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.

EPtalk by Dr. Jayne 10/5/23

Registration is open and agendas have been published for the 2023 ONC Annual Meeting, to be held December 14-15 in Washington, DC. Hot topics include artificial intelligence in healthcare, public health standards, policymaking, and of course information blocking. Mainstage sessions will be livestreamed on HealthIT.gov, but breakouts and other sessions will be in-person only.

I’ve never been to an ONC annual meeting, but it looks like there will be some good sessions covering racial bias in health care artificial intelligence. Given the fact that my state recently gave up some federal money because of antiquated public health systems, I’m particularly interested in the Thursday session on “Public Health Data Modernization at the Local, State, and Federal Level.”

The conference is free and the room block rate for hotel accommodation is $188 per night, which isn’t terrible compared to other venues, but be sure to budget an extra $55 per night for parking if you’re driving in. My conference budget this year doesn’t permit me to go, but if anyone wants to send me the scoop from that public health session, I’d be eager to hear what strategies are discussed.

I visited a family member in the hospital recently and took a moment to reflect on how much the technology in the patient rooms has improved since I was a trainee at the same institution. The chart carts and racks have given way to ergonomic workstations in each patient room. The IV pumps have become smarter and more connected, and the in-room patient education is a vast improvement from the crummy printouts we used to give to patients on the day of discharge. It made me think about whether any of our current technologies will still be in service in the future.

I was musing about this with a fellow astronomy and space afficionado, who mentioned an event that took place with the Voyager 2 spacecraft earlier this summer. Apparently it’s still alive and kicking at the tender age of 46 years, although it had gone quiet for a bit. Like parents who have to yell at teenagers from across the house, NASA engineers sent an interstellar “shout” across 12 billion miles of space to get Voyager to turn its antenna back toward Earth. The idea of a piece of equipment from that era still functioning today is pretty impressive. It will be interesting to see which healthcare technologies stand the test of time.

Planning for the American Medical Informatics Association AMIA 2024 Clinical Informatics Conference is underway, and its Scientific Program Committee leadership is seeking interest from those interested in joining the Committee. Members will review submissions and help define the content of the conference. Submissions are being accepted through October 13.

One of the hot topics around the virtual physician water cooler this week was the entry of Costco into the world of telehealth. Essentially, the retail giant is partnering with Sesame to offer discounted virtual primary care and mental health services. Even though I’m not in a traditional primary care practice anymore, I struggle with the transactional nature of some of these offerings, Amazon’s most recent one included. Use of on-demand services like this can fragment care, and I’ve experienced how hard it can be it from the telehealth provider side.

One venture capital leader hit the nail on the head: “From what I can tell, neither Sesame nor Costco have ambitions around a longitudinal relationship with the patient, and definitely no intentions of assuming risk, as it’s a cash pay offering. This is really a story around convenience and incremental growth.” Most patients probably don’t understand this, however. Certainly few of the ones who flocked to the independent urgent care where I worked understood what it means to get care from a third-party provider who doesn’t have access to your records. For the most part, they assumed that all doctors are connected and that I would know everything about them. Magnify that by patients chasing the cheapest visit and moving from provider to provider and it’s going to get messy.

From Off the Grid: “Re: remote work. I enjoyed your recent Curbside Consult on the topic, especially with the true stories from the trenches. I’ve also worked at companies that have handled this well, and also at those who are doing it badly. It seems like a lot of new leaders forget that companies have done this for years and have done it successfully. Check out this article on managing remote teams. I think it has good advice for newbies who are struggling to navigate these waters, which are less uncharted than they think.” The piece has a lot of good advice, including how to make sure that remote teams don’t experience burnout through having regular conversations about how people are doing but “without a string of action items.” It also discusses the need to have clear goals and objectives. I would add that those goals should be set not by management in a top-down fashion, but collaboratively. I still run across leaders that don’t understand how to create reasonable and/or achievable goals, and instead saddle their teams with either shifting targets or ones that simply cannot be accomplished.

I particularly like the article’s advice to “use technology, but wisely,” especially when it discusses communication hierarchies. Some of the most productive teams I have worked with have clear communication matrix documents that explain what should be communicated, by what means, and to whom. This avoids spamming or interrupting people who don’t need to be party to an issue and making sure that items that need attention get the focus they deserve.

My favorite self-organizing team had guidelines around how to communicate based on time sensitivity. For example, anything that needed attention in fewer than three business days required a phone call. Otherwise, an email could be sent, but with the assumption that the recipient had three business days to handle it.

In hindsight, that was luxurious compared to the noisy world of texts, Slack, Teams, various other messenger apps, and general chaos that I live in with my consulting clients. For groups using Slack, Teams, or similar platforms, encourage people to set their status accordingly so people don’t think they’re available when they’re actually busy with someone else and not checking messages. And for those organizations that expect people to be instantly available at all times – good luck, because if you think your teams aren’t using mouse jigglers or other strategies to look active, you’re deluding yourself.

Speaking of remote work, I’m currently on a project that involves mostly heads down work and very few meetings, so I’m taking advantage of the opportunity to do some travel with a friend. For the next few weeks, we’ll be seeing the USA in our Chevrolet, so here’s your “Where in the world is Dr. Jayne?” moment for the week.

What’s the most unusual roadside attraction you’ve visited? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 10/2/23

In my clinical world, I’m starting to see more patients who are struggling with the symptoms of Long COVID. That’s not surprising, since current data from the Centers for Disease Control and Prevention’s National Center for Health Statistics published a report that indicates that nearly 7% of US adults have experienced the condition.

The data brief from the 2022 National Health Interview Survey indicates that nearly half of those individuals also said they had Long COVID symptoms at the time of the survey. To meet the definition of the condition, patients must have a set of symptoms lasting three months or longer after the initial COVID-19 infection. These can include fatigue, brain fog, dizziness, digestive symptoms, heart palpitations, changes in smell or taste, chronic cough, chest pain, and more.

Many of the patients I see have tried to explain away their symptoms, blaming them on the overall stress of the pandemic, problems with work-life balance, or increased demands from employers due to inadequate staffing. A number of patients also come in with similar clusters of symptoms, but never had a formal diagnosis of COVID, either because they were ill before testing was widely available or were ill later in the course of the pandemic and never tested. Ohers don’t meet the criteria for Long COVID, but are struggling with symptoms like memory issues, insomnia, and fatigue that can be associated with a host of other conditions, including anxiety, depression, and burnout.

Let’s face it, we’ve all been expected to do more with less, and that has ultimately taken a toll. Many healthcare workers, IT folks included, are looking for strategies to make sense of all they’ve been through during the last three years. They’re also looking to find a way forward that doesn’t put them in the office or bringing work home to the detriment of their family time. They’re looking for ways to cope and the mechanisms they employ aren’t always healthy.

While institutions are putting resources behind setting up Long COVID clinics and creating programs to treat those patients, it doesn’t feel like they are setting aside ample resources to deal with COVID’s collateral damage to the broader healthcare world. It’s no surprise that all of us have taken on a substantially larger mental load in recent years, so I set out to find articles that looked at the concept of mental load and mindfulness both before the pandemic and since. How much is this constant need to burn the candle at both ends really impacting us?

The first article I came across was in the New York Times archives from 2016, and caught my eye because of its title: “Think Less, Think Better.” It’s an opinion piece, but references a study that looks at how mental load can negatively impact one’s capacity for original and creative thinking. I’ve certainly experienced that phenomenon, when I’m juggling too many balls or putting out too many fires and as a result tend to fall back on tried-and-true solutions rather than trying to find novel ones.

The author’s research at the time indicated that “innovative thinking, not routine ideation, is our default cognitive mode when our minds are clear.” The study cited in the piece found that “the mind’s natural tendency is to explore and to favor novelty, but when occupied, it looks for the most familiar and inevitably least interesting solution.” Companies that make it a priority for employees to have unstructured time for creative or innovative pursuits seem to have figured this out. Still, there are plenty of companies out there where employees are just marching from meeting to meeting (whether virtually or in person) without time to catch their breath, let alone time to think creatively.

It’s one thing to try to make space for creative thinking when you’re working in the software industry or in marketing or sales, but how does that apply to actually seeing patients or supporting those who do? I wondered how these ideas might be applied to the healthcare IT space. In an August 2023 article in the Journal of the American Board of Family Medicine (JABFM) titled “Thinking and Practicing Thoughtfully and Thoroughly,” an editor’s note offered examples of some of the challenges of trying to meet the needs of individual patients at individual visits while simultaneously advancing the overall health of the community.

That sounds a lot like what many of us do in healthcare IT, where we try to meet the needs of individual clinicians while balancing them with outcomes desired by the overall technology organization. Like physicians, those of us that work the technology front lines try to find the colleagues who have fallen through the cracks and aren’t getting the support they need, and we also try to fix the overarching structures that might be causing strife. Lobbying an EHR vendor to fix faulty software is a lot more similar to lobbying Congress to fix faulty healthcare policy than I had previously thought.

That particular issue of JABFM offered numerous examples of work being done by physicians to try to improve patient care. I would bet that the majority of the research wouldn’t have been possible without dedicated EHR and analytics teams behind the scenes creating ways to capture the data, extracting it, collaborating with investigators, and more. The examples made me wonder if those who might be far from the front lines think about the impact they’re having with every template build or every SQL query that they do in their daily work, or whether they just think of it as one more thing to check off the ever-growing list of things to be done. Does the data analyst think of how many grandmothers, or sisters, wives, or daughters are in the data set that’s being pulled for breast cancer screening? Do they find a way to make the work feel more valuable, or is it just part of the grind?

In many healthcare delivery organizations, understaffing is present at all levels, at the bedside, in facilities or maintenance, in technology infrastructure, and in the teams trying to pull it all together. When they claim an ever-eroding margin, how can leaders of those organizations try to make space for staffers to not only be mindful about their work, but to have the time to explore their creativity and truly try to innovate? Even if you wanted your staff to spend 10% of their time working on novel ideas, how do you backfill those four hours each week? How do you decide what projects don’t get done when there’s already a backlog? I think the answer in many organizations is to just keep pushing ahead and not look for creative solutions, which ultimately will likely deliver the same results as we’ve been seeing all along because we’re doing what we did all along.

I’d be interested in hearing from readers how their organizations are tackling these phenomena. Are leaders able to make space for thoughtful, meaningful work, or is everyone just back at it, possibly working harder than they did a few years ago? Have people just checked out or left the healthcare space because what we’re asking them to do is untenable? Are your leaders working to find a way forward? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/28/23

From Former Cerner: “Re: Oracle CloudWorld meeting. It’s hard to hear about the company’s goal (which is becoming more of a mantra) to ‘drive Cerner profitability to Oracle standards’ when you see what they’re spending money on, including a Formula One race car and of course the racing yacht. When you think about in the context of the fact that they laid off the clinical resources that a lot of us depended on, it’s absolutely nauseating. But I guess it might be a short-lived situation, since all of us are waiting to wind up on a layoff list some time soon.” I have several friends who work for Oracle, and all have shared the same sentiments. In addition, they noted the ongoing global focus (including the CloudWorld Tour 2024, which visits Dubai, London, Milan, and Singapore, among others) as detrimental to understanding the realities of the US healthcare system. Sounds like a lot of people at Oracle are job hunting, and I wish them well as they look for their next adventures.

From Atlanta Express: “Re: updating systems when new vaccines are rolled out. The new COVID vaccines caused havoc with the Vaccines.gov website. What did they think would happen when they authorized a new vaccine on the same day they removed the old vaccine, and removed all the vaccine inventory in the system? Especially when locations don’t have any inventory for the new vaccine? Searching for a ’location near me’ produces zero results. Lots of assumptions were made and now people are surprised, and everybody is scrambling.” I’m not surprised by any government chaos anymore. This seems like a classic cutover-type project, although on a larger scale. We’ve known for weeks that the new vaccines were coming even though we didn’t have a specific data for the Food and Drug Administration and other approvals. Organizations go through a similar process every year with updated influenza vaccines, so it’s disappointing to hear that this was messy. Hopefully, the lessons learned will be well-documented for the next vaccine update, which might be happening every year for the foreseeable future.

There has been a lot of whining by large health systems about the federal requirements for price transparency that were implemented in 2021. Some organizations worked hard to make it difficult for patients to find information where others quietly complied but didn’t promote the availability of data to patients. A recent article posted in JAMA Internal Medicine compared hospital online price calculators with prices obtained via phone for the same services. The authors used vaginal childbirth and brain magnetic resonance imaging (MRI) as their service price points. They concluded that “…at US hospitals, price estimates for shoppable services posted online correlate poorly with prices obtained via phone; these findings suggest that patients will continue to face barriers to comparison shopping.” Only 14% of hospitals had matching prices given via phone and online for childbirth; the figure for brain MRI was 19%. The authors also noted that at up to 12% of hospitals, billing staff couldn’t provide a price estimate even though the hospital had a functional online pricing calculator. Of course, it’s nearly impossible to comparison shop for urgent or emergency services, such as a same-day appendectomy or a critical fracture, so it remains to be seen how useful these price transparency tools are in the long run.

Although many organizations had already embraced electronic health records in the 1990s and early 2000s, it took until the US government’s so-called Meaningful Use program’s inception before other organizations fully embraced the concept. Over time, clinicians and their support teams have been asked to gather increasing amounts of information about their patients with the hope of improving clinical outcomes. First, it was basic medical information such as medications, allergies, and a problem list. Then, we moved on to smoking history, tobacco and drug use, and other factors that are linked to health outcomes. Now, organizations are being asked to collect information across a variety of domains, with social determinants of health receiving much of the current focus.

A recent Viewpoint article in the Journal of the American Medical Association cited the “Inadequacy of Current Screening Measures for Health-Related Social Needs” as something that needs to be addressed. The authors note the presence of new quality standards that are designed to promote health equity in the face of “an indisputable connection between social factors (e.g., low food security, housing instability), structural racism, poverty, and health.” In an unexpected twist, they note that “without additional considerations, these well-intentioned mandates will impede progress in health equity and have the potential to increase long-standing racial and socioeconomic inequities.” They point out that although policymakers use the terms somewhat interchangeably, there is a difference between social risks and social needs. Social risk screening requires validated screening instruments, and social needs screening involves asking the patient about desired assistance. Many health systems have created and employed their own screening instruments without looking at the difference between the two and that approach may lead to paternalistic care as opposed to trying to understand the patient’s perception of their unmet needs.

The authors have some specific recommendations for moving forward with screening in a productive manner, and not surprisingly, those approaches don’t involve standardized pre-visit questionnaires delivered via a patient portal. They recommend that regulatory bodies should provide incentives to health systems to better partner with their patients through a shared decision-making process. This involves cultural understanding and real conversations along with the flow of data among care delivery and social service agencies. They advocate for prioritizing social need screening over social risk screening, focusing on meeting the needs already identified by patients themselves. Staff members need to be trained to do this with empathy rather than just reading a canned questionnaire to patients and capturing their responses.

The authors call for strong social safety nets to better support patients, including nutrition programs and support of policies that promote equity. Unfortunately, in working with large health systems over the better part of two decades, I see a lot of people who still believe it’s easier and better to just throw technology at a problem, and I suspect we’ll be seeing more automated pre-visit questionnaires and fewer direct contact staff members as organizations try to tackle these issues.

How is your organization dealing with social needs data? Is it taking a technology-driven approach or using actual humans to make a difference? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/25/23

I’m not sure what the universe is trying to tell me about work life balance and people’s feelings about the return to the office, but my inbox this week was full of articles touching on the topic.

I’ve written in the past about the concept of so-called “quiet quitting,” where employees transition from going the extra mile for their employer to putting in the minimum effort required to meet the job description. The Atlantic took this one step farther with a piece — albeit recycled from 2021, yet presented as if it was something new — titled, “How to Care Less About Work.” Its premise is that workers need to evaluate how they want to spend their remaining time on Earth.

Spoiler alert: many employees agree that the days of working more than 40 hours a week for nebulous corporate goals are over: “It was seldom to create work that was meaningful or innovative, even if we could mumble something to that effect when asked what we like about our job. It wasn’t so that we could someday work less overall. We worked hard to prove that we were alert and available for more work.”

It turns out that The Atlantic piece is actually an excerpt from a book “Out of Office: The Big Problem and Bigger Promise of Working from Home” by Charlie Warzel and Anne Helen Petersen. I was intrigued enough to do some weekend reading and found it to be an interesting counterpoint to the numerous CEOs who are clamoring for a return to the office without clear goals for that change. The chapters keep it simple: Flexibility, Culture, Technologies of the Office, and Community. These are all topics that should be critical discussion in any work environment, whether remote, hybrid, or in-office.  I’ve been in several working situations where technology runs rampant and employees are struggling to even do basic tasks due to confusion about the best communication platforms to use for different situations, whether to call, e-mail, message, or text someone, and whether meetings really need to be had.

Like many of us who worked remotely prior to the pandemic, the authors had embraced remote work, moving from Brooklyn to Montana. They discovered it wasn’t as easy as they thought, and that it was important to figure out how to fit work into a rich home life versus always working because if was so easy to just log on without a commute.

As someone who struggled with one particular office-based consulting engagement a few years ago, I loved some of their descriptions: “unscheduled, drive-by meetings” were definitely one of the things I found challenging, especially since I was working from a cubicle on a main aisle in the office and was constantly barraged by people dropping by to say hi or ask questions. I’m always happy to help, but then it takes a few minutes to get back into the groove of the work you were doing, resulting in lower productivity.

There was one particular group manager that I swear never did work. If you popped your head above the partitions, he was always walking around chatting. Another favorite quote: “They [offices] elevate the feeling of productivity over being productive. They’re a breeding ground for microaggressions and toxic loops of hierarchical behavior.” That’s not to say that the latter elements don’t happen in the remote workplace, because I’ve definitely seen them.

The authors challenge companies to reconceptualize the workplace, “having honest conversations about how much people are working and how they think they could work better. Not Longer. Not by taking on more projects, or being better delegators, or having more meetings. Not by creating ‘more value’ for their employer at the expense of their mental and physical health. Instead, it means acknowledging that better work is, in fact, oftentimes less work, over fewer hours, which makes people happier, more creative, more invested in the work they do and the people they do it for.”

I think the idea of really exploring the concept of value is an important one, especially in companies that have a lot of meetings. It’s challenging to understand which meetings provide benefit for attendees and how to find the right balance of scheduled versus nonscheduled time. I worked for one company where its weekly product development meeting was simply an echo chamber for the chief product officer, and no one was allowed to question him. That, my friends, was not a value-added meeting.

Another quote that really resonated with me was around how companies monitor productivity of remote workers. Another part of reconceptualizing the workplace “entails thinking through how online communication tools function as surveillance and incentivize playacting your job instead of actually doing it.” I was at lunch recently with a couple of physician friends, one of whom had recently started working for a large health insurance company doing case reviews in a particular subspecialty where she has many years of experience. She whipped out her laptop and mentioned that although she had already finished her quota of reviews for the day, they went faster than expected, so she needed to log more online time to complete her day. Apparently since she’s new to the company, she’s being treated like a new employee rather than the seasoned reviewer she is, so she has to be sure to log a full eight hours until she reaches the end of her probationary period.

We all agreed that was ridiculous, but humored her in the situation, although it was less funny when her voice-to-text app started picking up our lunch conversation. If there was any AI involved, I hope it enjoyed our entirely too specific discussion of the best way to prepare fried pickles.

This reconceptualization, according to the authors, “will require organization based on employees; and managers’ preferred and most effective work times, and consideration of child-and eldercare responsibilities, volunteering schedules, and time zones.” I worked for a number of years at a large organization that had clients in time zones from Hawaii to London, with the majority of workers being remote. Although customer support teams were organized largely by geography (except for those supporting nationwide clients), we made it clear that we didn’t expect our Pacific time zone friends to be taking calls at 6 a.m. local time or for our Eastern time zone colleagues to still be working at 6 p.m. local time. It took commitment by leaders and team managers to realign meeting schedules into blocks that worked for everyone. We created a culture where it was perfectly fine to have lunch on camera (after all, many of us would regularly have working lunches in the office-based world) as well as to use the extremes of the day to complete personal errands outside of designated blocks where meetings were typically expected. Sure, there were fewer hours in the day which were acceptable for broadly attended meetings, but it caused us to really evaluate whether we really needed to be having so many meetings and how many people really needed to attend them.

The organization was ultimately acquired by another that didn’t share the same values on workday flexibility. The first thing they did was require people who were geographically located near one of the corporate offices, of which there were five at the time, to come into the office two days a week, just to be in the office. It didn’t matter if their teams were there or whether they would spend the whole day on Webex — management wanted to see bodies in chairs when they strolled through.

I immediately lost one of my favorite employees, who had been using her flexible schedule to help care for her husband following a serious illness. She would work from 6 a.m. to noon, take her husband to cardiac rehabilitation, then return after 3 p.m. to finish her day since it was easier to find an in-home caregiver to cover early morning and late afternoon than it was to find one to cover the full day and transport him to therapy. Of course, that meant she couldn’t come into the office two days per week, and the company was unwilling to accommodate her despite the fact that she supported teams that were all across the US and no one she worked directly would have been in the office.

I have so many other stories about what I’ve seen in my consulting travels, and so often when I give examples they fall into the category of “you can’t make this up.” It will be interesting to see what really happens with the remote work landscape over the next two years especially for technology and knowledge workers, like those of us in healthcare IT.

What’s the most egregious thing you’ve seen in a return to office strategy? Is there a way that your organization has done it well? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/21/23

I was back in the patient trenches this week, having needed an appointment at a practice where I’m only seen every two or three years. This time around it was less than three, which is the cutoff at which most practices consider you to still be an “established” patient, but they treated me as a new patient nevertheless.

Despite having information in the EHR that they could have printed and asked me to either update or confirm accuracy, they handed me the proverbial clipboard, with six pages of information to read and/or complete. I absolutely hate when medical office forms ask me to write in my insurance member number and group number when they’re right there on the card that the front desk staff just scanned.

I felt validated when a patient who came in shortly after me went back up to the desk and asked if they needed to complete that section, since they had already provided it in the form of the scanned card. I felt a little less validated when the staff responded back by saying yes, they needed it as a “backup to the system,” which could also have been accomplished with a photocopy rather than introduce the potential of a transcription error with a patient copying information from the card.

Across the multiple sheets, I was asked for my primary care physician’s name and phone number two times and was asked for my pharmacy address once and phone number twice. As is common in medical office situations, the documents had been photocopied so many times as to be nearly unreadable in places, which made me want to educate them on the virtues of putting the “master copy, do not use” sticky note on the last sheet in the folder to ensure a clean copy is used for future copies. Alas, I wasn’t there in the role of practice management consultant, so I refrained, although I was sorely tempted.

One of the papers I was asked to complete was essentially the SOAP note (Subjective, Objective, Assessment, and Plan for the non-clinical folks) for the office visit, including a request to complete the History of Present Illness, including the prompts that coding specialists look for when assigning billing codes. These prompts hadn’t really been translated to patient-friendly terms, and still read “location, duration, modifying factors, and associated signs/symptoms” much like you’d see in a CMS manual or a medical history-taking textbook.

I gamely played along and admit that I did enjoy the radio station playing in the waiting room, which was FM 106 coming live to us from Dublin, Ireland. I wish they had radio in the exam rooms, because I could hear in great gory detail what was going on in the room adjacent to mine. A medical assistant popped his head in the door (literally halfway in and halfway out) and asked a few more questions, then said the practitioner would be in to see me. She arrived quickly, addressed my problem, and I had no complaints about the clinical care.

Given the paper nature of the office visit thus far, I was surprised to see a link to a patient portal account before I even made it out of the parking lot. I logged on later in the day and was shocked to see the documentation – vital signs were documented including a weight that bore no resemblance to my own, even though no vital signs were taken. Exam elements that weren’t performed were recorded in great detail, alongside the procedure note, which was fortunately accurate as to what actually occurred.

If those exam elements were used to substantiate a higher level of billing, then what we have there is fraud, which is concerning. As a patient, I shouldn’t be placed in the position of having to correct my records, but apparently that’s where I am at the moment. Seems like a call to the office is in order when I get a break in my schedule.

I’m a huge devotee of evidence-based medicine, where we use science and data to help identify the best treatments for our patients. Taking a data-driven approach has also been a big part of my informatics practice, where I look at system utilization and how multiple physicians are using the system before I approve changes that might have only been requested by one user.

In the sprit of evidence-based practice, I was interested to see an announcement by the US Food and Drug Administration (FDA) about the decongestant phenylephrine, which is found in over-the-counter medications including Sudafed PE and some NyQuil products. An FDA advisory panel found unanimously that the ingredient is ineffective, and questions remain whether it will be banned or whether drug companies will be given time to reformulate their products before having to pull drugs containing the ineffective ingredient from the market.

These types of announcements are important for clinical informatics folks, including our colleagues in the pharmacy sphere, as we have to try to find these drugs in order sets and physician favorites lists and send out bulletins to let people know of the announcement if they’re a frequent user of the drug.

The change in this drug’s status is also important for those of us who have followed the methamphetamine crisis in the US, which forced pseudoephedrine behind the counter and led to increased use of phenylephrine as an alternative. It’s the law of unintended consequences, with patients caught in the middle as they try to self-treat minor illnesses. (It should also be noted that the rise in phenylephrine use was also due to another decongestant, phenylpropanolamine, being pulled from the market in part due to an elevated risk of stroke with use.) The reality is that we haven’t seen much action in the development of new drugs like these in recent years and millions of doses of a drug that isn’t much better than placebo have been used by patients generating well over a billion dollars in sales. Here’s to all the informatics folks who will be hunting down this drug in the coming weeks to months.

This week was Telehealth Awareness Week, as decreed by the American Telemedicine Association. There has been a lot of buzz about it online and plenty of people saying how much they think telehealth is improving the healthcare ecosystem, but there are still some downsides to the modality. Healthcare organizations that aren’t embracing it may unwittingly encourage their patients to have more fragmented care as they seek visits with third parties that aren’t considering the patient’s existing records or sharing back to the patient’s medical homes. Other healthcare organizations are frankly encouraging that fragmentation through third-party contracts. A fraction has found a way to make it work, either by building their own telehealth workforce or by using integrated third parties, but they’re in the minority from what I see. On the telehealth platform where I practice as a physician, I have zero access to patients’ records and it makes delivering good care much more difficult than it needs to be.

So many of my colleagues are hyper focused on research in the realm of artificial intelligence that they might be missing out on other interesting topics. I was absolutely blown away by this article in Plos Biology that looked at how music can be reconstructed from brain activity in the auditory cortex. The article’s opening line “Music is core to human experience, yet the precise neural dynamics underlying music perception remain unknown” is a powerful one. In addition to not fully understanding perception, we also don’t understand what makes one person love a particular piece of music and another perceive it like the proverbial nails on a chalkboard. The authors worked with data from 29 patients who listened to a Pink Floyd song, ultimately reconstructing something recognizable out of the neural recordings. Music perception was more dominant in the right brain and researchers localized a particular part of the brain to perceive rhythm.

The authors noted that their findings show the possibility of “paving the way for adding musical elements to brain-computer interface (BCI) applications.” I was talking to a young colleague about this, and he profoundly stated, “Because if you’re going to do trippy mind control research, Pink Floyd is the way to go.” In case you’re wondering, the specific song used in the research was “Another Brick in the Wall, Part 1” which was cited as constituting “a rich and complex auditory stimulus.” Don’t worry about volunteering to be a research subject in this area soon, since the participants all had surgically implanted electrodes due to a diagnosis of drug-resistant epilepsy.

If you could only listen to one album for the rest of your life, what would it be? Leave a comment or email me.

Email Dr. Jayne.

Curbside Consult with Dr. Jayne 9/18/23

Over the years, I’ve been on a number of panels and attended several forums to discuss the participation of women in clinical informatics. One of the most memorable ones was last spring as part of the CHIME track during ViVE, when the CHIME League of Women presented “Mentorship in Action.” We had a chance to understand how mentor/mentee pairs have been instrumental in boosting the presence of women in healthcare IT.

Just anecdotally, when I look at the composition of leadership teams in non-healthcare IT organizations, it seems like there are more women than I see in my own field, but I don’t have any data to back up that sentiment.

A recent article in the Journal of the American Medical Informatics Association titled “Accomplished women leaders in informatics: insights about successful careers” looked at some of the challenges faced by women in the field. Although the study had a relatively small sample size of 16, they looked at women in both academia and industry.

I wasn’t at all surprised when I read the findings: “We conducted a thematic analysis revealing: (1) careers in informatics are serendipitous and nurtured by supportive communities, (2) challenges in leadership were profoundly related to gender issues, (3) ‘Big wins’ in informatics careers were about making a difference, and (4) women leaders highlighted resilience, excellence, and personal authenticity as important for future women leaders.”

The authors also noted that “Sexism is undeniably present, although not all participants reported overt gender barriers” and that “women are underrepresented in scientific dissemination, substantially less likely to be in leadership positions, and have not achieved salary parity with men.”

I also wasn’t surprised at some of the statistics, namely that the majority of academic programs and clinical subspecialty fellowships in biomedical informatics are led by men, at 75% and 83%, respectively. The authors also note that men have also held the majority of leadership roles within the American Medical Informatics Association and have received nearly two-thirds of the awards. The article goes on to say that although the National Institutes of Health has recommended conscious effort to promote gender equality, women continue to cite gender imbalances in leadership hierarchies as barriers to advancement.

The article cites specific examples of the themes, some of which really resonated with me. Regarding the idea that careers in informatics are serendipitous, that’s exactly how I wound up in this field. I was looking for a clinical job close to home, and the one that seemed the best fit also had been identified to be a pilot for the “paperless practice” concept for a large health system. The idea that careers are nurtured by supportive communities rings true for me as well, as women made up the entire leadership team of that project, and we supported each other throughout the project’s lifecycle.

One of the major differences of that team compared to others that I’ve been on is that we understood how each other operated and how each other’s efforts supported the team’s overall goals. There wasn’t any competition, and when one of us achieved a milestone or was recognized for something we did, there wasn’t any sense of someone getting ahead or outshining the rest of the team. We shared in each other’s accomplishments as much as we commiserated when things didn’t go well. We stood up for each other when things weren’t quite right.

That concept wasn’t unique to us, as noted by one respondent who explained her strategy to address subtle sexism in meetings: “A colleague who is male will say more or less the same thing [the female said], and that’s what gets picked up on. I call it out. I say ‘Oh, it’s so great that you’ve taken her idea, and now we have it in front of us.’”

Other respondents specifically called out the lack of female participation on boards, as well as differences in how male and female colleagues were treated by leadership. I’ve certainly seen the latter over the last two decades. Sometimes it’s more subtle, such as male leaders inviting male subordinates to sporting events but not their female counterparts.

But in the most egregious situations, I’ve seen male leaders refuse to meet alone with a female subordinate because of concern for potential accusations of impropriety. Male leaders who follow the latter policy actually create an exclusion zone that prevents females from advancing. I would suggest that if they aren’t comfortable meeting with their teams privately, then maybe they’re not the right person for the leadership role.

Women cited specific situations that continue to occur, including differences between recognition of men and women, financial disparities, and women being “spoken over” in meetings. When I see the latter occur in a meeting and don’t see anyone call it out, it’s hard not to think negatively of the leader who allows such behavior to occur on their watch.

Respondents also noted the importance of “being authentic and genuine, not pretending to know something you do not know or being someone you are not, and being true to oneself” as key to being a successful leader. As far as those characteristics, the idea of not pretending to know something you don’t actually know comes up often in leadership books, specifically with references to the idea that men are more likely to project knowledge they don’t possess versus women who are more likely to admit that they need to research or investigate, with the latter being perceived in some circles as a sign of weakness.

It’s like when I was a young physician in that paperless practice. I mentioned in a media interview that having computers in the rooms was great when I needed to look something up. I thought that idea made me sound progressive and that I was seeking the best information for my patient, but in reality, I was chastised by the sponsoring hospital’s vice president for giving the idea that as a physician I wasn’t all-knowing.

The article arrived in my inbox while I had been reading “The Great Stewardess Rebellion: How Women Launched a Workplace Revolution at 30,000 Feet” by Nell McShane Wulfhart. Although the book is about the unequal treatment of female flight attendants in the early days of commercial air travel, there are still a lot of parallels with what women are experiencing today.

Women are often still expected to behave a certain way and have certain appearance standards that aren’t equally applied to their male counterparts. I’ve seen plenty of examples where a woman’s appearance or hair style are called out in a virtual meeting, where no one ever calls out the man with obvious bed head or the one who just slaps on a ball cap to remedy the situation. I’ve heard comments that women look “tired” and “stressed” on days that they don’t wear makeup, which is just a sad commentary on the state of things.

Even though some of the things I read in the article were disheartening, I’m glad that the ideas it brings up are receiving attention in academic circles. Only when we study an issue can we hope to find solutions.

How does your organization handle gender equity? Does it tolerate obvious imbalances or does it engage when people speak up? Leave a comment or email me.

Email Dr. Jayne.

EPtalk by Dr. Jayne 9/14/23

Updated COVID-19 vaccines should be available soon, following approvals by the US Food and Drug Administration and the Centers for Disease Control and Prevention. They’re recommended for everyone age six months and older, so I anticipate that quite a few IT folks will be scurrying around to add the vaccine to EHRs near and far.

Although many healthcare folks seem to have stopped following the data, hospitalizations have been increasing recently, but might be leveling off. I’ve been traveling and have definitely seen an uptick in masking, with the most recent trip revealing about 5% of passengers and 20% of service workers being masked. The latter are less likely to have paid time off than other categories of workers and are likely to have negative impacts from illness, so it makes sense. Of the people who are masking, most seem to be wearing higher-filtration masks rather than basic surgical masks, and I didn’t see any cloth masks. Of note, two of my recent flights have been less than half full, so it appears the summer travel season is indeed winding down.

As far as masking in healthcare environments, I’ve seen a couple of articles addressing the topic. A recent opinion piece in the Annals of Internal Medicine suggests that healthcare organizations should make decisions that place patient safety first and should consider masking “as part of routine healthcare policies.” They suggest that care delivery sites “should be mindful of continuing areas of uncertainty while integrating the lessons learned into our hospital-based practices to prevent harm to vulnerable patients rather than reverting to suboptimal pre-pandemic behaviors.” I appreciate the fact that they called out the notion that the good old days weren’t necessarily that good in many care locations. In addition to vulnerable patients, there are plenty of vulnerable healthcare workers out there who deserve a safe work environment.

Regardless of the COVID case counts, the reality is that a lot of hospitals and health systems are still stressed. Some of the urgent care centers in my area have been closed for an extended time period due to lack of staffing, and many of my former colleagues have retired or left practice for other pursuits. My hospital colleagues tell me they’re still having staffing issues especially in labor and delivery, and apparently there’s a shortage looming for anesthesia medications, so it might be a bumpy winter.

I visited the local Costco for my flu vaccine this week and it was a seamless process, although I skipped the hot dog and soda combo and instead went for the sample of Kinder Bueno chocolate on the way out the door. There’s also a new vaccine out for Respiratory Syncytial Virus (RSV) intended for pregnant women as a way to protect their newborns, so I anticipate people are updating their EHRs and clinical decision support reminders to promote that one during patient visits as well.

This month’s issue of the Journal of the American Medical Informatics Association features an interesting back and forth about so-called EHR “gag clauses,” in response to a recent article that looked at whether those clauses had negatively impacted the inclusion of screenshots in peer-reviewed literature. Informatics guru Ross Koppel submitted a letter to the editor noting that informatics experts had been pushing for removal of those clauses since 2009. He also mentioned that informaticists may still be living in a climate of fear that vendors will punish them for publishing screenshots, regardless of moves by ONC or anyone else to remove such gag clauses. He concludes by stating, “Ethical vendors should have welcomed feedback about problematic EHR screens, rather than punishing medical informaticists who sought to improve those EHRs by demonstrating their dangers to patient safety.”

The authors of the original article responded to Dr. Koppel, agreeing with his comments but also pointing out that ONC and scientific journals should encourage the inclusion of screenshots in submitted articles and also that such screenshots should be included in safety bulletins and other documents covering EHR issues. They suggest that research needs to be done to understand why screenshots aren’t being included, and one way to do this would be to ask authors whether they’re aware of policy changes that prohibit gag clauses. They conclude by calling out Dr. Koppel’s comment that “…we should all be troubled by EHR vendor actions to prohibit sharing screenshots and that the EHR vendor insistence that the gag clauses are necessary for protecting intellectual property (IP) is meaningless if the IP is protecting poor design.” For those of us who have worked in EHRs that range from suboptimal to downright dangerous, that’s pretty much a mic drop right there.

As medicine has become more complex, the need for patient advocacy has increased. I was surprised to see a recent research letter in JAMA Internal Medicine about the prevalence of industry ties in patient advocacy organizations. The authors looked at the top 50 US patient advocacy organizations (ranked by revenue) and looked at ties between their senior leaders and the pharmaceutical or medical device industries. They found that a whopping 74% had board members or senior leaders with prior or current industry ties, with half of the organizations having conflicts of interest among paid staff or executives.

Although past ties are certainly worrisome, having a current conflict of interest seems particularly concerning. I appreciate the authors’ methodology. They used publicly available data from GuideStar to identify the high-revenue patient advocacy organizations and investigated the LinkedIn profiles of those listed on the organization websites. They also used other readily available sources such as annual reports, public tax documents, personal websites, and publicly posted biographies.

The authors listed some limitations, including “incomplete disclosure of board members, senior paid staff, or executive employment history, as well as the possibility of omissions from website profiles, limited (and likely underestimating) our characterization of industry ties.” Overall, they raise the concern that industry is influencing the advocacy organizations’ positions on patient education, policy making, and treatment guidelines. Definitely something to think about when you’re following the money in the complex web of the healthcare industry.

What do you think about conflicts of interest in patient advocacy organizations? Leave a comment or email me.

Email Dr. Jayne.