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Amy Maneker, M.D. joins us to discuss EHR usability, best practices, and informatics. We ask the question, how are we doing and what can we do better. Also, we explore Walmart's healthcare plans and take a look at the most recent California legislation to combat opioids.


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 Welcome to this Week in Health It where we discuss the news, information and emerging thought with leaders from across the healthcare industry. This is episode number 37. Today we look at, we look beyond Amazon to Walmart to explore their plans in healthcare. Um, and, uh, plus we take a closer look at what California legislation California is doing around the opioid, uh, epidemic.

And, uh, look forward to, uh, digging into that again this week. Uh, it's a very important topic. Uh, I'm at the Becker's conference this week and, and hearing a lot of, uh, conversations around what health systems are doing, uh, to address this, this podcast.

Trusted partner that has been moving health systems to the cloud since 2010. Visit Healthcom to schedule your free consultation. My name is Bill Russell, recovering Healthcare. I writer and advisor with the previously mentioned health lyrics. And, uh, so before I get to our guest today, uh, just call out once again our, uh, YouTube page and, uh, if you get a chance this week in health, a great resource for your staff.

Over 300 videos curated on, uh, different topics I wanna call attention to. Uh, next week we're gonna have a, uh, special episode, a little different episode. Uh, I've interviewed. A handful of people at the, uh, at the Becker's conference here in Chicago, and I gave, uh, all, all five of the people that I interviewed at Marks and among others, uh, David Chow, among others who are here.

I gave 'em all the same five questions. They all answered them. So you'll get a. A little perspective of, uh, cross section of what large and small hospitals are doing and different, uh, uh, we have some children's hospitals. We, it's, it's all over the board. Uh, some really interesting conversations. Look forward to, uh, bringing that to you next week.

No video next week. But, uh, some, some great audio from, uh, bar tables with background noise and those kind of things. My sound engineer will.

Doing this podcast has been a great mix of, of having, uh, some friends on the show and meeting new friends, uh, with great backgrounds, uh, that, uh, that agree to come on the show. Today's guest was introduced to me by S Shade, uh, who's one of the original guests on the show who I'm always greatly appreciative of the people who, uh, took a risk early on, uh, to come on the show.

Uh, Amy is our guest today. Amy is board certified in Pediatrics and clinical Informatics, and today we're joined by Dr. Amy Man. Morning Amy. Welcome to the show. Hi there, Abel. Well, you have a, you have a great background. I'm, I'm really excited to, uh, to get into this board certified in, uh, pediatrics, but also board certified in, in clinical informatics.

Can you give us a little, uh, I, I, I don't think all of our guests are, are familiar, including myself with, uh, board certified clinical informatics. So you could give us some background on that. So, um, clinical informatics became a board specialty, I wanna say in 2013. And you need to be, have a primary, uh, board certification and then you can do a clinical informatics board certification.

My generation can, um, grandfather in with some fairly stringent criteria for experience and then take the exam and then we're transitioning to you do a fellowship just like in any other board specialty. So, you know, Someone may do a residency in internal medicine and a fellowship in gastroenterology and get board certified.

They can now also do a residency in pediatrics or internal medicine and a fellowship in clinical informatics. And there's a fairly, um, growing opportunities of to do fellowships like, so there's a number of programs that have developed in the clinical informatics arena. Yeah, it's pretty, pretty interesting to me how many physicians are.

Um, or making this move into informatics, making the move, uh, into, uh, really trying to address this challenge with, uh, E H R usage and those kind of things last night on either side of me at the dinner table. Uh, were physicians who are the, they're living in the informatics world. So I, the, the, the role's expanding, and I assume this, the, the, we're gonna see more people become board certified in clinical informatics as it moves.

Yeah. I expect so. So, uh, lemme give people some of your background. So, uh, university of Pennsylvania undergrad, uh, Penn Medicine, uh, residency at Presbyterian, New York City Fellowship and pediatric emergency medicine. Uh, rainbow Babies and Children's Hospital in Cleveland, Cleveland's, where you ended up, uh, settling down and eventually made the mo move into informatics.

Uh, give us an idea of your journey, how you went from, uh, practicing medicine every day to, uh, making that transition. Was that. Does that happen for you when the E M R sort of came into your environment and you stepped into a role? Or, or did it happen another way? I get asked this question a lot because of, um, both my age group and being female.

I'm a relatively unique, um, I. Person in the clinical informatics space. So I often get asked this, and it's a little bit of an interesting story. It was a, it was by accident. So I went to this, um, a phenomenal medical school. I was probably the highlight of my education. And I think at penned they groomed you to change the world, not to necessarily see one patient at the, at a time.

Although it's fine to see one patient, so I think I always thought I would think broader. So I finished my residency, I finished my fellowships with peds, peds emergency medicine. By that time I have two young kids and a husband who works a lot, and I'm just paddling my canoe and I'm working and I got, I'm very good at organizing and kind of just

Pulling all the pieces. It's kinda like project management and innately. And so I got tapped on the shoulder very early to do a lot of administrative tasks. I won't list them all for you. They were great to learn how healthcare worked, but they didn't really inspire passion in me. And then, um, I'd kind, I'd been acting as an interim division chief.

They hired division chief. This is like 15.

I don't know whose office and says, Hey, you know, you're really flexible and open-minded and you have this time. Could you help out with this multi-million? Do you know hundreds of millions of dollars E M R implementation across a nine hospital academic health system? I'm like, sure. You know, and I actually didn't really know.

In fact, my kids, I think were laughing hysterically at the time. I didn't know a lot about technology or computers, but I really felt like as soon as I got involved, I thought, this is transformational. This is the tool that can improve quality and value of healthcare. For, for America. And so I came in from, from above, like as I say, I came in from above.

I didn't come in like, Hey, I write code. I know about sql. I learned about all the tools and I know about SQL Code and, and NoSQL and, and which, You know the value of each, but it's really the goal is to improve quality and value of healthcare. So I kind of got bit by the bug and you know, things that you're passionate about, you learn very quickly.

And then I did some additional education and, you know, in short order, I basically functioned at that hospital. The C M I O was only 40%, and I basically did the other 60% in a similar . Different title, but similar role. And, um, the rest is history. The rest is history. Does that answer? Yeah, no, that's, that's a great answer.

My, my Microsoft updates just popped up on my screen here, so I. Have to, oh, sorry. Close some things down. And it, it's one of those things about a podcast you do, you, uh, you know, you have to shut down your email and all these other things that pop up and you just forget that one thing. So, um, you know, that's, that's a fascinating story, and I think we're finding that more and more that, um, physicians have gotten pulled in.

They've either gotten pulled in or they look at it and go, this can be done. Uh, you know, this E M R implementation could be done better and they step up and they go, you know, let's, let's tackle this, uh, this challenge or this problem. And, and it's, it's, uh, as you say, you know, coming in from a, I I'm, I'm the other side, right?

So I come in from the, I know technology backwards and forwards and, uh, I the first thing when they say, Hey, consolidate these, These nine EMRs across 16 hospitals. First thing I say is, yeah, I can't do that. I need, I need help. And so I went out into the organization and found someone like you, uh, who really, a physician who really understood, um, the first of all, had a passion and understood, uh, what, what data and what the m r could do for healthcare.

But also, uh, it was phenomenal with relationships. It's. 80% if not 90% a people job. I mean, you are organizing corralling people. And, um, what was, what was that aspect of it like for you in terms of, um, you know, so you, you get this E M R role and you know, as a physician you're managing your own practice and managing your patients and those kind of things.

And then you step into this role where you're really corralling, um, hundreds of people, if not thousands of people trying to get them. Um, uh, to make a pretty significant transition. Uh, what, what did you learn about the people aspect of it and really motivating people and? . Um, so I wanna comment first about the patient aspect.

So people sometimes say to me, oh, do you miss taking care of patients? And I still do, but a very small amount. But when you're in, when you're working in informatics, you're affecting whole populations of patients. So in some ways it's much more impactful than seeing one patient at a time. So if you build an E M R to do, make the right thing to do, the easy thing to do and improve care, you're much more impactful.

Then, you know, that one kid who I saw. So that was, that's just the patient comment. Um, and I'm sorry, your question is how do you get PE people? I think a lot of it is, it's two things. It's one, you became evangelical and you, you get people to understand the value and also informatics, you know, Everyone thinks, oh, just put a hard stop, put an alert, do an in baskets message, and all those inherent things.

In fact, one of the things we'll talk about later today is what everyone thinks will solve. It doesn't. And so I think it's also getting people to say, well, what are you really trying to achieve? And let us work on how the software can do that. And so it's that I one of the most. Things I say most commonly in meetings is, what are we trying to achieve here?

And so it's not just in the software, it's, it's just in general and like pulling everyone back and saying, okay, so if that's what we're trying to achieve, let's agree to that and then figure out the best path forward. So I think a lot of it is, um, corralling, educating, and then a lot of it is also listening, um, to people.

And then, and a lot of it's storytelling. You know, Hey, I understand your concerns. Like open notes is an, is an international, that's gotten a lot of press lately and a lot of people have concerns, but start telling the story of the places that have done it successfully and apparent of the patient's value and of the data and um, and it's much less threatening when you start telling a story.

Yeah. And list and, and resonating with, you know, quality and value of healthcare and what it means to the patients and what it means to your practice. Yeah, absolutely. So now you're stepping into the, uh, consulting realm with Starbridge Advisors. This is a new chapter for you. So, uh, so if people are interested in working with you, they actually.

They actually can, uh, through Starbridge. So that's, that's exciting. Um, so one of the things I like to do with our guests is ask them a pretty open-ended question. What are some of the things you're working on, uh, today that you're excited about? Uh, or what are some of the things that are going on right now?

It's, it's really the floor is yours. You could talk about. Some people feel bad, they feel like they need to talk about their kids or that kind of stuff. Nope, I have a good one. Okay. So I think one of the hottest topics, both for me personally and across the industry and I suspect is how do we address the E M R, whatever brand you're on's, role in provider efficiency and satisfaction.

You know, people say physicians are burned out. I was at a social event the other night and the neurosurgeon next to me kind of heard what I did and immediately started complaining about clicks. To me, no joke doesn't even work at anywhere where I've worked. Um, but I hear about the clicks and so I think we're really trying to, we're beginning to address that and one of the most helpful tools.

So I. Did a project on that at my last organization, but IS class is doing this arch collaborative and I think we're getting some really good, fascinating data. And so what class is doing is they're asking, I think they're probably close to 120 organizations, and they basically say, Hey, to all the users.

Does your, do you agree? How do you feel about, does your E H R enable you to deliver high quality care? Then kind of like when we do population health, you look for the bright spots. So what are the characteristics of places that, where everyone says, yeah, it's pretty good here. The m r. So it's not what you think.

So you ready for the big surprises? Sure. Love it. Uh, so you're gonna share some of the things that Arch Collaborative, uh, found Yep. With their initial, uh, findings and that I've had, and I've also, um, had personal similar experience, but I think it's more powerful to talk about. This national data.

Absolutely. So they found, I'm gonna give the big surprises first that it spend doesn't correlate, voice recognition doesn't correlate. And, um, scribes doesn't correlate with improved user satisfaction. That's, that's wild. That's hard to believe actually. Uh, 'cause you hear that a lot if. You know, if I didn't have to do the data entry, this, this whole thing would be fine.

That, that's an interesting finding. So, and in fact this week, um, JAMA had an article about scribes and satisfaction in, um, 18 P C P practices. I. , which shows the opposite. So then now that I've kind of reigned up, you know, everyone's assumptions, what are successful organizations and, and what they found, and I've personally found is it's really about how do you help support the users to use the E M R.

And it's, it's. Hates it's robust, high quality, or at least the perception of really good training at first, it's ongoing support and the ability to personalize, which I tied to ongoing support. And one of the things that I really think, and it hasn't been borne out yet in the, they haven't gotten is granular.

It's ongoing ownership and engagement of the physicians. Need ownership and engagement. Not each and every one, but like someone in each specialty needs to own the content and understand the software, and that's what really makes a difference. One more thing is the organizations that haven't had good data have keep trying to, it looks like they throw money and technology at it.

Well, the organizations with high user satisfaction seem to have a more of a culture of, of support and relationship with it. And the other thing is that everyone complains about entering the data. And this is my concern about the JAM articles. No one talks about getting the data out, which is as important as entering the data.

Sorry. Now escalate. Yeah. Yeah. So, so I'm curious, so do they talk, um, if, if somebody wants to see these, you, you can go to the class site and download, um, a, uh, P D F on some of the high level findings on the arch collaborative. It's pretty, uh, pretty, pretty good reading. So what do they find about being able to customize the environment?

So, um, you know, I, I, I know in our E M R implementation, there was a lot of. Uh, a lot of conversation around, you know, customizing the, the workflows or customizing the order sets or customizing the, uh, the experience. Uh, you know, for instance, a, a cardiologist doesn't wanna look at the same things as a, uh, uh, as a, uh, er doc for, for example.

So, um, so people want to be able to at least personalize, personalize, that's a better word for it. Yeah. So that's actually what they. We typically call it, and they're finding the value of personalization. And here's the interesting thing is, is very, it does correlate and it's not just about data entry.

It's, once again, it's about data retrieval. So people need to be able to person personalization. And many of these EMRs have unbelievably robust ability to personalize, but someone has to help someone do it and make the time. 'cause like if you're gonna build some, you know, patient lists or whatever views, you're doing it once, you're not gonna remember it.

And so personalized personalization of the EMR is wildly underutilized. It's there, but people don't know how to do it or have the time. And so if what they're finding is, if people have the time do personalize, they have much better user satisfaction. And I would offer, you need some support. I need someone to help you.

And you probably need some physician ownership and engagement. 'cause someone in your specialty. Has to say, Hey, here's what my people really need. Um, and either make it happen or help them make it happen. The personalization. And we, we, we could do the whole show on this. 'cause I, my, my, my other question is on training, 'cause you know, one of the, one of the challenges obviously is making that time, making it available.

And even when you do make the time available and, and you're gonna, uh, compensate the physicians for training, um, you still only have a, you know, Hit and 15% don't wanna in training. Um, and then you get after the fact. And sure enough, there's a huge correlation between the physicians who did not get training and the physicians who did go through the training.

Uh, and you end up spending an awful lot on elbow support at that point, and, uh, helping them to personalize it. What did, what do you find to be, or what did the Arch Collaborative find to be a successful model, um, for ensuring. Effective training across the board. So I think what we're finding is that there's no one clear model, and the one thing we are finding is there's initial training and then there's ongoing training.

And I think we never realized, you know, in many other industries where people use software so intensively, So accountants, engineers, they get ongoing training and I think none of us knew. We put in the C M R and now we're all learning. You gotta do ongoing training. And what I think where no one has quite gotten down to, is there a particular model for that right now?

And I, um, I think it's. It's all over the map of how you can do it. And even when I did an organization, we did it by specialty. We did it different for each, for many different specialties based on number of providers, just based on all kinds of nuances. So I suspect that underneath it all, there's some key factors you have to do, but how you do it could be very variable, you know, based on your environment, based on your resources, based on personalities.

Yeah. You know, we'll probably have to dedicate a whole show at some point. For E M R implementations, there's so much Great, yeah. Uh, there's a great body of knowledge and, and, uh, um, and this is beyond, this is really more than implementation. In fact, I think this is really the year 2, 3, 4. This is years later when everyone's suffering and miserable and talking about the cliques, like the neurosurgeon the other night.

And what they're finding is it is they need support and training. Yeah. Yeah. So it's implementation and uh, ongoing optimization. Uh, but really what is, it's a shift from a project mentality to a product mentality, which it's, it's a project mentality is, Hey, we've got it in, we're done. Mm-hmm. , and, and you see implementation as a project, and optimization is a project, and really it should be a product mentality.

And a product mentality is, uh, you know, you, you're looking at this thing over the life of people using the software and you go, And you create roadmaps and you create, uh, enhancements and you're constantly listening and updating, but you're taking more of a long-term view instead of a start and finish kind of view.

It's a, I think you sum it up. I think product mentality and I think training, support, whatever you wanna call it, is an ongoing thing. And I wanna call out optimization 'cause of a number of us, including, um, people at the arch collaborative. It's, we call that the optimization fallacy. And what we're learning is if you just go in and optimize, You come out and you aren't really that successful.

And many times a large part of the optimization is successful training and support. And in fact, in my experience in another organization, it was mostly training and support with a few minor build changes made the biggest difference. Interesting. Well, you know, we, we've already taken the first, uh, 25 minutes of the show on this.

We haven't even gotten to the news story, so I'm gonna, uh, I'll kick it. So we do two things in the news and soundbites. Uh, I'll do the first story, I'll do it pretty quick. 'cause we, we talk about this topic, uh, pretty often. Uh, but we always talk about it, it feels like to me, we always talk about it from an Amazon perspective.

And, uh, I wanna talk about the other player in this space that has over 140 million weekly customers. Uh, most of which are, um, lo lower income, uh, seniors and, and those kinds of things. And they have stated their intention to step into this, uh, care navigation, primary care role. And that's Walmart. And there was a a C N N, uh, money article, uh, Walmart once spring, everyday low prices to healthcare.

And, uh, they talk about, you know, their anthem deal, uh, to entice more Medicare enrollees to buy over the counter medications. Uh, they talk about tapping the Humana executive, uh, Sean Vinky, uh, to lead the health and wellness division. They also talk about the fact that they were in, in, uh, uh, negotiations to, uh, are not negotiations, but they were looking to buy PillPack before Amazon actually purchased them.

So what, what does a. Uh, an organization like this offer, and it's kind of interesting 'cause as you look at this article, you realize, uh, they're already one of the, the leading pharmacies in the nation. They have, um, as we said, just a a hundred and some odd million people. When I say 140 million people walking through their doors every week, 3000 in store vision centers, free health screenings at over 4,700 locations up to four times a year.

Uh, you can, uh, they actually have people who help, helping people to enroll in the Affordable Care Act and Medicare Advantage Plans. Uh, they, they even tried their hand at, uh, urgent care clinics in Georgia, South Carolina, and Texas. And, uh, they haven't expanded that. So I imagine, you know, it's, it's just a pilot and they're seeing how it works and they're gonna work out the kinks of that.

But just their sheer reach and their, their volume. Uh, makes them a, uh, makes them a, a, a viable, uh, player in this space. Uh, what they're really looking to do is to tie up those, uh, Medicare, medicaid, uh, markets and start to, uh, market their other, uh, services to them, right? So they can, uh, they can offer, uh, help with, uh, uh, food and, and healthy grocery items and.

It's not necessarily a medical play per se, it's, it's more of a retail play, but by, uh, by taking advantage of their footprint and, uh, their relationship and, and their data. I mean, if we go to informatics, which is your background, they, they know a lot about these, uh, these people who are coming into their store, as we've talked about with Amazon before.

If you look at somebody's Amazon shopping history, you could tell an awful lot about that person. And Walmart has that kind of data. Um, and so they're, they might be able to step into a gap because of their knowledge level that a, that a, uh, health system might not be able to, uh, to help guide and direct, uh, somebody from that, uh, navigation role.

Let's turn this to a question. So you are your first, uh, engagement with, uh, Starbridge advisors. You're hired by Walmart. They want you to be their physician advisor. Um, what, what gaps do you think they can fill? I mean, we've talked about a lot of gaps that they're stepping into, but are there gaps that they can step into and fill that, that, uh, would be interesting given their, their, uh, breadth of locations and the number of people that are already walking into their doors?

So I think the one thing I would like them not to do is not to create silos. So you don't want them taking action and not sharing that data. So whether it's through an h i E or shared platform, you wanna make sure the data is shared. I. Then I guess that's really the next thing, is they could really play a very valuable role in closing care gaps.

So, you know, as that article mentions, a lot of people in certain parts of the country go to the Walmart as like the community center. They're there a few times a week. They could give flu shots, they could give Pneumovax, they could do diabetic foot exams, but that would not be helpful if they're not sending that data back.

So that those care gaps are closed in the patient's records. That's interesting. 'cause that's, c v s did implement Epic. Um, I don't know if Walmart implemented an an E M R. Um, I don't know. Have, have you read anything about that? I don't. I. You know, I don't know. I will say that when I read that article that you sent, it made me think one that Walmart is, in some ways, maybe the big sleeper here, that we're all focusing on others.

And that occurred to me as well. And it doesn't have to be that they implement Epic. There are other ways, but it's more that the data is shared. 'cause I think there's. You know, if we talk about the overall greater good and not just the retail space, you know, or the good for Walmart, there's some real value they could bring by.

'cause they're seeing these, you know, huge volumes of patients that have significant medical issues and that they could close care gaps. And as I said, just, you know, diabetic foot exams, um, flu shots, Pneumovax. So, so let's talk about sharing data. So you have all these new partnerships, Cigna Express Scripts, c v s, Aetna, and now, now we're talking about Walmart, which in of itself is a C V SS Aetna or Cigna Express Scripts.

I mean, they're, they're in, in all those spaces and trying to get into insurance and other things. So, um, what data are we sharing? So I, we're the health, we're, I'm on the health system side. You're, uh, you're now an advisor for Walmart. We sit down at the table, what information do you want from me? As the health system and, uh, and actually I'll have you answer both questions.

What information do you think, uh, the health system should get back from, from Walmart? Well, I think at minimum they want, um, it to flow effortlessly if they close care gap. So if, if the patient, if they give out flu shots, they want it to go into their system. So you know, that patient got a flu shot. So A, the patient isn't bothered getting a call.

B, they, you know, They don't clo they don't spend resources tracking them down. So I think any care they give you want it to flow effortlessly. And then I think if we got to the next level, it's like, what social determinants of health or what data could you get? Could you do, well, there's a privacy issue, but would you want them to share data on their, um, buying history to, to help.

Um, stratify their health risk or help report on their health risk. I mean, I think that's getting to the whole next level. I was just starting really simple that if they were gonna get into healthcare space, just make sure the data gets fed back so that someone has a complete picture at the patient level, and then the population level of who's gotten what care.

Yeah, it's interesting. Right. You know, and, and potentially, rather than doing a massive, uh, E M R implementation across all of Walmart, um, you know, they. We talked about this last week, they could tap Apple on the on the shoulder and say, look, you're starting to get data from the E M R through fire. Yes, we'd like to give Apple the information.

So patient comes in, we give 'em a flu shot, we give, we put that into their Apple record. Then when they go back, they're actually the carrier of the data and they go, okay, I, they can approve to upload it to whatever care provider they go see. Now obviously some of this stuff's pretty sophisticated at this point.

Given where we're at. But that's the, that's the promise of fire and that's the promise of sort of the consumer records starting to follow people around. No. Yeah. Correct. And you know, I purposely did not mention implementing an E M R 'cause I didn't think that was kind of the direction Walmart would go.

I was more about sharing the data. Yeah. You know, back to my question of what are we trying to achieve? What we're trying to achieve is getting the data to the, to, so the patient has complete record, how to do it. Is a different story. Yeah. We often get caught up, especially in software of the how and forgetting the, what we're trying to achieve.

Yep. We go right down the rabbit hole of what we want. Hey, I wanna, I want a hard stop. And you're like, yeah, maybe not. Yeah. I mean, uh, Walmart, I, I, I don't know what the C V Ss, uh, epic implementation costs, but, uh, you know, a Walmart implementation I'm sure is, is well over a billion dollars. So it's not a.

You know, we go down a, a rabbit hole that's gonna cost a billion dollars. So it's interesting how that, uh, I'm gonna kick it to you for your story. Uh, tee it up for us and, and let's discuss it. So my story is the LA time story on the Cures Act that goes into effect October 2nd in California that requires that, uh, physicians check the P D M P.

And I'll be honest with you, it was really, I used this. An excuse to talk about this is CMS Prescription Opioid and Heroin Epidemic Awareness Week. I know it's a hot topic, so it's funny. The two hot topics are user satisfaction with the E M R, which we just talked about, and, and physician burnout and the opioid epidemic.

And you know, I don't have to remind everyone that drug overdoses involving opioids killed more than 42,000 people in 2016. In fact, there's a very interesting quote by, uh, Physician, a transplant surgeon who he went to get organs like the first, in one day, it was three young people who died of opioid overdoses.

And so he really got converted to addressing that as well. And he said his quote is, becoming a new opioid user is probably the most common surgical complication in the us. And so I thi I think what's going on in California is well intentioned. I'm not gonna get caught up in all the challenges because it's very challenging to check the P D M P, but I do wanna comment that on the C M S O one C has put, as part of this, um, prescription opioid and heroin Epidemic Awareness Week, they put some really nice tools out.

Um, so they put. Um, some like electronic opioid clinical decision support, some standards out, and they have this nice little infographic that I don't think we all realize that health, it is probably one of the, there's lots of tickets to. But it's probably one of the key things to combating this epidemic.

And some of the things are really simple, and it was funny. I've implemented this and Judy Faulkner actually mentioned it on the stage at U G M, some of the little things can make a big difference. So if you just change your gamer defaults to the day supply being three for opioids, that's huge impact.

And in fact, this transplant surgeon talks about, Hey, we used to give people 30 pills of . When they left, even from, you know, my a c l repair or my wisdom teeth out, and that is a huge risk factor. So sometimes it's the little things California is. Actually asking, you're putting the burden on physicians, like now you have to go check the pd D M P.

And I think to really be do that effectively, it has to be integrated into the E M R. Um, and so I think there's some real downside to the, the California law, but I think you gotta, we're all gonna need to integrate the P D M P locally into the m r. Yeah, so I was a c i O in in California, and the, so the challenge with this always comes, you know, where's the burden gonna fall?

It's, you know, it is it gonna fall down to the doctors where you just put in a whole bunch of stops, manual stops and, and checks and, uh, alerts and, um, you know, call out to this database. Oh, by the way, you have to launch another window. Go into, you know, this, uh, this thing, or, or quite frankly, or we're not looking at discrete data, so, Filtering through a whole bunch of PDFs to find the data they want.

Are we gonna put the burden on them? Uh, but regardless, uh, a lot of these policy things tend to, um, create a just a ton of work. Um, and so the burden falls somewhere. How, how do we make sure that this burden doesn't fall unduly on the physicians? You know, I completely agree. I, I think one of the first things is you have to put the pd, you have to make it integrated and effortless and serve up.

So it's not another task. It's when you go to prescribe an opioid, that information is served up to you. And in the perfect world, you actually, um, The data is more than just the pd D m P, like it looks at overdose experiences and other things, and so it even can do some logic to say, Hey, this patient's at risk.

Because I think this whole thing of, Hey, you go look, you go interpret the data, you know, is really onerous. And so I think you, you have in the perfect world, you have to both integrate it and put some logic into, and so the data is, is as part of the workflow is offered. Yeah. Does that make sense? Yeah. And the other question I have, I, it may sound insensitive, I don't mean it to be, but the, um, 'cause clearly, um, the risk of, uh, an opioid, uh, overdoses is, uh, is tragic and, and difficult.

But, um, you know, hcaps, we talked about this last week, so hcaps calls for. Uh, there's a question of did you manage the pain effectively? And one of the things that physicians have talked about is, you know, we give them so many days of opioids to make sure that the HCAP score is, you know, so that we manage their pain.

The other thing is you don't give 'em enough of the opioids. They just had an a C L replacement and they have to keep coming in 'cause it's a physical, they have to show up and you have to have a conversation with them in order to, to give 'em an opioid. And they're like, you know, I had to come into this hospital four times to get my pain medication refilled.

And you know, the hcaps comes in and they go. Did they manage my pain? No, they didn't. And you take a hit on the hcaps. Is, is that a real problem? I mean, do we have things that are sort of competing or opposed here? Well, let's back up. You know, I'm been in this long enough that I remember the day and age when they're like, oh, the fifth vital sign is gonna be pain.

And it's, you know, addressing everyone's pain. And no, you can't get addicted to opioids and we need, we need to give med or pain meds. And so I don't know that we know it, but it feels like we created this a little bit. And, and I think in the future we're gonna, maybe that HCAP question needs to be removed because of, we need to address pain differently and we need to change the patient expectations.

And so if everyone's afraid of that grade, we're not gonna be able to do that. But I, yeah, no, it's a real conundrum and I can't help but think that. Part of it was part of this epidemic was created by pharma part. You know, there's multifactorial, but part of it was created by the healthcare system. You can't help but think that there was a role there.

Healthcare is, uh, healthcare is complex. It's not, it's not simple. Yeah. So, um, so I'm gonna move to the soundbite section. You know, during, during this section, throw out some questions, one to three minute answers. Uh, if you go longer, I'm not gonna stop you. Um, so, uh, here we go. Let's just jump into it. So you're a physician.

And you're a technologist. So, uh, how are we doing? Uh, we talked about this a little bit, but we have all this technology. We've, we've put it out there, especially the E H R, um, you know, how are we doing amongst the physicians? The clinicians, uh, you know, just in general are, are, are we making progress? Are um, are we still sort of in the stuck in the, in the mire?

I think we're doing better than maybe we think we are. So we really do need to address it. And I think. Physicians in particular, but all the users are struggling. And we talked about it. Maybe a lot of it is, is we're seeing more and more that we need ongoing support and training. But I think we're for, and, and so I think, let me back up.

I think we need to change the, um, narrative and people need to start seeing the E M R as their friend and get the ongoing support and training they need. But I think we're also forgetting what life was like so. You know, I'm in the trenches and I hear physicians. There's a lot of complaining. The neurosurgeon yelling at me about the clicks.

But you know, we forget. I used to, I've been an ED physician for a long time, and a patient used to come in and tell me this story about this whole workup, whole story, and I basically would be, I'm not kidding, you be looking at a white piece of paper, you know, hi, and writing it down and starting all over again.

And now I can say, oh, and I saw you saw Dr. Jones last week, and I see these sets of labs and those all look good. Well, let me do this and then do that. And what a value both to the healthcare system. It makes my life easier, but what a value to the patient. And so I think the narrative, there's such physician burnout.

We're not supported in our use of the emr, so we're blaming it, but we need to get over that. We need to provide ongoing training and support, and we need to start seeing the value. And we also need to put time and energy, and I think you summed it up. It's not a project, it's a product. So we need to put time and energy into improving the content and the decision support in m r.

I think we just talked about that. With the opioids, like we need to serve it up and organizations need to realize it's an ongoing, um, it's a never ending. It's not a project, it's a never ending, um, tool that we need to support and we.

provider, you know, physician level ownership, engagement to help someone develop something like, Hey, here's what I need in the workflow to be able to check the patient's opioids. Here's the where I need it and what I need. Yeah. So I think we've made huge strides and we need to change the narrative and acknowledge the strides.

I think we don't wanna be complacent. There's a long way to go. Yeah. And it's the narrative in the stories. I remember, uh, Dr. Te Gandhi was sharing a story and she goes, without the E M R this wouldn't be possible. And, and, uh, John Alka was share. This was when I was up at, uh, Harvard, uh, at their, uh, school of Public Health.

Uh, John Lanka shared a story about Vioxx and without informatics, you know, that would've gone on a lot longer than it did. And, and, and there's, there's a lot of those kinds of, of stories. The lead story in Detroit. Yeah. And we, we just, we, we need to keep telling these stories of, hey, Data informatics is, is going to, is impacting, um, you know, the e Ebola, I mean, we were able to roll out a whole bunch of things when that was, that scare happened a couple years back.

We were able to roll out a whole bunch of things because of the E M R that probably would've taken. Months or months, you know, or potentially even a year to roll out across 16 hospitals. So, and I was actually in a place where, um, I don't know if you remember, one of the nurses had been to the Akron, Cleveland area.

No, I, oh, she did. She gone bridesmaid shopping or I can't remember. And so we had to roll out all those screening questions, but we could. Which you never could have done. So I do, we need to change the narrative, but I also think you are, you're right, it's a product and the users need ongoing support and training to be able to use it efficiently.

So one of my, well, I think it's one of the next questions, so I'll be quiet. . Yeah. So, uh, I'm gonna go back to the, the arch collaborative here. So, Uh, one of the E M R implementations that you are a part of, uh, received an 84% score, uh, on their class net e m r experience. Uh, score. Um, two things. One is talk a little bit about that score and the value of that score.

And, uh, the second is, uh, you know what obviously training, but were there some other things that your team did to achieve that, that level of, uh, proficiency? So I do wanna call it that, that was way beyond the implementation. That was five or six years later. So back to being a product. Got it. I think the score just gives you an idea of where you stand relative to the nationally, and then it gives you some, you can really dig into it and gets granular.

And so what we learned there is that. We really had some real opportunities in personalization. But what we did, in fact, this was one of my favorite parts, uh, the story I love to tell is, um, we, it was part of a larger organizational initiative and we, instead of being reactive about the EM R's role and provider efficiency, we were proactive and we said, okay, we're gonna do advanced training.

And we're gonna do have ownership and engagement. We're gonna draft physicians to, to have part of their job, be the E M R. And out of that, we're gonna have, um, good enhancements, optimization, and good configuration in the E M R. So advanced provider training initially, um, the response was, I have a very funny slide.

And these are, they're cartoons, but they're real people. And so one person, a leader said, we don't need training. You just need to get rid of the clicks. Another personal leader said, my docs are really smart. Just fix the 10 things they tell you to fix. We smiled and we created this advanced provider training, which was specialty specific.

So you train the cardiologists together, they don't need to know the same as the ER docs. And you also need, this is the ownership engagement. You need a champion, a physician from within to decide the content. So one of my favorite jokes was, I would say, brought to you by, you know, Dr. Smith, not the training team.

So if you didn't have a good champion, you didn't have good training and, and then also do it in production so they can clean up and do their end basket. So we did all that. Remember, they're demanding, we don't need training. And we did it and we smiled and we kept saying, and we got great results. And then this is a slide with a cartoon, but these are true results.

The person who said we just got rid of the click, said, well, I need you to train my 160 primary care providers. When can you do that? Then the other person literally said this in the cartoon, but it was a true thing. Hey, this is what we've always been asking for. Thanks for doing it. So I, I think people don't realize the value of training.

And if that neurosurgeon the other night yelling at me, literally at a social event, if I had said to him, Hey, it's really training and support, he wouldn't have bought it. And I get it. And then the funniest is, so after we did some pilots, I used to get hate mail when, when I couldn't accommodate a specialty.

So, you know, endocrinology, we, we can't get you for a few months. And people would complain and then people would say, so when do we gain that training again? So this was two, two hour sessions in the classroom and it was required. And, and people were complaining you didn't get to us. That wasn't what I expected.

Yeah. So I think, um, the other secret sauce, which I should mention is that organization always from the get go, from their go live five years before had this very robust just star, what they called provider liaisons at the elbow support. And I think that team was the secret sauce that got us the five years with before.

And then they were also the secret sauce that kind of really helped with the execution of the training. Helped with figuring out the personalization later and would partner with that physician champion or what we then called an Epic medical lead, and that's the ongoing ownership and engagement. So I think those were the ingredients that were specific to that one organization, but they were also a few

They, they map back to what the arch collaborative's finding at a national level. It's just how you do it can vary, you know? It's interesting we, does that make sense? Oh yeah, absolutely. And you know, one of the things we've, we've talked about on the show and I've talked about with other, I. Uh, uh, people in, in the industry is just, you know, the, the training we need now is not necessarily technology or even medical.

It's, it's socio, it's, you know, a sociology background would be good. 'cause it's, it's changing the culture. It's, it's understanding the culture. It's, um, and it's really moving that needle. It's, it's, and what you described is you've created a culture. Uh, you, you've changed the culture in, in the process of rolling out the emr.

Um, you know, and that, and that ends up being one of the critical success factors is, you know, is it you're rolling something to these people or are they, um, or are they a part of, of changing the way that medicine is, is delivered in, in that, uh, organization? And do they feel like they're a part of it? Are they a part of a community?

Are they part of a learning community? It's, it's, all that stuff is, is just, um, you know, it's, it's the new to new, new tool set for all of us. And I think in that particular organization, it was years after the implementation. I think if I was to do an implementation again, we've all learned is one, the import of robust training but of ownership and engagement and not just for the go live, it's for, it's a product and so you need physicians and all kinds of people, but you know, I'm a physician to own and be engaged in the content and the workflows of E M R forever.

And you know, in order to get a doc to do something, you need to enable them. So you need to sometimes give them time. You need to empower them. So when they make a decision, and you need to set expectations. So, hey, remember I talked to cardiology? You're the champion for training. Here's the, here's some time you get to make the decisions, but you're gonna get consensus and some expectations.

And then ongoing, you know what their role is. I think we didn't know all that. And so we implemented the emr and then the docs kind of thought, oh, I put the content in. We're good. Yeah. All right. So, uh, last two questions here. So you built out a clinical informatics teams. What are, what are some of the key roles that you had to fill and, and where'd you find that talent?

So I'm gonna talk about the physicians. There are some other key roles. It's, you need to draft physician informaticists and I would offer that the vast majority of the time you have to train them or find training for them. So, um, Often you have to find them from within your organization. 'cause of the, my Informatics team was, they were part-time informatics and the majority time clinical, so you have to draft them.

And you don't want, and I actually, I think the answer is you wanna recruit them. 'cause you actually don't wanna draft them. You want volunteers. You don't want people who are drafted, quite frankly, I used the wrong term. So you really get the message out there that it's an opportunity and it's not the technology.

You get people to understand that it's a really, a quality and process improvement tool. And then train them in informatics. And I think you'd be amazed about how many bright docs really do wanna improve quality and process. And I think that's the hawk. And the guy who walks into my office, and this would happen to me, Hey, I know s Q L code.

I'm like, congratulations was less likely to be a good, um, fit for the team than the person who said, Hey, I have all these ideas how we could be doing better care. And, and then introduce them. Hey, here's the tool, how to do it. Because it really is a tool to improve quality and value of healthcare. And then it's creating a team and really teaching everyone informatics and the verbiage and then also teaching them the, they have to understand whatever your E M R is better because they need to be able to have, know the language to be able to speak to the analyst.

Then they become, they can speak medical ease and they can resonate with the. Clinicians, you know, docs, nurses, whoever, and they can speak to the, um, analyst team and then they can un they can make things happen. Yeah. So, uh, that's a good segue to where have you found that informatics program has the greatest impact on care?

I. Say that of the clinical information. I think it's in qual in in quality and value and workflows. It's, it's twofold. It's making the E M R more usable and understanding the clinician's needs and maybe training and support. But why are you doing that? You always have to say, remember, my favorite question is what are we trying to achieve if we're trying to improve quality and value of healthcare?

So once you get past people using it, so why is that data asked in the E M R? Um, let's use that data elsewhere. Let's make the E M R work for us and serve up some information. And we talked about that. Don't make me go out and check the pd, DM P serve up the info. We even serve up when that patient's at risk.

And I think if you can get a good informatics team, they will be able to help the organization build that E M R to do some work and really improve care. I. Absolutely. So Amy, thank you for coming on the show. Um, is there a way for people to follow you at online or, I'm probably best, um, connect with me through LinkedIn.

I'm on Twitter at maner underscore Amy, but I mostly listen on Twitter. I don't really tweet. I mostly follow all kinds of things like you, Starbridge advisors all. Um, but LinkedIn is a good way to reach me. Absolutely. So Maher, just the spelling and, and if people want to, you know, with all that experience, if people wanted to, uh, uh, talk to you about stuff, they can, they can go through Starbridge and, and, uh, and have Amy working with you tomorrow, which would be, uh,

I think a, uh, you know, wonder, I, I know if I were still in my role, I would love to have you, uh, in. Um, it's great and I think that's what we're finding now is, uh, people have experience. It's, uh, you know, we're now a decade or more into this E H R, um, journey and, uh, we're, we're getting smarter and we're getting, uh, more experience and more success stories.

And the more we can spread those around, uh, the better care is gonna be in all these communities that we, uh, Um, so again, thank you for coming on the show. You can, uh, you could follow me at the patient CIO on Twitter, uh, on the health Lyrics website. Uh, I do writing as well. Don't forget the, uh, show's Twitter, uh, account this week in h i t.

And check out the website at, uh, this week in health

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