communicate follow up instructions to patients.

As someone who has done a lot of process engineering work, these are the “people” and “process” parts of the equation, but I continue to see organizations that try to solve them with “technology” alone. I’d love to see more organizations put their money towards solving people and process problems, whether it’s integrating a checkout person or scheduler into a telehealth workflow or making it easier for patients to self-schedule certain tests and procedures or doing a better job of reminding patients of orders that aren’t completed. Certainly, technology is part of all of those solutions, but it’s not the only answer.

How is your organization making it easier for engaged patients to receive the services they need? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/20/23

The Centers for Disease Control and Prevention (CDC) has launched an initiative to tackle burnout in healthcare. The Impact Wellbeing initiative falls under the auspices of the National Institute for Occupational Safety and Health (NIOSH). According to the tagline on its website, it’s designed for “building a system where healthcare workers thrive.” It will provide “evidence-informed solutions” and resources to hospital leaders on avoiding burnout and promoting wellbeing for workers.

I was pleased to see that the website encourages hospitals to use materials from the Dr. Lorna Breen Heroes’ Foundation to address how hospitals can help staff address mental health needs without being penalized. Many hospitals and healthcare organizations still have questions on their employment and credentialing applications that stigmatize mental health conditions rather than supporting those that live with them.

As an example, one job for which I applied asked, “Have you ever been treated for a mental health condition?” with boxes to check yes or no, but no way to provide explanatory information. A better way to approach this is to ask whether the applicant has any current impairment that will prevent them from performing the duties of the position. There are plenty of mental health conditions that are episodic, and asking about past conditions that may be resolved hasn’t been shown to do anything but prevent people from honestly answering the questions.

In looking at some of the other materials on the site, as well as interviews with NIOSH staff that appeared in the media at the time of the announcement, it feels like the organization’s leadership understands that talking about resiliency or offering wellness programs doesn’t scratch the surface where employee mistreatment is concerned. Healthcare workers encounter bullying, harassment, and moral injury on a daily basis and those elements need to be addressed as part of an overall solution.

The initiative also encourages the leadership of healthcare delivery organizations to involve those affected in the process of defining the issues and solving them. I don’t know when it became a revolutionary idea to talk to people in order to understand their needs, but I’m happy to see recognition of the idea featuring prominently in the campaign. Organizers can use the NIOSH Worker Well-Bring Questionnaire to better understand where their workers are across domains that include policies, culture, environment, personal health, and home/community factors.

Although I appreciate that the focus of the campaign is on hospitals since they’re such a critical part of our healthcare infrastructure, I’d like to see these elements addressed in other care delivery sites, such as urgent care centers. There are 14,000 urgent care centers in the US, and according to data provided by the Urgent Care Association, more than 25% of adults visited an urgent care center in the last year.

Unfortunately, the level of regulation for those facilities varies from state to state, and in talking to physician colleagues, abuses are becoming more common as private equity companies expand in the industry. For a while, we saw a lot of emergency department physicians leave those environments to go to the relatively slower pace of urgent care. However, as the complexity of patients presenting to urgent care rises, and the number of patients physicians are expected to see each hour increases, we’re seeing physicians leave those environments as well.

Given the reliance by hospitals on nurses to deliver patient care, there’s a lot of push by nursing organizations to improve things. Since urgent cares use many more non-nurse caregivers — such as medical assistants, emergency medical technicians, and unlicensed patient care technicians — to deliver care at a lower cost, there aren’t many advocacy organizations looking out for those workers.

Quite a few urgent care centers are physician owned and operate more under a private practice model than an emergency care model, so that adds another element to the problem. In my area, a local multi-site urgent care center recently closed after the physician owner was arrested, leaving staff and patients in the lurch. Other organizations have struggled to absorb those visit volumes in the face of their own staffing shortages, and it’s been a bit of a mess.

Meanwhile, capable physicians sit on the sidelines because they’re not willing to go back to abusive environments. At my former clinical employer, nearly all the physician employees left when the private equity company that acquired it started tightening the screws to squeeze out more profit. I know at least six of us who would return from our early retirements if the working conditions were less atrocious.

In speaking with colleagues across the country, this experience is in no way unique. One local urgent care chain classifies its physicians as hourly employees, but pays a “shift rate” that requires them to stay until all patients have left without additional pay for the additional time. I’m not sure how that’s legal under state labor laws, but they’ve gotten away with it for a number of years. On the other hand, it might be one explanation for why they have locations that are mothballed because they can’t staff them.

I admit I didn’t read every single word on the CDC website for the program and didn’t follow every link, but I didn’t see any mention of how organizations need to do more to believe workers when they complain or how to take action when issues are reported. There is still a culture at many organizations of just saying “it is what it is” or “suck it up” when employees report exploitive practices. People are suffering from compassion fatigue, which can lead to lack of empathy and may contribute to workplace bullying if left unchecked.

At one local hospital, nurses scheduled for 12-hour overnight shifts routinely have to stay for 14 or 15 hours due to staffing issues. I guarantee that situation is not doing much for morale or burnout prevention. Even among healthcare workers, I hear comments like “you chose healthcare, what did you expect?” which doesn’t help solve the issue. I have a handful of non-medical friends who understand what we go through, but when medical folks can’t even support each other, how can we expect outsiders to understand what we’re going through?

It will be interesting to follow the progress of the initiative over time and to see how many organizations are using the tools and trying to drive positive change vs. just paying lip service to the idea.

If you’re a care delivery organization leader, had you heard of the initiative before today? What steps are you taking to drive change? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/16/23

As a frontline physician who has dealt with my share of angry patients, I’m always worried that one of them will follow me home from work or show up at my house. I’m vigilant about my personal information and make sure that it’s difficult to find me through real estate or other public records.

Recently Doximity announced a free service called DocDefender that can help physicians remove their personal information from public websites. I decided to give it a whirl. I initially tried to find it through my Doximity account, but wasn’t successful. A web search took me to the right site, but I had to go through an email authentication process to get started. From there, the system started scanning and found my information on 17 out of 35 targeted websites.

The removal process is supposed to begin automatically with results in two to 60 days. I should be receiving regular updates on the removal process, so I’ll provide updates in the coming weeks. It’s also supposed to provide periodic checks to identify new listings, so we’ll see how that goes.

While I was digging around my Doximity account, I stumbled upon Doximity GPT, which is described as “A medical writing assistant that can compose patient education, recommendation letters, grant proposals, ortho poetry – basically any writing task you can think of.” I found the idea of ortho poetry to be intriguing but not compelling, so I asked it to write a haiku about clinical informatics instead. It did not disappoint:

Data flows like streams,
In clinical realms it gleams,
Healing in light beams.

Telehealth organizations across the US are jumping into the weight loss business, making it easier for patients to obtain prescriptions for costly injectable medications, although their ability to jump through the hoops imposed by payers is highly variable. Employers are starting to try to control costs, and Mayo Clinic’s employee health plan has announced that it will cap weight loss medication expenditures at $20,000 per patient as a lifetime maximum. Since some of the medications run up to $900 per month, for patients who are already in treatment, we’re going to see what is essentially an unregulated, uncontrolled clinical trial where time and financial means will be influencing outcomes. The caps don’t go into effect for patients using the drugs for diabetes, which creates a strange “chicken or the egg” situation where prevention or risk reduction isn’t covered but treatment of disease is.

This is largely the result of our payment system, where everyone is trying to control costs for their attributed patients, but doesn’t have the means to take advantage of long-term savings. For example, let’s look at an obese 55-year-old patient with pre-diabetes. If they can achieve weight loss, they likely reduce their chances of developing diabetes, which saves money down the line. When you look at the costs of diabetes care or the complications of diabetes, those expenses would likely occur in 10 to 15 years, when Medicare might be paying them as opposed to commercial insurers.

There’s no incentive for a commercial payer to absorb the cost today in order to realize the savings down the road, because the patient won’t be on their books then, and might not even be on the books in a year or a month, if they work for a healthcare IT company that includes them in a reduction in force as we’ve seen plenty of recently. The math just doesn’t work, but inability to get treatments that could improve quality of life and reduce disease burden is a reality for so many patients today.

Mayo Clinic is just following the example of other healthcare employers that have dropped coverage, including Hennepin Healthcare, Ascension, and the University of Texas System in Austin. All of those popped up in a web search as being in the same situation. My crystal ball predicts that many more organizations will be changing coverage over the coming months unless the prices of the drug come down or there’s evidence of a way they could save money by covering it.

This week included my regularly scheduled annual visit to Big Medical Center for follow-up imaging and a consultation with my care team. I received the email reminder of my visit and confirmed it by completing the electronic check-in process the same day the reminder came out. The next day, I received a phone call, right in the middle of typical dinner hours, asking me to again confirm the appointment. However, I had to listen to a minute and a half of recordings about parking and arrival times before I could confirm. They should have told us to allow an extra 20 minutes to deal with the parking and construction situation, because it was rough and I barely made it to my appointment on time. Good thing they didn’t check my blood pressure because I’m sure it was up there.

I was seeing a new provider at this visit, since they’ve changed how the department runs. I wasn’t impressed by the fact that she had a bunch of handwritten paper notes about me, or that she didn’t use the EHR at all during our visit. It would have been one thing if her notes were accurate, but they weren’t, as I discovered when she tried to offer me genetic testing that I’ve already had.

We discussed the existing results, which I wonder if she missed because they’re scanned into the EHR as opposed to being discrete data, and she relied on my memory to tell her what testing I had completed. From there it was off to the imaging department, only to be told that they’re not doing real-time results anymore, which is one of the reasons I use this facility. Results will come to me via the patient portal in a few days, which I suppose is adequate, but the availability of real-time results was one of the reasons I tolerated the long drive and the general hassle of using this facility.

As a last bit of frustration, they used to schedule your follow up at the checkout desk, and they don’t do that any more. The new process is a bit bumpy and I had to wait for the clerk to write the appropriate phone number on a sticky note so I can call back and self-schedule. At a minimum, someone needs to make a half-sheet handout they can give patients that includes all the pertinent information. In the time it took her to write it down, she could have scheduled the appointment since it’s for a year out and my calendar is wide open. I wonder how many patients will be lost to follow up this way, as those sticky notes disappear into purses and tote bags.

As a final insult, when I returned to the parking garage, the car next to me had parked over the line to the point where I couldn’t get into my car. Fortunately, I’m spry enough to do the gymnastics needed to climb in the passenger side and crawl over the console, but I’m betting a good portion of those visiting a world-renowned cancer center might not have the ability to do so. Still, I’m glad it happened to me and not someone who just finished a treatment or who just received life-altering news, so I’ll view it as my good turn for the day.

After I got home and decompressed from the experience, I walked to the mailbox and found a fundraising solicitation from the organization. I’m no stranger to the concept of so-called “grateful patient” fundraising, but the timing on the solicitation gave me an idea. What if I challenged them to fix their messed up processes in exchange for a sizable donation? I’m sure I could solicit patients and family members to participate, as well as physician colleagues who don’t want their patients to be frustrated by the care delivery experience. I’d even throw in some complimentary consulting services to sweeten the deal.

What are the simple things that facilities could do to improve the patient experience? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/13/23

One of my professional organizations has a forum for members to help us stay connected about hot topics. I got my chuckle of the day when one member referred to scope creep on federal information blocking rules by saying the content “has now metastasized” to a document that’s nearly 80 pages.

I’ve been in the consulting world for so long that I assume that scope creep will be part of nearly every project. However, when you think of scope creep in terms of being a cancerous growth, it reminds you just how insidious it can be. For those of us who have been around the informatics block for a while and have some implementations under our belt, we understand the phenomenon.

Sometimes scope creep happens because the initial project scoping wasn’t done properly. The “creep” represents efforts to try to get features or requirements added to the project that should have been there in the first place.

How did they get missed, you ask? In my experience, it tends to be combination of factors. Sometimes the right shareholders aren’t at the table when the project is being defined. I’ve seen that happen plenty of times when IT folks are tapped to run what are essentially clinical or operational projects. I think that organizations are getting better at this, however, forming dyads or triads of leaders to ensure that projects have the right people at the helm to deliver results.

You have to be careful with this approach, though, since the old adage of “too many cooks in the kitchen” can easily happen in healthcare technology projects. Having unclear leadership can also lead to problems with prioritization of work efforts and challenges when there are identified barriers that need to be addressed. I’m personally a big fan of formal project management documents that spell out the who, what, when, where, why, and how of a project. It’s essential to capture the goals of the project, expected outcomes, and the change control process if you want to avoid messes later. When you don’t have that kind of documentation, it’s easier for people to claim something was in scope when it wasn’t, or to claim that the project team didn’t deliver when the expectations weren’t well documented.

One of my favorite ways to combat scope creep is to make sure that project deliverables are tied to specific budget items, and that all of those items roll up into the master budget so that everyone can have clarity on how much a project is costing and where the money is coming from. This requires that the project includes people who have solid skills at estimating work accurately and who have a good understanding of their teams’ productivity. I’ve worked with managers who claim a project will be an 80-hour build when it really takes less than 10, which does the project a disservice. Conversely, people who underestimate the complexity of a task or who underestimate their teams’ ability to deliver can create havoc on a massive scale.

Even when a project is properly scoped and estimated, having strong documentation of these estimates and costs makes things easier to manage later when people ask for additions to the project. I’ve been known to ask them to estimate the work effort for their proposed addition, then hand them the budget and timeline documentation and ask them what they propose to alter in order to make their request a reality. Does your department want to pony up the money for us to hire contractors to build the additional content you didn’t mention during the original scoping meetings? Or do you want to give up some other content in exchange for what you now realize is a must-have? Those aren’t fun conversations by any means, but people tend to take them less personally when there’s data in front of them than when it’s just the CMIO telling them no.

There is always going to be a certain amount of scope creep on a project, and usually I see that when the team uncovers an element that they weren’t expecting, or a key element of the project doesn’t work as planned. For example, on a big EHR project I was brought into when there was a lot of leadership infighting, we discovered that laboratory interfaces had been deliberately excluded from the scope due to budget constraints. It’s ridiculous to try to do an inpatient EHR project without laboratories, so we had to add them in, of course after educating the steering committee why they shouldn’t have allowed them to be excluded in the first place. That’s a bigger miss than you typically see on a project like that, but a good example of why at least some percentage of contingency overhead should be included in every project.

When there’s an excessive amount of scope creep, or when organizational politics become too big of a distraction for the project team, I’ve been known to suggest that the project be put on hold while it is re-scoped. Sometimes that approach is the proverbial shot across the bow that people need to get their attention, or to get them to understand how big of a concern it is to handle requests for changes to a project that’s already in flight. Especially in organizations where there are dozens of projects running in parallel, it’s understandable that people might be having trouble keeping track of which elements are part of a given project and which might be included as a separate but parallel effort.

That illustrates why communication plans are so important, so that it’s easier for people to understand what is in our out of scope or to find the information if they generally don’t know. Making sure people understand project timelines and budgets is a key part of this. I’ve found it’s harder for people to ask that new requirements be added to the scope when they can clearly see that the project calendar is running in a yellow/orange status, or that the budget is squarely in the red zone. Sometimes the people who ask for additions aren’t in the weeds with a project, and being able to quickly show them where things stand is key.

I’m working with some relatively new clinical informaticists who are honestly some of the smartest people I’ve ever met. However, most of them don’t have a tremendous amount of experience in project management or the sausage-making that happens when you try to bring a new project live with actual healthcare organizations. I’m trying to teach them as much as I can about the behind-the-scenes work that makes the difference between a project that feels like a slog and one that just flows. Some of that you just have to learn through experience, though, and I don’t envy them the knocks that they’ll undoubtedly take as they move forward in their careers. There’s a certain level of “been there, done that” that we all have to reach, but I’m glad I can help them when the going gets tough.

What’s the worst scope creep you’ve ever seen in a project? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/9/23

Several readers messaged me trying to get my thoughts on exactly which companies I think might be “in bad shape” following my recent discussion of the Olive shutdown.

The short answer is that a lady never tells, but readers didn’t even have to wait a day to see a non-healthcare answer, as WeWork filed for bankruptcy. The company had a pre-COVID valuation of $47 billion and has had to cope with the upheaval that the pandemic brought to the office-sharing and remote work space. Now there are questions as to how the company’s bankruptcy will impact the commercial real estate market, since the company had billions of dollars in lease agreements, including those for seven million square feet of office space in New York City alone.

One reader sent me the recent Block (formerly Square) shareholder letter, which mentions that they will cap employment at 12,000 people “until we feel the growth of the business has meaningfully outpaced the growth of the company.” They went on to say, “We know the inverse is true today.” A quick web search indicates that the company has about 1,000 more employees than that cap, so I hope they have the foresight to buff up their resumes.

As a public company, Block is required to release certain information and there’s the potential for shareholders to hold the company’s leadership accountable for performance. Block’s futures are closely tied to the retail economy, so it will be interesting to see what happens over coming months given the current state of things in the US.

Speaking of post-COVID challenges, a couple of my colleagues who are infectious disease specialists brought to my attention that the Centers for Disease Control and Prevention is working on an update to its Isolation Precautions Guidance, last updated in 2007. The newest document isn’t due to be complete for several more months, but a draft was finalized last week. It recommends that masks be worn to reduce respiratory pathogens such as influenza and COVID-19, but the mentioned masks are medical masks or surgical masks that aren’t as good at preventing transmission as N95 and other respirators. There’s great concern among physician and nursing leaders that the relatively weak recommendations will allow hospitals to go for the cheapest option rather than making sure that employees are adequately protected.

There’s a lot of discussion about burnout and turnover among frontline clinicians. I would offer a suggestion that one way to make employees feel more valued and appreciated would be to provide higher-level protection to anyone who wants it, without making them jump through hoops or reuse personal protective equipment which has already been anecdotally reported this respiratory season. I’ll take a giant pack of N95s or KN95s over a pizza party any day.

I had a lot going on at the end of October, so I missed the fact that the Federal Communications Commission (FCC) voted to begin the process of restoring net neutrality regulations that would keep US internet providers from slowing down services on their networks based on content. As expected, broadband providers plan to fight the effort, claiming that it is burdensome and that the effort is a regulatory overreach by the FCC. Public comments on the proposed rule are open and the earliest we’ll see a potential change would be 2024. If you’re looking for some scintillating bedtime reading, the Notice of Proposed Rulemaking and a fact sheet are available for your perusal.

Also in my October mail bag was an overview of a new proposed rule that details “disincentives” for information blocking that was recently published by the US Department of health and Human Services. The proposed penalties include losing “meaningful user” status in a given EHR reporting period, which leads to economic penalties; receiving a zero score for Promoting Interoperability under the Merit-based Incentive Payment System (MIPS); and restrictions on participating in the Medicare Shared Savings Program. The proposed rule also describes the process to occur when an organization is accused of information blocking.

It still baffles me that organizations are struggling to get on board with this, since in the vast majority of situations, having greater access to patient data benefits patients and clinicians. I understand the financial ramifications and the desire for organizations to want to restrict competition, but it just comes off as being anti-patient at this point. Physicians in my area are happy to name and shame when organizations do it, and I’ve seen those revelations steer referral patterns away from uncooperative organizations. More information can be found on the related HealthITbuzz blog.

I recently became aware of a new startup that is working to mitigate how often artificial intelligence systems hallucinate or make up information. Vectara has about 30 employees and has raised $28 million in seed funding. Its founders include former Google AI researchers with deep expertise in the field. The company cites the rate of hallucination by AI platforms as ranging from 3% (OpenAI) to 27% (Google’s Palm chat). Meta’s systems rang in at 5%. The company plan to offer solutions that will mitigate the risks of hallucination, bias, and copyright infringement. Putting on my marketing hat, I like their logo, which feels clean and has forward mobility, and the use of color just kind of grabbed me. Including such a spectrum definitely reduces the need for people to debate which Pantone color is the “right” one.

A reader also asked me what I thought about the recent news that Cigna is considering an option to jettison its Medicare Advantage business. Perhaps Cigna has figured out, as have others, that it’s becoming harder to make a buck in the Medicare Advantage space while keeping patients happy and avoiding pressure on physicians and providers to overstate patients’ complexity. Medicare Advantage only comprises 4% of the company’s external revenue, so it makes sense for leaders to consider bringing in some cash so the company can focus its efforts elsewhere. There’s also the tidbit where Cigna is paying over $170 million to settle claims about its previous track record of trying to make patients seem sicker than they really are. As I re-enroll with insurance plans, I’m avoiding Medicare Advantage because the rewards don’t seem to be worth the administrative headaches.

Is your organization doubling down on Medicare Advantage or have they decided to pursue other interests? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 11/6/23

Everyone is talking about the recent shutdown of Olive. Looking back over the last several months, HIStalk has been full of mentions of companies that abruptly shut down, declared bankruptcy, or are otherwise in bad shape. Plenty of other healthcare and health-adjacent are companies in those situations, but they don’t always come across our radar or aren’t noteworthy in the healthcare IT realm, so it’s difficult to know what the true number of companies in this situation might be.

In talking with friends who know the industry well, most are in agreement that it’s time for a lot of companies to pay the proverbial piper since they can’t deliver on the promises they made in exchange for startup funding. They forecast that many more companies will be trying to reinvent themselves over the coming months. Those that are successful may live to fight another day, but others may become the stuff of fire sales or ultimately closures.

Taking a look at Olive, some of the problems that they experienced are readily visible at other companies. They promised the use of artificial intelligence and advanced technology, but it was more sizzle than steak as it became apparent that they were using screen scraping tools and less-than-intelligent technologies. In visiting their booth at HIMSS, the team was more excited to talk about their big purple recreational vehicle than it was to talk about their actual solutions. When we did get them to discuss their business, there were plenty of vague ideas, punctuated by delusions of grandiosity. I wasn’t surprised when the company had layoffs in the summer of 2022. CEO Sean Lane explained in an interview, “Our fast-paced growth and lack of focus strained our product and engineering resources and prevented us from executing quickly on key initiatives.”

How many other companies out there are guilty of this? Plenty of startups go after what they perceive is the brightest, shiniest object, throwing their muscle behind initiatives without doing the level of due diligence or project planning that is needed to set themselves up for success. Product and engineering teams often work in a certain degree of chaos, but good people in those disciplines aren’t going to do that indefinitely, especially if other things are going on in the company that make things feel unstable.

I have no knowledge of how those particular teams felt at that particular company, but I’ve consulted for enough startups to have seen some wildly inappropriate leadership behavior that would make anyone vote with their feet. People don’t generally enjoy having projects shelved on a whim, or see funding diverted to initiatives that they know deep down are non-starters. They don’t like CEOS who yell at their teams, micromanage, or have Jekyll and Hyde personality swings. People also tend to be uncomfortable with the idea that their company might be selling vaporware, and are more likely to move on when that starts. One can only pull a rabbit out of the hat so many times before it becomes tiresome.

We know from the postmortem of Theranos that some of these high-flying executives may be lying to their board members and to their investors, as well as to their employees and clients. I haven’t seen any salacious tell-all stories yet about Olive, but will be interested to understand whether there was actual fraud involved or just flagrant mismanagement and a lot of excuses. In this situation, I think there is likely to also have been an element of failure to estimate exactly how much it would cost to try to do artificial intelligence work properly. It’s often much more expensive than people think, especially if you want to do the right kind of training and validation with your models. I’ve seen several companies who claim to have “AI-driven” this or that, when what they really have are sophisticated decision trees and a lot of manual intervention and hard work behind the scenes.

It’s particularly grating when I see a company that is operating in what seems to be a somewhat shady fashion, and I look at their list of investors and see only hospitals and health systems represented. These are their possibly spun-off “innovation” arms, or their venture capital funds rather than the care delivery organizations themselves, but the ultimate source of the money being used for investment is the same – payments from patients, insurance carriers, and the US government. These all boil down to being funded by you and me, in the form of our insurance premiums and tax dollars.

It also makes me angry when I see these care delivery organizations throwing major chunks of cash after technology solutions, when they haven’t yet cleaned up messes of inefficiency that could be handled by solutions they have already purchased. They’re not willing to spend the money to hire analysts and trainers to fully implement the EHRs that they’ve spent tens (if not hundreds) of millions of dollars for, or to optimize those systems to actually improve patient care for the physicians and providers or to improve the patient experience. However, they’re willing to buy other solutions that may just make terrible processes run faster and make their patients and caregivers more frustrated than they already are.

Frankly, you can buy a lot of vaccines, deliver a lot of charity care, and discount a lot of procedures for the hundreds of millions of dollars that are spent annually on solutions that fail to deliver value. Looking at some data on the largest organizations in the most recent year I could find (2021), venture funds run by large hospitals laid out more than $2.7 billion in funding rounds. How much prenatal care could that provide, especially since the US now has the highest infant mortality rate among high-income countries?

They can make the argument that the companies in which they invested are going to bring value that lowers the cost of healthcare, improves outcomes, and more, but the proof is ultimately in the pudding as far as what they are actually able to achieve. I can’t think of anyone I’ve talked to in the last several months that thinks the US healthcare system is stronger or better positioned to handle the challenges it is facing despite all this money being spent on technology. All of the practicing clinicians I speak to are on the frazzled edge, constantly being asked to do more with less, being forced to cut staff, or finding that services have been reduced. Maybe it’s time we start spending healthcare dollars on actual bread-and-butter healthcare delivery and ensure that patients are receiving a minimum level of care before we start writing big checks for pie in the sky ideas.

What do you think about the future of tech unicorns in the healthcare space? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 11/2/23

The state of public health in the US continues to decline, and I’m worried about the potential lack of available data for COVID surveillance. Now that many people with COVID are either testing at home or just not testing at all, it’s more important than ever that we use wastewater surveillance to help predict rising cases.

Politico reported on a contract dispute between the Centers for Disease Control and Prevention and one of its surveillance contractors, resulting in a quarter of testing sites being shut down. The situation might not be resolved until early 2024, which is concerning local officials across the country. Wastewater can also be used to monitor Mpox and changes in opioid use with only passive public involvement in the process. Let’s hope CDC can get the situation resolved so that communities aren’t going into a potential COVID surge blind.

Yet another company is wading into the telehealth space, and this time it’s GNC, the vitamin and supplement company. Their press release lists three tiers of service, with graduated annual fees relative to the services offered. The offerings include not only physician visits, but also a list of up to 400 prescription medications that are shipped directly to the patient with a $0 copay, along with discounts on other medications at retail pharmacies.

I’m still struggling to figure out how the economics of some of these offerings work. The Basic offering for individuals costs $34.99 per year and provides free virtual urgent care, virtual “lifestyle” care, and a list of 100 free prescriptions. Plenty of physicians are airing their dirty laundry on Facebook these days, reporting that the typical payment for physicians for a virtual urgent care visit is $25 to $30 depending on whether the visit is audio or video. Even if you’re mailing out a dirt cheap generic medication, adding in the postage for that one visit and its associated treatment will break the budget for that $34.99 annual subscription.

How are they making their money, you ask? We can only guess at this point, but I suspect that they are going to push all kinds of nutritional supplements and vitamins. If not during the visit, I’m sure the patient will receive marketing emails and text messages. I would bet that they’re also monetizing the patient information to outside firms as well.

Looking at the other plan options, the Plus option is monthly ($9.99 for individuals and $29.99 for families of up to six people) and gets you the benefits of the Basic tier plus free virtual primary care and zero dollar access to the full 400 medication formulary. The premier option jumps to $39.99 per month for individuals and $59.99 for families, and adds free virtual mental health care and virtual physical therapy. Looking at GNC Health’s website, there’s no mention of how they will coordinate care with your existing care team, or what they will do if you need care beyond what they offer.

I also found a likely untruth in their FAQs, which state that “Only the medical professionals in our provider partner’s network can access your personal identifiable health data.” I suspect personnel in quality assurance, customer service, and others will have access to the data. Most people don’t consider a customer service agent or call center rep to be a medical professional, and since I doubt GNC is going to have medical assistants or nurses fielding patient complaints, they might want to update their verbiage.

I found it interesting that their text refers to “medical doctors,” so I wonder if they are excluding doctors of osteopathy? It’s more likely that they just need a better copy editor.

Digging deeper on their menu of services, they leave the door wide open for urgent care with mention of “other individual medical concerns.” I was pleasantly surprised to see they offer emergency contraception since that’s such a charged area of practice in many states. The medication list for Basic members is pretty decent, too. I didn’t have a lot of time to try to figure out what provider group they’re using, and I doubt they have built their own, so if anyone knows, please share with the rest of us. Good luck to GNC as they wade into this, and I hope they engage the help of a solid physician copy editor soon.

Speaking of copy editing, I’ve been using Grammarly for the last couple of years, mostly because my employer pays for it and I’ve found it to be a handy tool. While I was traveling over the last couple of weeks, I was using a different laptop and didn’t realize that it wasn’t connecting with Grammarly. The service perceived that as inactivity and ended my 110-week streak. Gamification is a big thing for encouraging some people to stay persistent, and I have to say that I enjoyed earning the different badges from time to time. I consulted the internet to see if there was any way to reinstate the streak, and it doesn’t seem there is a remedy. It also sounds like there isn’t a way to pause your participation, which is really a negative for people who want to take an actual vacation and not write for a while. It sounds like there have been a number of requests from users to Grammarly for that kind of feature, but they haven’t created it yet. Come on, folks, let’s help enable some work-life balance here.

Earlier this week, Mr. H made mention of a survey that indicated that 25% of medical students in the US are considering leaving the field or selecting careers that don’t involve treating patients. Globally, students’ main concerns include mental health (60%), clinician shortages (60%), burnout (63%), and income (69%), and 12% of students worldwide are considering stepping away from medicine. This is not a new phenomenon. When I graduated more than two decades ago, fully 10% of my medical school class did not go on to residency training. They chose PhD programs, MBAs, law school, or business careers.

Students in the US often graduate with huge student loan debt, which often leads them to avoid pursuing lower-paying specialties such as pediatrics and family medicine, both of which we need desperately. Over the last three years, students undoubtedly had the chance to see that resident and attending physicians were treated as expendable and were subjected to crushing workloads in many fields, including emergency medicine as well as the two specialties previously mentioned. As in any high-pressure scenario, something has to give. In the face of untenable work expectations, loss of privacy, increasing violence, and economic pressures, the fact that people are opting out is not surprising.

I stumbled upon this chap during my recent travels, and I had no idea what it was until I Googled it. Spokane’s famed Garbage Goat has been helping clean up the city since the World’s Fair was held there in 1974. The goat connects to a vacuum that helps it “eat” pieces of trash and was built by the late Sister Paula Mary Turnbull, famous in the area as “the welding nun.” I love finding wacky things when I travel, so couldn’t resist sharing. It’s just over the hill from a giant Radio Flyer red wagon, so if you’re in the area, be sure to catch them both.

What’s the most interesting piece of public art you’ve seen? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/30/23

Among telehealth physicians, there’s a lot of chatter about an upcoming change in Centers for Medicare and Medicaid Services (CMS) policy that would require physicians and other healthcare providers to report their home addresses when conducting virtual visits from home.

This hasn’t been an issue during the last couple of years because CMS had issued a waiver for the requirement due to the pandemic. However, the agency has indicated that the waiver will end on December 31. Many organizations, including the American Hospital Association, the American Telemedicine Association, and the Alliance for Connected Care have come out in support of healthcare workers, citing privacy and security concerns as well as the rise in violence against healthcare workers.

As someone who has been stalked by a patient, it’s scary to think about patients being able to easily find your home address. Much of the information providers give to CMS (in the form of applications and enrollment documents) winds up on publicly available websites. A simple browser search can provide a surprising amount of information on physicians who haven’t taken steps to protect themselves. Although this is getting a lot of attention right now, it just scratches the surface at highlighting how the patchwork of laws in the US isn’t conducive to helping physicians deliver high-quality care when they want to be 100% virtual.

Problems with governmental agencies are highlighted when physicians apply to deliver telehealth care through national platforms. For example, the major players in the industry require physicians to have a current and unrestricted Drug Enforcement Agency (DEA) number. They use this as a way of screening out “problem” physicians who might have lost their controlled substance prescribing privileges. The companies in question don’t even allow their physicians to prescribe controlled substances and most of the ones that I’ve worked for actively prohibit any controlled substance activity.

Then, there are various states that have their own controlled substance agencies, which typically require the use of an address where controlled substance activities are taking place. This adds to the confusion for those of us who are practicing telehealth but not ever prescribing controlled substances, yet have to attest to the DEA and these state agencies that we have a physical location where they can theoretically come inspect our records.

In my situation, I “see” patients on a handful of telehealth platforms, all of which keep my records electronically. The evidence that I do not indeed prescribe controlled substances is housed on a variety of servers and I have no authority to grant access to any of them. It’s been a decade since I had a prescription pad in my hand. Yet, on the advice of counsel, I keep a locked file cabinet in my basement that houses my controlled substance records. It contains copies of my DEA certificates, state controlled substance authority certificates, various applications and renewal forms, and nothing else.

It’s pretty ridiculous that they expect you to have locked files, since many of us haven’t seen a paper chart for decades. If you ask my state what I should do, they tell me I should surrender my state controlled substance certificate because I’m not prescribing controlled substances. If I do that, I have to surrender my DEA certificate. And if I do that, I can’t work. Every time I have to renew one of these and attest that I’m following the rules, it makes me cringe.

There’s plenty of shared culpability here, from the agencies that haven’t kept their regulations current with how care is being delivered at present to the telehealth organizations that require certifications that don’t make sense for the work they’re hiring us to do. I understand using a variety of strategies to help root out bad apples, but I also take issue with physicians being asked to skirt the truth in order to earn a living.

Not to mention, the cost of maintaining DEA and state controlled substances certificates is not insignificant. There’s also now a continued medical education burden for maintenance of the DEA certificate. Although fortunately there are plenty of free courses out there that will fulfill the requirement, it’s grating to have to spend a minimum of eight hours on coursework that isn’t relevant to a physician’s current practice situation.

It’s also grating to know that some of the big telehealth players are doing some things that could best be described as “sketchy.” One well-known platform where a colleague recently applied to work wanted him to begin a payer enrollment and credentialing process without providing any kind of contractual agreement. I gave him a heads up that their standard non-compete agreement would likely contain a clause that would be a problem with his other employment obligations, but when he asked about it, they went radio silent.

Speaking of credentialing, that’s another problematic element for physicians who want to be 100% virtual since we’re often asked to provide information that’s not relevant (DEA number, anyone?) along with current malpractice insurance policies even if they’re not relevant to the organization where we’re trying to get credentialed.

Although a lot of telehealth physicians have day jobs and are just picking up extra telehealth hours for extra cash, some do it full time. Even though they may have a large organization backing them as far as having a non-home work address they can use, and where they can keep their DEA and state controlled substance numbers registered, in many circumstances they’re still having to fudge the attestations when they sign their renewal forms for those certifications simply because they’re NOT prescribing controlled substances. Now, many of us have to revisit whether we’re going to opt out of Medicare or whether we want to take the risk of having our home addresses made public. Opting out of Medicare brings its own problems, and further narrows the options for positions where we can use our skills.

The DEA and state controlled substance certificate issues don’t impact the majority of physicians who deliver telehealth services, because the vast majority of them have a physical practice location where they might be prescribing controlled substances and the issue becomes moot. However, the Medicare address issue affects many more physicians, including those working for large health systems who might be at home when they engage with their patients via telehealth. I’m hopeful it will get more attention. If we can get this issue resolved, maybe we can get some of the other issues resolved, although I’m not hopeful because it’s way too easy for organizations to simply use a DEA number as a proxy for past good behavior.

What do you think about making physician and healthcare provider addresses publicly available? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/26/23

From Jimmy the Greek: “Re: clickbait healthcare headlines, try this one: ‘Designing Playful Experiences with Imaging Capsules.’” Jimmy kindly shared a link to Exertion Games Lab, and I found the section header of Ingestible Games just as compelling. Capsule endoscopy was first approved by the US Food and Drug Administration in 2001, but its use is limited. The website notes, “We believe that the capsule’s experiential perspective is often overlooked, i.e. we argue that there is also potential for  ‘fun.’” The company created a wearable system named InsideOut where users can see a real-time video of their digestive tract as the camera capsule travels through and can interact with a couple of different games that harness the images. There are links to scholarly articles if you’re interested, as well as a video of the concept in action.

Halloween is almost here, and IMO has shared 13 ICD-10 codes appropriate for the occasion. The codes address injuries related to sewing, pumpkin carving, and handcrafts, as well as open bites of the neck which might occur in vampire-rich areas. My favorite is R46.1 Bizarre Personal Appearance, which I hope to see a fair amount of when I’m handing out candy next week. For your further entertainment, they did a winter holiday code update last year.

The CHIME fall forum is coming up, and Genzeon gets my thumbs-down award for silly giveaways. This Arizona-shaped luggage tag was mailed to attendees and is just one more piece of conference swag for many attendees to add to their trash cans. Colorado State University had a blog piece about this earlier in the year, noting that the annual spend on promotional products in the US is in the neighborhood of $20 billion, with estimates that 40% of it ends up in landfills.

I personally prefer when conferences let you pick and choose the promotional items you want rather than handing you a pre-filled swag bag. At last year’s CHIME event, light-up cowboy hats were a popular take-home item. I wonder how many of them are still in use. I won’t be at CHIME this year, so if you are going, feel free to send me your swag report.

Everyone is talking about burnout, but an article I read this week introduced me to the concept of “rusting out.” It’s described as being on the other side of the spectrum from burnout, and is defined as what happens when an employee’s talents are underused. It can lead to disengagement and lowered productivity. I’ve seen this phenomenon first hand. A good manager will be on the lookout for it and discuss ways to better use the skills of workers.

Although the article mentions recommending workers for retraining programs, in some situations, it could be much easier. This might involve removing repetitive lower-level tasks and adding more complex projects that encourage critical thinking or problem solving. This is tricky to do as a manager, especially if you don’t have resources towards which you can shift those repetitive tasks. Depending on the culture of your organization, it can be difficult to make the case for realigning resources, but executives who ignore these kinds of requests do so at their own peril. 

A friend sent me a link to a digital tool called Wellspring, which is designed to help clinicians individualize treatment plans for menopausal patients and uses guidelines from the UK’s National Institute for Health and Care Excellence. There have been many shifts in recommendations for treatment of menopausal symptoms over the years. It is challenging for physicians to make time to address them when they’re pressured to deliver quick visits that satisfy all the check-the-box metrics in front of them. It will be interesting to see if there is any movement on this type of tool in the US and whether frazzled physicians would be willing to adopt it.

I’ve written in the past about some of my experiences with my local health system. I had another one this week that makes me wish I could do some consulting work for them.

I’m registered with their high-risk breast cancer program, which means I have imaging studies performed twice as often as people of normal risk. The program handles pre-approvals with the insurance company since most companies won’t pay for additional screening without appropriate supporting documentation. Additionally, the imaging appointments are scheduled in conjunction with clinical appointments, so that the studies are read and results are given to me before I leave the building.

I received a letter from the hospital this week telling me that it was time to schedule my mammogram and I should call for an appointment or visit the mammogram van, along with a schedule of its locations. Since my next imaging is always scheduled before I leave the office, this made me worry that either my appointment had been canceled or something else had happened to it. As a patient, this causes anxiety as well as time spent calling the hospital to confirm or logging into the patient portal to confirm whether there is an appointment or not.

In addition to the inconvenience factor, there’s also the clinical appropriateness factor. Someone who is part of this particular high-risk program shouldn’t be doing a walk-in at the mammogram van. The letter had my medical record number on it, so it’s not like it was a generic letter. Given the capabilities of the health system’s EHR, there’s no reason that they should be sending out letters like this. It’s entirely possible to construct the outreach campaign by filtering out those patients who are already scheduled for imaging so that we don’t send patients on a wild goose chase looking for their appointments.

It’s wasteful to send out scheduling letters for patients who already have appointments on the books. If you insist on sending something, send a reminder letter with the date of the upcoming appointment. Additionally, patients who are flagged as being part of the high-risk program should likely receive a different letter, even if they are overdue for their imaging and don’t have anything scheduled. The program prefers that these patients call the coordinator to set up the appointments since they get linked with clinical appointments, rather than just showing up at a facility.

I talked to a colleague about the situation, looking for suggestions on how to advocate on behalf of patients. She promptly one-upped me by sharing her experiences with a health system that continued to reach out about her mother’s appointments more than a year after they were made aware of her passing. These are just things that shouldn’t happen given the technology we all have in place.

Is your organization maximizing its use of EHR reporting and recall campaigns, or is it traumatizing patients? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/23/23

I traveled this weekend to attend a celebration of life, marking the passing of a longstanding healthcare IT colleague. Many of those in attendance had known each other for decades, from the early days when electronic billing systems began to spawn clinical systems.

It was great to hear so many memories and to reminisce about how the industry used to be. Many of the companies that people worked for are no longer in existence, having either become part of another organization or sold for parts after an acquisition. Most of us were in agreement that the industry continues to be topsy-turvy and that it’s unclear how much or how fast new technologies like artificial intelligence will really have an impact. Hopefully, the next time we get together will be for a less solemn occasion.

I also recently had the chance to meet up with another former colleague, who was passing through my city on the way to a consulting engagement. He’s one of the super-techy types who took me under his wing when I was at the beginning of my clinical informatics career. I’ll always be grateful that he was willing to spend the time making sure I really understood the options that were being discussed versus just trying to get me to make a decision so the tech team could move on.

I’m pretty sure our conversation picked up where we left off the last time we saw each other, as if we saw each other every day, and I’m so grateful for those professional relationships that have turned into genuine friendships. In many of the informatics roles I’ve filled since the beginning of the pandemic, it seems like there’s so much understaffing there really isn’t time for those friendships to develop because everyone’s just scrambling to get the work done.

Once in a while, I see a scholarly article with a title that can only be described as clinical informatics clickbait. This time, the article in JAMIA not only caught my attention, but also delivered. As a clinical informaticist who has spent a good chunk of her career in emergency departments, how could I not be drawn to an article looking at how disaster hazards are represented in SNOMED CT? After all, I used to teach a class called “Things that can get you in the great outdoors,” so this was right up my alley.

Electronic health records are well positioned to gather data about the impact of various disasters on populations and sophisticated analytics platforms can help health systems and governmental agencies understand the respective responses to such happenings. In crafting the study, the authors looked to “determine the extent of clinical terminologies available to capture disaster-related events” as well as to map the United Nations Hazard Information Profiles to the SNOMED CT terminology.

I settled down with a nice cup of tea and dug in. Through the mapping process, the authors identified more than 200 disaster hazard concepts that had the potential to negatively impact health. These included not only things like chemical or biological disasters, but also those related to weather, flooding, earthquakes, or extraterrestrial factors. They noted that “geographically unique” hazards such as heat wave, cold wave, smoke, and drought were not found in the SNOMED CT data, coming to the conclusion that such concepts need to be added in order to improve clinical reporting. As someone who dealt with a variety of heat-related and smoke-related complaints during the long summer of 2023, I can attest to the impact that extreme heat can have on a population, especially when they don’t have access to air conditioning, fans, or transportation to cooling centers.

The authors highlighted the frequency of disasters by listing some of the events of 2023 that happened prior to publication. These included major earthquakes in Turkey and Syria; floods in South America, Indonesia, and Australia; multiple cyclones, wildfires, and more. Technological disasters included a coal mine collapse and shipwrecks. Along with other less major disasters, these events impacted 100 million people and cost $190 billion in economic losses. They also made the point that it’s not only the injuries and loss of life, but the impact of these disasters on healthcare facilities, the healthcare workforce, and the greater healthcare delivery system. They call on organizations to create strategies to make healthcare systems more resilient to disasters whether natural or human caused.

In reading the article, I thought about the current state of “resilience” in healthcare in the US. Prior to the COVID-19 pandemic, we didn’t have a lot of reserves to draw from at baseline. There was already a nursing shortage, a primary care shortage, and intermittent supply shortages when factories were hit by natural disasters or there were minor supply chain disruptions. Along came the pandemic, which exposed problems with strategic national stockpiles in the US and a rapid outstripping of global production for medical supplies. Those of us who were on the front lines vividly remember telling us we could wear bandanas to work to try to protect us from airborne pathogens and saw the pictures of our colleagues wearing trash bags when they couldn’t source barrier gowns. Although most of us have returned to relatively normal lives, the horror was real and continues to hit some of us, sometimes daily.

It doesn’t feel like healthcare delivery organizations (or policy makers for that matter) have risen to the challenge of addressing these issues for the future. As a nation, we’re not doing a great job of assessing risk, setting health priorities, or building workforce capacity, all of which the authors deem as essential for meeting future health needs. We already have a tremendous amount of data that we’re not acting on, so although I agree with the authors that more data might be better in planning for the future, I’m skeptical that it will be as useful as it might otherwise be. Certainly, there are more progressive nations out there who might actually make use of the data, and then in a decade or two the US will follow along.

I recently visited a country that has embarked on a half-century plan to eliminate certain invasive species and to return the environment to its natural state. If only we could translate that kind of initiative to the US and use it to promote public health and reduce the burden of chronic disease. Especially over a long-haul study horizon, we’ll need good data to evaluate whether interventions are working and whether we’re achieving the desired objectives.

Although the authors state that the risk of natural disasters is higher due to climate change, they acknowledge that “real-time data demonstrating the adverse impact of climate-change related events on populations, healthcare workforce, and healthcare systems, including natural disasters at the point of care, is lacking.” They attribute this in part to the absence of appropriate concepts in the clinical tools used in electronic health record documentation.

I would go further to add that there need to be additional abilities for clinicians to have easy access to this data, including access to patient-generated health information and pulling data from patient histories or linked geographical information. As an example, I spent a number of years living in a community that was directly impacted by chemical contamination. The federal government has identified particular ZIP codes in their efforts to track the downstream impacts of that contamination; if I could provide that in my patient history, which could serve as a proxy to prevent physicians from having to search for the appropriate codes for soil contamination.

The authors also acknowledge that many areas of the world don’t have health information system infrastructures that support the capture of such codes, and those areas are more focused on “the challenges of providing basic care for vulnerable populations in resource-limited settings.” They also note that there are gaps in the contact infrastructure for some countries to participate with SNOMED International in requesting additions or updates to the terminology and expressed concerns that many of the nations at highest risk for natural disasters are not members of SNOMED International. Although some may see this as a bit of a niche area in clinical informatics, I thought it was a thought-provoking article. I’ll have to reach out to my colleagues who are more closely involved in terminology to see what their thoughts might be.

What do you think about the data infrastructure for tracking disaster-related health outcomes? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/19/23

Clinical informaticists are often asked to help their organizations with strategies to combat health misinformation, whether it’s through implementing patient education solutions, providing input for patient-facing websites, consulting on social media campaigns, or creating content for distribution through mixed channels.

The Kaiser Family Foundation recently released results of a health misinformation tracking poll pilot with the goal of following health-related misinformation in the US, especially in communities where misinformation can gave the greatest negative impact. This round of tracking looked at important topics: COVID-19/vaccines, reproductive health, and firearm violence. Plans are in place to investigate other health topics in coming months. A Health Misinformation Monitor report will be distributed to those who are working to fight health-related misinformation.

Those of us seeing patients on the frontlines spend a good chunk of our time counseling against misinformation. It’s challenging because we would often rather use that time to talk about other important topics like dietary changes, lifestyle adjustments, and cancer screenings. We’re still seeing patients that are falsely convinced that COVID vaccines are killing healthy patients, that sex ed causes promiscuity, and the increased rates of firearms deaths “aren’t a thing.” In addition to taking time away from other health topics, having these conversations over and over is exhausting, so I’m excited to see what this new resource makes available for clinicians.

I’m onboarding a new consulting client and a significant amount of time is slated to help the organization improve productivity. We’re going to work to streamline its meetings, improve communication, and get some process guardrails in place. As I met with several high-ranking members of the company this week, it was obvious that one of them was multitasking on his phone the entire time we were meeting. I’m no stranger to the fact that conflicts come up, but what I experienced was not only rude, but also wasted the resources of the others who were on the call. I’m still figuring out all the dynamics in this organization, but at least one person who wasn’t on that particular call also mentioned the behavior as “habitual” for this leader. True leadership is being willing to reschedule meetings, to step out when you have a conflict or distraction, or to delegate meetings to others who can cover them.

In the worst case when one has to field text messages during a call, can I offer a pro tip: install the relevant texting app on your laptop so that you can manage your phone’s messages without actually having to touch your phone (let alone have it visible to others on the call). The solution won’t necessarily help with inattentiveness, but it will reduce the obviousness of undesired behavior.

Speaking of communications and productivity, one of the biggest time wasters I see among the large organizations I work with is trying to use too many “pull” communications and not enough “push” communications. Pull refers to materials that someone has to go to in order to get information, such as visiting a page on the company intranet or going to a reporting dashboard. They require effort on the part of the end user, who may need to remember that they need the information and also may need to remember where they need to go to get it. Push communications put the information in the hands of the user without a hunt. This method can be great for distribution of data that’s episodic, like a weekly census report.

I just had a conversation with one of my clients this week about using the right method for the right data. They were using a compound push/pull method. They pushed a link out to the audience on a daily basis, but then the users had to click the link, log in to a dashboard, and reset a filter to today’s date to see the daily data. A simple stopwatch exercise showed that this took about 30 seconds for the recipient to get to the right data, assuming they didn’t get distracted by another task along the way.

I asked the sender what the purpose of the email was and was told that it was to distribute end-of-day metrics that are finalized during a 2 a.m. reporting package. That sounded reasonable, but the need for users to log in and adjust filters to see the data didn’t. I talked to a couple of data consumers, who agreed the process was annoying. They are required to look at the data daily, but said that greater than 95% of the time they don’t need to do any further digging, so a snapshot would be fine.

I multiplied the daily review of data times the number of people looking at it times the average hourly rate of the end users. The company is spending $7,500 annually for employees to click links and adjust filters. In comparison, automated distribution of each day’s static data can be added to the reporting package for about $120 in work effort. I’m not surprised that no one thought of this before. It’s magic moments like this that make consulting fun as well as beneficial to the client. I’m hoping that they take this as an a-ha moment and look at some of their other communications to see what kind of savings they can generate.

It’s also a good exercise for organizations to examine how well their communications are reaching the target audience. If you’re maintaining a website for people to visit to get information, how many unique visitors is it getting and at what frequency? If you’re sending emails, what is your open rate? If you’re throwing things out in a Teams or Slack channel, are you measuring whether the materials actually make it to the audience? It’s important to understand too that different people consume information differently, and for some really important notifications, you may need to send them through multiple channels – email, messaging, intranet/web sites, and more.

People also need reminders when there are deadlines. Simply sending it once and then claiming “well, it was on the Slack channel” doesn’t help with knowledge distribution for most organizations.

From a patient advocacy standpoint, I’m excited for plans to eliminate the reporting of medical debt for consumer credit scoring. The initiative is being handled under the Consumer Financial Protection Bureau, which has rulemaking authority for the Fair Credit Reporting Act. The process involves convening a Small Business Review Panel to identify next steps. Medical debt impacts millions of patients and it can negatively impact their employment prospects, ability to obtain housing, or purchase a vehicle. The rulemaking process doesn’t move at the speed of light, so it will be 2024 before we see how this is going to shape up. Some credit agencies are already excluding paid-off debts and small debts from reporting, but the new initiative will expand consumer protections.

I’m finally able to say “that’s a wrap” to my recent travels. I’ve also caught up with some old friends, made some new friends, and got to learn about both mining and particle physics at the same place, so how can one top that? Now that I’ve been bitten by the travel bug, it’s only a matter of time before I decide where I’m heading next.

If you could go anywhere in the US for vacation, where would you visit? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/16/23

Generative AI continues to be a hot topic around the virtual physician water cooler. My colleagues have come to expect me to have my finger on the pulse of innovation, even though interacting with these solutions is a small part of my current work in clinical informatics.

OpenAI recently announced that “ChatGPT can now see, hear, and speak,” heralding an opportunity for a “more intuitive type of interface” that allows the user “to have a voice conversation or show ChatGPT what you’re talking about.” The blog details the potential of the technology to impact daily life.

As an aspiring amateur chef, I’m intrigued about the potential to “snap pictures of your fridge and pantry to figure out what’s for dinner (and ask follow up questions for a step by step recipe).” At any given time, my kitchen has a stack of recipes that I find intriguing. It would be great if artificial intelligence could parse them and determine which ones I might be more likely to make, and what ingredients I need to make their creation a reality.

Plus and Enterprise users get first crack at the new features, with voice coming on mobile platforms and images being available on all platforms. As for voice, the goal is for users to be able to have a conversation with the virtual assistant after choosing one of five voice options.

As an early adopter of the Garmin Nuvi back in the dark ages before Google Maps, I miss my former trusty companion “Ken the Aussie” and was hoping that there would be a similarly engaging option available with the new solution, especially since the company states they worked with professional voice actors to create the options. Alas, I didn’t find an internationally-accented voice – the options are named Juniper, Sky, Cove, Ember, and Breeze.

I can’t wait to explore the image options. One of the use cases that OpenAI lists includes “analyze a complex graph for work-related data.” I have some absolutely crazy pictures of whiteboard drawings that I’ve collected over the years and can’t wait to unleash AI technology on those and see what sense it can make of them, if any. New York Times reporter Kevin Roose got a sneak peek at a beta version of the technology recently and shared his results. He noted some issues:

• Taking a picture of the front page of the newspaper, he asked ChatGPT to summarize it. The AI hallucinated, “inventing a statistic about fentanyl-related deaths that wasn’t in the original article.”
• The technology “flopped” when asked to assist with a crossword puzzle.
• It referred to a stuffed dinosaur as a whale.

It was also unable to assist with deciphering a diagram for assembling a piece of IKEA-esque furniture, although I’m less surprised by that than the other issues mentioned. He also noted limitations in how the technology processes images of human faces, although he mentions this is functioning as designed. Developers wanted to avoid it being used for facial recognition or critiquing people’s appearance. As someone who has cared for teens who have been cyberbullied, I’m grateful for the latter.

The New York Times reporter found the voice capabilities to be particularly powerful, referring to it as “Siri on steroids” with a “fluid and natural” voice that has “slight variations in tone and cadence that make it feel less robotic.” He notes that his request to hear the story of the Three Little Pigs “in the character of a total frat bro” was “a sleeper hit.” (The example is available in the article, if you’d like to give it a listen – I agree it was pretty funny.)

Honestly, I can’t wait to ask it to tell me a story about healthcare IT from the perspectives of some of the archetypal personas we see in the industry: the exuberant CEO, the frustrated project manager, the surly end user, and the burned-out clinician. It would probably be more entertaining than some of the talks we saw at conferences like HLTH, hands down.

Earlier in the month, OpenAI had also announced that its Dall-E image generator was being incorporated into ChatGPT. When AI-generated images first came on the scene, there were a lot of concerns about copyright issues, competition with human artists, and the role of AI in the creative process. Now that the technology is becoming more accessible, some of my physician colleagues have also been concerned about the potential for using generative AI to create images that can be passed off as medical records in order to manipulate a physician into providing treatments or medications for which a patient might otherwise be inappropriate.

There was a big discussion among our group about the potential for diversion of controlled substances if patients presented with AI-generated x-rays, CTs scans, or MRIs. I’m seeing an increasing number of physicians paying attention to political happenings, so of course there was concern with the potential to use AI to manipulate upcoming elections. Of course, there are plenty of bad human actors that already have the technology to do those sorts of things, but somehow things just seem scarier to some when automation is involved.

OpenAI isn’t the only company that’s doubling down on chatbot investments. Google recently released improvements that allow Bard to access information from Gmail, Google Docs, and Google Drive accounts through a feature called Bard Extensions. It can also draw from YouTube and Google maps for information. Although those enhancements potentially represent a substantial increase in generative power for sophisticated applications, I’m more interested in straightforward but potentially complex tasks, like helping me parse through the hundreds of emails I receive each day across both my personal and HIStalk accounts and helping me identify which ones might be most intriguing.

Given my consulting work helping organizations streamline their meeting calendars, I’d also love to unleash a chatbot to parse calendar data to help me figure out which meetings should be moved to maximize attendance, which should be kept where they are, and which might be able to be eliminated. Of course, most of the organizations I work with are still devotees of Office 365, so Bard isn’t going to be much help there.

What do you see as the areas with the greatest potential for generative AI, and what do you see as the biggest potential pitfalls? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 10/12/23

The theme of this week’s edition of “Where in the world is Dr. Jayne” seems to involve cities that have either “falls” or “rapids” in the name. We just left the fifth iteration, and I have to say each one has been inspirational in its own way. 

This particular example was flanked by a historic site commemorating a failed business venture that attempted to harness the power of the falls. The owners would control the volume of the pool upstream and unleash it when there were wealthy investors visiting, making the falls seem as if they could generate more power than was realistic.

Reading that plaque instantly reminded me of some of the things I see day in and day out in healthcare IT. Sometimes it’s hard to figure out what’s real code and what’s vaporware because the demos are extremely slick. Of course, those of us who have been in the trenches for a while know that everything is always cooler before you actually buy it, but it was interesting to be reminded that companies have been overstating their potential as long as there have been commercial endeavors.

HIMSS registration is open. This year, I’m branching out to a different hotel. It’s right next door to the place I usually stay, so I won’t be hiking longer to the convention center, but I’m hopeful that it will be better maintained than my old standby was the last time I stayed there.

I was hoping that the new management would innovate on conference pricing, but they’ve kept the tiered pricing structure that makes me feel like I’m being nickel and dimed. A Basic Conference Pass is $945 and includes the opening reception, exhibit hall, education sessions, and “select networking events.” You have to spend an additional $300 to get the Conference Plus Pass, which includes the mentioned items plus the post-conference recordings.

I always appreciated those when they used to be part of the base package since it’s impossible to cover the entire exhibit hall for HIStalk and make it to a decent number of sessions. Not to mention that it always seems like there are two sessions I want to attend at the same time, so that was nice. The pricier pass also includes a pre-conference forum and the Thursday night special event. For an additional $90, you can get the Provider Executive Pass, which includes access to the CXO Experience and an Executive Summit. It looks like the session recordings can be added on for the bargain price of $199. The Thursday night event is available a la carte for $85, but no details about the event are available yet.

I went through the process and noticed some subtle changes to the registration process. Depending on what I listed as my “Worksite,” I saw different options for the passes that were available to me, including a disclaimer on the Provider Executive Pass that said it was “subject to HIMSS approval.” I was also asked if I’d like to participate in the new Hosted Buyer program, which provides two nights of hotel accommodation and travel expense reimbursement in exchange for two hours of time meeting with qualified exhibitors. I was asked to “provide up to 2 goals/objective you have for HIMSS24” and of course the first things that came to mind after “avoid the Florida humidity” were snarky, including “find a coffee line that’s less than 30 minutes long” and “exhibit hall booth crawl with Matthew Holt.” The latter has a greater chance of happening than the former, but we’ll have to see what wishes the HIMSS conference fairies grant me in 2024.

During some downtime during my travels, I went hiking with an old friend who also does information technology work. Her organization is open to the public several days per week and sits in the social services realm, so employees tend to be more office based, although they allowed some employees to work remotely at least part time during the pandemic, particularly on the days when the office wasn’t open to the community. In an effort to double down on culture building, they decided to use one of those non-client-facing days to conduct an all day team-building event.

I have to say, her recounting of the day puts some of the “forced fun” events I’ve heard of into perspective. First, management advertised a “secret breakfast location,” where they would ask people to leave their cars for the day. My friend drives a classic convertible that is in the process of restoration and probably shouldn’t sit out uncovered all day, so she asked if she could have the address in advance to drive by and make sure it would be OK, and was told no. Of course, nothing says respect like not trusting an employee to keep a location confidential while making sure their needs are met.

After breakfast, a bus was to pick the group up and take them to their next location. The “limo bus” that arrived was complete with LED lighting and a bejeweled pole dancing apparatus, which left many of the mostly conservative employees dumbfounded. Employees were driven on that ultimate party bus to the local Walmart, where they were given $20 and 20 minutes to scour the store with a buddy and buy something with the caveat that it “can’t be anything you really need” and that they would have to show it to everyone later and explain why they bought it.

My friend thought that was an odd task as there were several things she would have preferred to spend the unexpected money on but didn’t want to have to explain her purchases to the group. At first, I wasn’t totally understanding the assignment as I thought it was to spend money for something for a donation item to a good cause or something similar, but as she clarified the process it seemed even weirder. Ultimately she ended up with a denim jacket since that would fit the assignment, but she admitted to me that she’d likely take it back and spend the money on what she needed in the first place.

From there it was back on the party bus, with other activities that she felt weren’t that productive as far as bringing the team together or helping them get to know one another. She described the pace as frantic and rushed and said they didn’t feel they had enough time to complete what they were being asked to do, and it was just stressing people out. Towards the end of the day, management asked the team to complete survey cards, collecting them in a hat. They then asked participants to draw a random card out of the hat and read it to the group, and I bet they were surprised when comments such as “exhausting” or “total waste of time” or “we have a pole, where’s the dancer” were read aloud.

My friend is betting they might have a different strategy as they plan for next year’s team-building event, but personally I can’t wait to hear what they come up with. Team-building is a tricky business. Done well, it can create new relationships and strengthen existing ones. Done badly, it can highlight how disconnected leadership is from the team.

Speaking of disconnects, one of the side topics around the virtual water cooler this week was the idea of hospitals and health systems purchasing naming rights for stadiums and other public venues. Although the physicians in the discussion see the value of naming as a marketing tool, they questioned how organizations can spend millions of dollars on those opportunities when they can’t find money to retain nursing staff, recruit scarce subspecialty clinicians, or manage medical debt and collections policies in a patient-centric manner.

I wondered how pervasive this issue is and did a quick tour through a Wikipedia listing of sponsored sports venues in the US. I found 23 instances of the word “health” appearing in those names, including AdventHealth, Atrium Health, Dignity Health, Mayo Clinic Health System, Mercy Health, Sutter Health, and UC Health. Comparing the US to other primarily English-speaking developed nations , there were no examples of the word “health” or “hospital” in the listings from Australia, Canada, New Zealand, or the United Kingdom.

Does your health system employer have naming rights or sponsorships in the community? Does it contribute to better patient care or is it a distraction? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/9/23

Hitting the road over the last couple of weeks, I had to really strip down the essentials of what I needed to get my work done. It’s definitely a shocker to go from having either multiple monitors or one ridiculously large monitor to a single laptop screen. I know there are portable second monitor setups out there, but I wanted to see if I could manage the laptop life for more than the week that I usually travel at a time.

My travel companion is in the process of relocating, so I was a bit limited on the overall space in the car due to the household goods crammed into every square inch. I’m the kind of person who has lived in a tent for the better part of a month, so I figured I could find a way to make it work.

It got me thinking about the things I use every day in my home office and how that setup compares to when I used to work in a corporate office and when I go on site for consulting engagements. The home office is always my first choice because it has exactly what I need and I can leave out the things I use often and store the things that are more occasional-use items. The corporate office was similar, although I didn’t have anything on my desk that I’d be sad about in the event it disappeared. We had a standard set of corporate-issued supplies, like a stapler, three-hole punch, and tape dispenser that I don’t really remember using since the whole point of our project was to be paperless. I had an inordinate number of push pins, though, since our cube walls were secretly fabric-covered bulletin boards and I certainly took advantage of that as a way to hang pictures, flyers, and other bits of decoration.

When I travel for consulting engagements, I’ve been fortunate that most of my clients provide nice “hotel” space that includes a multiple monitor setup with docking station and ethernet cable. I had one client whose idea of a productive workspace was an L-shaped bank of bar-height countertops that faced a wall on one side and a set of floor-to-ceiling glass windows on the other. We had to vacate our station at the end of every day, so I ended up carting everything around all the time. If you came in later than others, you were stuck in front of the windows with their never-ending glare.

The stools that they had at these “desks” weren’t exactly the right height, either, and their lack of a footrest meant that your feet ended up dangling. The other option was a cushy armchair with a folding desk on one of the arms that was barely big enough to hold your laptop and definitely wasn’t large enough to accommodate a mouse. In either setup, the idea of a second monitor was a figment of my imagination. I can’t say that I was sad when the engagement ended.

As employers demand that people return to the office, it’s going to be important to create the kind of spaces that make people actually want to come to the office. Will they have a designated space that they will share with one or two other people, or will it be a free-for-all every day to see who works where? Will they have the amenities needed to be productive, such as dual monitors? Will there be company-provided snacks or drinks beyond the stereotypical burned coffee? Many of us have become content in our home office hideaways, and it’s going to take time to reorient us to office rules, such as making sure to take our containers out of the refrigerator before clean-out day and to avoid bringing allergens to the office that might negatively impact our colleagues.

As people go back and forth in a hybrid situation, it will be more important than ever to make sure accounts sync seamlessly between the corporate office and the home office. People also need to figure out what the must-haves are for each office environment and whether they will need to bring things from place to place to feel they have what they need.

I ran across an article recently that talked about dealing with digital clutter, which might be a contributing factor for anxiety and frustration. The author specifically calls out things like photos, old presentations, expense receipts, and other digital artifacts that might be rarely seen but are always present. Then there are the physical objects, including charging cables, old phones, the keyboard that your company shipped to you that you don’t like but will need to possibly return some day, and more.

The author offers some strategies for decluttering. On the topic of power cables, the recommendation is to toss anything that doesn’t have an identified device that it goes with. If there are extra cables, one shouldn’t keep more than two of each version. Further recommendations include discarding anything that hasn’t been used in six months, although we’re reminded to be sure to discard it responsibly. I’m lucky that my city does an electronic recycling event every other month, but not every community is that fortunate.

For cables that are used regularly, the article recommends organizing them as much as possible, including attaching them to desk legs or bundling them for neatness. I’ll admit, I have a pile of twist ties on my desk. I’m always meaning to do some cable management, but I never get around to it. I wonder what that subconsciously indicates about me.

The author goes on to talk about “digital hoarding” and managing obsolete data. They recommend getting rid of files that haven’t been opened in years, purging smartphone apps that aren’t used, and cleaning up photo libraries. Quick decluttering can involve removing duplicates or photos where our technique was less than ideal, or just organizing images into folders. More extensive decluttering involves curation where we determine if particular photos are something we want to see again in the future.

Honestly, if I tried to get into that, I know I’d have an acute case of analysis paralysis, so I’m going to take a pass on that suggestion. It’s definitely easier to clean up data, at least for me. Deciding to purge client files after a certain number of years or months seems cleaner than trying to make a value judgment about whether I think I will want to look at it in the future.

At least for the foreseeable future, I’ve stripped my needs down to what can fit in a business-style backpack and a 40-liter duffel. My traveling companion doesn’t care if I’m wearing the same two pair of Columbia pants all the time, and we are intentionally not going anywhere that requires a fancier level of dress. I’ve got my laptop and a small travel mouse, although I do wish I had brought my full-size one, but I’m sure I’ll eventually get used to the tiny one. I’ve adapted from my ever-present stack of sticky notes and my trusty whiteboard to their digital counterparts, and it was fun to remember that’s how I used to do it back in the day when I traveled every other week, since I had forgotten. Of course, I’ll probably feel different about this when I get back to my bank of monitors, but at least for now it’s fun to rough it a little bit.

What are the office essentials that you absolutely must have, whether at home or in a company facility? Leave a comment or email me.

Email Dr. Jayne.