Rae Woods (00:02):
From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. My name is Rachel Woods. You can call me Rae. This week we are releasing a very special episode of Radio Advisory. A couple of weeks ago I was at a major healthcare industry event. I was at VIVE in Los Angeles with I think there were 6,000 other healthcare leaders. You know that this is one of those big industry events where executives from frankly all around the world gather together to talk about the future of healthcare. In particular, the focus is on digital health. I am about to go live with four incredible guests to talk about reimagining the workforce with the help of technology. We talk about why AI alone won't solve all of our problems, and we get really honest about how to make the most of our existing technologies. I hope you enjoy this very special episode live from the VIVE main stage.

(01:10):
Hello everyone. Welcome to the VIVE stage. Come on in, get settled. We are here to talk about the intersection of two challenges or maybe you think of them as two opportunities, maybe you actually think it's a little bit of both. We're going to be talking about on the one hand the ongoing workforce crisis. We're going to be talking about burnout. We're going to be talking about turnover, labor shortages, looming retirements, and at the same time we have to acknowledge that there is this rise, I might even call it an explosion, of new technologies, of new innovations. I mean, just look around this room and you can see the kinds of things that I'm talking about. My panel and I are going to discuss what the intersection of those two challenges actually means for today's workforce. I'm going to ask my first guest to introduce herself to my right.

Dr. Tina Shah, MD, MPH (02:13):
My name's Tina Shah and I'm a pulmonary and critical care doc and the Chief Clinical Officer of ABRIDGE. Just to share a little bit about my background, I am the burned out doctor. I actually got burned out when I was in my clinical training and it's put me on this journey for over a decade to try and figure out how we help these elite athletes known as doctors and nurses and physical therapists and case managers be able to practice at their utmost. I have been privileged to actually work for two White House Administrations and for the US Surgeon General trying to design the nation's strategy on burnout. And now, I'm privileged to work for ABRIDGE, which is a generative AI company that is solving for burnout or a piece of it by helping relieve administrative burden that doctors and other clinicians face.

Dr. Syl Trepanier (03:04):
Good afternoon everybody. Sylvain Trepanier, and I serve as the System Chief Nurse for Providence based in Renton, Washington. Providence is a healthcare system where we practice in the state of Texas, New Mexico, California, Oregon, Washington, Montana and Alaska. I have the privilege and the honor of supporting 36,000 nurses across all of those seven states. I've been a Chief Nurse for over 20 years, and since 2008 I've been in regional and in system role. I take my role very seriously where today I have the opportunity to make sure that I, about introducing any type of technology within the work setting to ensure that we're not unintentionally creating more havoc than we anticipated. I'm looking forward for this conversation.

Dr. Jesse M. Ehrenfeld, MD, MPH (03:59):
Good afternoon. My name's Jesse Ehrenfeld. I am the President of the American Medical Association, the nation's largest most influential group of physicians. I'm an anesthesiologist. I practice in beautiful Milwaukee, Wisconsin and I'm an informaticist. I spent nearly 15 years leading an informatics research team developing clinical decision support, AI tools. I hear every day from my physician colleagues, our members across the country about the excitements, the challenge of working in a such deeply broken healthcare system where it is increasingly hard to do the things that we know our patients need, but we're going to have to rely on technology and obviously we're here to talk today about what that means for our healthcare workforce.

Dr. Nele Jessel (04:44):
I'm Nele Jessel. I'm Chief Medical Officer at Athena Health. We are an EHR technology company, so the technology that is by and far maligned by providers. It's still the number one reason contributing to provider burnout. I am a pediatrician by training as well as a clinic informaticist and I have leveraged technology many years ago in my own practice to allow me to automate as much as I possibly could and really allow me to focus on my patient care and practice old-fashioned medicine in a high technology setting. That's my passion and that's what I want to bring to the table as Chief Medical Officer at Athena Health. We really want to empower clinicians and clinical staff and practices to focus back on patient care and have the technology work for them in the background.

Rae Woods (05:33):
What I really love about this panel is the diversity in the group that we've brought together. We've got two folks that are really here to represent the voice of the clinician, the voice of the nurse, the voice of the physician. We've got folks that are representing, I'll call it an old technology at this point, Nele, and we've got folks really representing the next generation of what innovation can look like. And at the same time, all of you have real world experience in what it feels like to practice medicine and to deal with what I kind of like to call the technology hangover that a lot of folks are dealing with today.

Dr. Jesse M. Ehrenfeld, MD, MPH (06:05):
Look, all of us sitting on the stage have had bad technology thrust upon us, designed in a vacuum without the voice of clinicians. And that is a mistake that unfortunately too many entrepreneurs, companies continue to make over and over and over. We are not going to solve for these problems if we don't really have people who understand the workflows and the challenges at the design development and deployment phases of these technologies.

Rae Woods (06:30):
100%. Let's take a moment and actually name the voice of the clinician today. I have to admit that all five of us have been working on this problem for some time. Our audience has been as well, but let's actually just ground ourselves in this moment. How would you define the state of the clinical workforce as we have dealt with this rise in innovation, the rise of generative AI? How would you define the state of the workforce today?

Dr. Syl Trepanier (06:55):
It's better than it was yesterday. In the midst of the craziness that we've all gone through over the last four years, I feel we're getting into a better place. What I do worry about though is that there are a significant amount of clinicians who I chat with that are waiting for things to go back to "normal", like something's going to pass and we're just going to go back to where we were.

Rae Woods (07:26):
[inaudible 00:07:26] grit our teeth and get through it.

Dr. Syl Trepanier (07:27):
That worries me a great deal because quite frankly, it was not Nirvana. Remind ourselves it was not Nirvana to begin with. There's a lot of stuff that really needs to happen that worries me a great deal.

Dr. Jesse M. Ehrenfeld, MD, MPH (07:40):
We have a healthcare system in crisis. At the peak of COVID, two thirds of physicians, numbers are similar to nursing, and we're burnt out. It's gotten a little bit better. So yes, we were better than we were yesterday, but not by much. My parents lost their primary care physician because that practice stopped taking Medicare because we got another 3.37% payment cuts January one, 10% cuts over the last four years. I lost a classmate of mine, incredible physician, he worked here in LA in emergency medicine, to suicide during the pandemic. A colleague of mine left the practice that I helped recruiter to running LGBT Health because of regressive state laws that get in the way of patient physician autonomy around gender affirming care.

(08:25):
All of these pressures are making it hard. They're sucking the joy out of the practice of medicine. Meanwhile, it's do more with less in many cases with technologies that quite haven't lived up to what we know they could do. We live in an AI era. We all want these things and yet there's this concern about what does it mean for privacy, the physician-patient relationship, the ability of the teams to actually deliver the care that we so desperately need to do? The technology has to help us because we just don't have the people that we need to do the care that has to be delivered.

Rae Woods (09:00):
Absolutely. And Jesse, you're making such an important point, which is that a lot of folks falsely equate the workforce crisis to COVID, to something that was temporary that we need to get over. But as all of us have started to address, it's the fact that there are deeply rooted challenges in the way that we define, treat, deploy the clinical workforce of today, and we have to address that. By the way, we can do a lot of that with technology, but I'm not sure that we can do all of it. Let's take a moment and actually talk about the root causes of the workforce challenge. I do want to talk about technology first. So Nele and Tina, please share with us why is it that technology hasn't solved all of our problems yet?

Dr. Tina Shah, MD, MPH (09:46):
We had this golden opportunity with the pandemic and we saw innovation and technology, but the bottom line is right now there is such a lack of trust. We're pairing that with the fact that 63% of physicians are burnt out. The rates in nursing is pretty similar and we literally don't have people that are ready to take a chance. It has to work perfectly and it has to work for people, otherwise they won't even try it. So there's a loss in that. Additionally, technology has historically and ironically completely omitted the human in healthcare. I am tired of technology being done to me and making me work for technology. We have not measured the cognitive load that technology brings in when it's implemented in our clinical workplace. In the absence of that, a good idea can turn into death by a thousand point solutions.

Rae Woods (10:39):
Yes.

Dr. Nele Jessel (10:41):
Yeah, I will agree with this. I think the common wisdom is that technology is not perceived well by clinicians and clinical staff because it was developed without the input. That is all true, and I think we've gotten much better, especially over the last decade or so at changing this. People like Jesse and me and Tina are now on board with most technology companies to try to help guide the development. I do believe, however, that there's three things that differentiate the healthcare technology industry from all other industries, and that's why it's such a challenge to actually truly leverage technology in healthcare.

(11:16):
Number one, there's a really high regulatory burden in healthcare NCPDD, ONC, CMS just to throw out a few acronyms that we all have to adhere to that don't always, or I should say rarely take clinical workflow and clinicians perspective in consideration. Second, technology healthcare I think is the only business line where there is no one-to-one relationship between the person receiving the services and the person providing the services. There's always a middleman and not just one middleman, but many middlemen. The question I always get from providers is, "Listen, I don't understand. Why can't EHR technology work like a famous online-direct-to consumer business that also starts with an A that all of us are very used to and it's super easy?"

(12:04):
I wake up in the morning and I decide, you know what, today I really want to purchase a pair of cat socks because cat socks make me happy. So provided I have a credit card and a stable home address, I log on, I order it in the morning, it gets delivered to my door a couple of hours later. Perfect. Now visualize the same transaction as a healthcare transaction. I decide I want to order a pair of cat socks, makes me happy. First, I have to go get the opinion of the merchant who sells me the cat socks, are cat socks really the right thing for me? Engage in a shared decision-making discussion. "No, I think you should try dog socks because they come in a pack of 10 and you can actually have a 90-day supply of dog socks. Your credit card merchant might not pay for your cat socks because they prefer to pay for dog socks."

(12:50):
Okay. We finally arrive at the shared decision that yes, cat socks do make me happier than dog socks because I'm actually a cat person, not a dog person. Took the whole hour of the transaction. Now the merchant has to submit a 10-page document to my credit card company outlining why cat socks are necessary because we've tried dog socks and they didn't work. They actually make me depressed because I'm not a dog person. I'm being facetious, of course, but you get the gist right? Healthcare is so much more complex.

Rae Woods (13:18):
[inaudible 00:13:18] Know you're going to pay for the dog socks or the cat socks.

Dr. Jesse M. Ehrenfeld, MD, MPH (13:23):
And you know what?

Dr. Nele Jessel (13:24):
You know where I got the idea for this? Jesse was wearing these awesome penguin socks yesterday.

Dr. Jesse M. Ehrenfeld, MD, MPH (13:29):
You know what you forgot? Thank you. You know what you forgot is that that first bill that you got actually said that this was not a bill.

Dr. Nele Jessel (13:34):
Exactly. And then finally the cat socks arrive, but now I don't want to wear them anymore because I'm so exhausted by all of this. So now my merchant who sold me the cat socks gets dinged because my sock wearing adherence score is actually really low. That affects their bottom line of their business. The third thing is in healthcare technology, we treat the symptoms not the underlying disease. Healthcare is such a complex beast that all of us tend to concentrate on treating the symptoms because no one wants to touch the underlying disease, and this is why it's not enough, and I speak as an EHR technology vendor to simply reduce click counts. We actually have to cure the complexity that is healthcare.

Rae Woods (14:15):
That's where I want to get to our clinician representatives. If technology can, not always, but can treat the symptoms as opposed to the underlying root cause, what are some of the underlying root causes of the workforce crisis that we need to name because we need to solve them?

Dr. Jesse M. Ehrenfeld, MD, MPH (14:31):
We have a healthcare system that is increasingly overly bureaucratic, impersonal, and it still amazes me that we have hundreds and hundreds of offices that rely on fax machines to send documentation to third party payers to get services approved. How is that possible and where are the fax machines here? They're not here because that makes no sense. And yet, that is the reality of the healthcare system that we work in, which is incredibly frustrating. Prior authorization, the number one pain point for physicians. Now, look, there are a bunch of companies here on the floor that have a tool that will do the adjudication. It will use generative AI to help with the appeals letters.

(15:08):
We should not be creating those tools, right? It's the nuclear arms race of prior authorization. We ought to solve the root of the problem, which is to get rid of this overly burdensome overuse process.

Dr. Syl Trepanier (15:17):
At the end of the day, there are certain things that we as clinicians have control over, which is as part of our practices, respective practices. I mean, I've been a nurse for 35 years this year. The entire world has changed around us. We talked about all the various technologies that came in, all the widgets and what have you. When I walked into a hospital 35 years ago and I received an assignment as a nurse, and when I walk into a hospital today to receive an assignment, it's the same thing. It's the same way that we approach the work. This is just not a nursing thing. This is an entire healthcare team. We have to somewhat figure out and understand that the work itself actually needs some rethinking so that we can approach this differently.

Dr. Jesse M. Ehrenfeld, MD, MPH (16:04):
There's no way that we will ever be able to meet the demand, given the population demographics, the shrinking healthcare workforce, and the growth of chronic disease, if we continue to try to shoehorn the solutions around the delivery system the way that we've been doing it. The only way to do that, that re-engineering, that reimagining the delivery system is by embracing these technologies.

Rae Woods (16:27):
Yes, it is essential for the workforce. It's essential for the patients. It's essential for where the system is going. There is a question from the audience that I want to give to the panel now. It speaks to some of the larger root causes and it's the mental health crisis that exists among today's clinicians. Can you talk a little bit more about what we can do to address mental health meaningfully among today's clinicians?

Dr. Jesse M. Ehrenfeld, MD, MPH (16:48):
We've got to do two things to address the mental health crisis amongst clinicians. One is we've got to get rid of the system drivers of burnout, and that's all the things that we've been talking about. But the other issue is we have to make it possible so that when people need help, they can get it. Today that is not the case. There is so much stigma around raising your hand and saying that I need something. Whether it's a substance use issue, you're depressed, you need coaching. Because in many jurisdictions it can threaten your license. It can threaten your credentialing at a facility and be the end of your livelihood.

(17:21):
When I graduated from residency, a wonderful colleague of mine went to apply for her license. She had received therapy in high school. She was a very well-adjusted, high-performing person, and she checked the box that said, have you at any point ever received mental health counseling? And her license got held six months? We should not allow that to happen.

Dr. Tina Shah, MD, MPH (17:40):
I need to double-click on what Jesse just said, and even the nature of the question that was asked really well intentioned, but I want to come at it with curiosity in that this is a panel talking about burnout. One of the first questions we received was about mental health. It highlights just how everyone wants to do the right thing, but we're making the wrong diagnosis. When you have a mental health condition, you need therapy, you need medications. When you have a toxic healthcare system, you need system treatments all the way from the regulatory all the way down to what my boss does to make my life better.

Dr. Nele Jessel (18:13):
I 100% agree with you Tina, and I think in medicine, you can't find the right treatment until you make the right diagnosis. That goes back to my earlier point about a lot of the physician burnout implies that it's my fault somehow. I didn't manage my time correctly. I didn't see enough patient or too many. It's not us. It's not because I have a mental health problem. Maybe the system is giving me a mental health problem, but it's the wrong question. There is significant challenges within the system and they go far beyond technology.

(18:45):
I would always argue that technology is just the scapegoat because it's conveniently in the face of physicians and clinicians everywhere 24/7 it seems like these days, right? There is much larger system challenges. Mergers and acquisitions. Someone said yesterday, she left practice because she felt infantilized by all the requirements of producing more RV use, making sure she does this and does that. It took the autonomy of making the medical decisions out of her hands and she did not feel like she wanted to practice medicine anymore under those circumstances.

Rae Woods (19:20):
I am getting the sense from the executives that I talked to that the momentum has stalled a little bit in this very conversation perhaps because the challenges are so deep. The question I have for all of you is what do you say to that naysayer that is perhaps sick of seeing burnout on an agenda at VIVE or wanting to move on from this, or wanting to believe that technology is going to fix everything? What do you say to that naysayer when it comes to burnout?

Dr. Tina Shah, MD, MPH (19:46):
I have to jump in here. When I give talks, I have this one slide that's the human brain. What I say to CEOs is that the decisions you make literally can cause brain matter changes in your clinicians that give short-term and long-term memory loss and make it difficult for them to do high-quality medical decision-making. This isn't a theoretical issue that people aren't feeling good and they're burning out and turning out. This is about patient safety. This is about the body of literature that shows that medical errors even harming patients directly due to physicians being burnt out and other clinicians. This is not a joke. This is real now.

Dr. Jesse M. Ehrenfeld, MD, MPH (20:27):
I will say, look, we've done a lot of the easy things to try to alleviate some of the pressure on the workforce, and now we're left with the system level fixes that we have to come collectively together to bring forward if we're going to actually make a difference. And that's hard. That's really, really hard to do.

Rae Woods (21:39):
I do want to start talking about technology. We are here at VIVE. I'll be honest. I'm looking out on the show floor and I see dozens and dozens of technologies, tools, innovations, frankly promises that are meant to address some of the biggest challenges in healthcare, the workforce crisis being one of them. But in my opinion, before we can have any conversation about the future, we have to talk about the investments that we've already made. We have to talk about the technologies that we already have, which Nele brings me to the electronic medical record, the electronic health record.

(22:11):
I hope you don't mind me saying this, but I feel like a lot of today's clinicians almost scapegoat the EHR. They blame the EHR for everything. As kind of the resident expert on our panel about the EHR, the Chief Medical Officer of Athena Health, what do we need to do to ensure that our existing technologies or existing investments actually work for today's clinicians?

Dr. Nele Jessel (22:35):
Tina and I were talking about this earlier. There is a lot of tech debt and legacy EHR systems because they were originally developed as systems to ensure payment. Then once EHR became a thing, and that was my point about EHRs often being the scapegoat today, the level of transparency dramatically increased. Previously it was fine when it was on paper to write my quick little left L-A-O-M, left acute otitis media, amoxil. Done. Today, we have all the data and now we're required to write very extensive notes. We are required to collect extensive amounts of data because once that level of transparency was brought to the table, everybody and their mother jumped on that ship and was like, "Oh, I can have data now. Legible data. I want more of it." So clinicians basically turned into data entry clerks and EHRs have supported this development.

(23:28):
That's one of the reasons why EHRs are hated today, by and large, by clinicians. I will say it's getting a little bit better. We do an annual physician sentiment survey similar to the AMA at Athena Health. This year's survey, actually 64% of physicians said that they felt that EHR improved patient care and 54% felt it made them more efficient. Now, that sounds dreadful, one and two, but I was like, [inaudible 00:23:54] action. We went from everybody hates EHRs universally to 50% are saying "This is actually pretty good," and may make a few more improvements. I think we've made great progress, especially over the last decade or so, but there's a long way to go.

(24:08):
We want to change physician sentiment. It is not helpful to hate something that is arguably the most important tool in your arsenal, and that if you don't leverage it correctly, it has pretty dramatic patient safety implications too.

Dr. Jesse M. Ehrenfeld, MD, MPH (24:22):
I think that's right. What we hear is that EHRs were the number one dissatisfier physicians for years running. It's now number two. So it's not as disliked as it was what's number one, but it's still not perfect. Number one's prior authorization.

Dr. Nele Jessel (24:37):
I think it's still not perfect, and I think it really behooves us to change physician sentiment because if you hate something, it leads to avoidance behavior and it actually makes life worse for you. Our study shows that too, that physicians who report that they do actually like the EHR, work on average two hours less per week in pajama time, those dreaded extra hours that all of us spent working outside of business hours. Now, that may not seem like much, but they also tended to view technology more favorably in general. They were more excited about the potential of AI.

(25:10):
I think changing physician sentiment and taking the emotion out and bringing it back to... Listen, the EHR is just a tool. Let's teach you how to use it correctly. This brings me back to where I think we all fail. We give clinicians a couple of hours when they first go live on EHR, and then they're left to fend for themselves. No one gives them ongoing training. There is no CME. Other technology that we use in medical practice there, there's ongoing in-services, you get CME, so how about BMA gives category one CME for ongoing EHR training? That would be an opportunity to entice physicians to actually want to learn how to use the tool correctly.

Dr. Jesse M. Ehrenfeld, MD, MPH (25:50):
There are CME programs, nobody takes them. What I will say is that there is a lot of PTSD out there because of the experience of EHRs. It's a foundational technology that so much has to be built on because of what it means and what it represents and how it's integrated into the flow. What we have seen through our Joy in Medicine recognition program, AMA program that we use to recognize health systems that have restored the joy to the practice, is there are optimization approaches. They're not sexy. They take real work, but they're effective and they can lead to from really dramatic results in terms of lifting up clinicians to feel empowered to regain control of their workflows using these technologies. Unfortunately, it's just not happening at scale the way it needs to across the country.

Dr. Syl Trepanier (26:34):
One of the biggest challenges that I've noticed is, so the nurses who are spending 24/7 in acute care setting into an EHR, is we've also created a plethora of other types of technology that may or may not work very seamlessly-

Rae Woods (26:55):
We've added on.

Dr. Syl Trepanier (26:55):
... with the EHR and we've kind of added it on, and it's created all sorts of complexity. And quite frankly, in some cases, some safety issues.

Rae Woods (27:02):
Yes.

Dr. Tina Shah, MD, MPH (27:04):
I would totally agree with you. This is why I'm hoping I can coin this term. Please repeat it often to everyone, you know, death by a thousand point solutions. I want to bring it down to the human level. This is what's happened in healthcare. We have experienced such a large sense of betrayal. This is the foundation of that term "moral injury" that if you imagine us as bank accounts, we have a negative balance right now.

(27:29):
And so when we think about bringing in new technology, we have to get back to the human feelings and emotions, the foundation, the fact that we feel a sense of betrayal by the entire tech community, by the country, by society, by the regulators, by our bosses, by the health systems. So how do you deal with technology in that phase? Here's where I think generative AI has a ton of prospects on how we can start writing this ship. The first is making sure that the design includes clinicians front and center.

(28:00):
In our company, our CEO happens to be a practicing cardiologist who's tired because he just worked an overnight and then flew out to VIVE. We need to actually design upfront and not make the mistakes we made in prior times when we had these waves of technology coming out where clinicians have to be front and center.

Rae Woods (28:17):
I'm going to repeat what you just said. We need to make sure that we don't make the same mistakes that we have made in the past. I will say, and I am sure all of you'll agree with me, that the sentiment around generative AI is quite different than the sentiment around the EHR. In fact, I do want to read for you all an anonymous, it's not really a question, it's a comment that just came in, but it speaks really to what all of us are saying. It says, "I don't want training. I want the EMR to be so intuitive that I don't freaking need training."

Dr. Jesse M. Ehrenfeld, MD, MPH (28:47):
Who has read the manual for their iPhone? Nobody. Is there even a manual for the iPhone? Why can't we have those technologies? We need that. Now, I will say the AMA released some survey data in the fall. It was fielded last year, National Representative Survey. 41% of US physicians are equally excited about AI and generative AI as they are terrified. There's this enthusiasm, we want these tools, but buyer beware, let's make sure that they actually integrate work, don't cause problems.

Rae Woods (29:17):
That brings me to another question that's come through, and frankly a question that I get often. I agree that there's dual excitement and fear. In fact, I travel all around the country having conversations with executives. What's been interesting to me is the number of physicians who have said, "My hospital's actually blocked Chat GPT on my intranet," and that doesn't stop them from using free generative AI. It just means they have the frustration of having to pull out their phone to do it as opposed to using the internet, which of course creates a whole other host of challenges.

(29:49):
The question that's been asked is who needs to be involved? What changes in policy in the regulatory landscape need to happen so that we can reduce this feeling of fear about what this technology can do and who's responsible for ensuring safe use of it?

Dr. Tina Shah, MD, MPH (30:03):
I think we need to start with the mission. I mean, the mission is we have clinicians leaving in droves. We can't wait. We can't think about it and ponder it for five more years and then implement something. Let's start with the fact that we have clinicians that are excited, and let's start with what their biggest pain points are. I'll just share, in ABRIDGE we're actually working on reducing the clinical burden. We're not going for the largest thing, perhaps the shiniest object. We're going for what makes the clinician's job so hard today?

(30:32):
I think when you start introducing delight, in our case, we're saving doctors two to three hours a day from paperwork. They're actually going home and seeing their family members. Marriages are being saved. It's actually kind of insane, the comments we're getting back. It's starting to blend into therapy time. But can we just start simple? Can we just take away dumb and low value things that clinicians do and let's bring in technology to solve for that.

Rae Woods (30:55):
Said another way, we shouldn't wait to harness these new tools for the regulatory environment, the policy environment to be perfect because there are things that we can do today. What would you say about that?

Dr. Jesse M. Ehrenfeld, MD, MPH (31:09):
But we do need the right regulatory framework. We do need federal rules around making sure that these technologies are safe, are effective, protect patient privacy, are safe. Because if we lose the trust of the consumer, whether that's patients or physicians, we are going to lose out on the opportunity for these innovations to help us, and we cannot let that happen. That requires a whole of government approach on the regulatory side.

Dr. Nele Jessel (31:32):
We do, and I 100% agree with you. I think the challenge is that today a lot of the regulations are overly prescriptive and that stifles innovation. I do feel obligated to go back to that comment because as the EHR vendor, I have to respond to it. I could not agree more. If anybody, as our Chief Product Officer talk, that's the Holy Grail. We want to make EHR technology as intuitive as the iPhone, as an Android phone, as whatever else we all use out there. However, that is today very challenging because healthcare is a different beast from all those other lines of business. There are regulations that are so highly prescriptive that oftentimes the design has to meet those regulations and it leaves clinician workflow by the wayside.

(32:18):
We have those conversations with the ONC all the time. Just one many examples, Mickey Chapati, who I adore, he's phenomenal, but he knows. Take interoperability, for example. Most physicians would agree that interoperability is awesome. Getting data is great. Well, we get so much data today and it's so uncurated that actually contributes to overload, cognitive overload, physician burnout. So how do we make this better today? Today the requirement is that data that comes in from external must be side by side with data in the chart. All of us on the clinician side hate that reconciliation workflow with a vengeance. I have yet to meet the physician who thinks that CCDA reconciliation is awesome and they would like more of it. There's more innovative ways of doing this, but it's not possible yet.

Dr. Syl Trepanier (33:07):
Let's not forget that to your point about bringing the clinicians into the thinking right at the onset, that at the end of the day, there's an entire healthcare team around that. We have an opportunity right at the onset to make sure that we don't have those silos. Because when her and I work side by side, we can undo each other's work in a snap second. If we don't have the technology that actually really embraces working together collaboratively, right at the onset, we're going to create a whole slew of issue.

Rae Woods (33:40):
I want to get to this larger kind of system of change. But before we do that, I think it would be helpful for us to actually name what new innovations, and I'm going to focus on generative AI specifically, can do for the clinical workforce. I think a lot of the excitement and a lot of the fear around Gen AI is that we don't know when we roll the tape forward far enough. In fact, my colleagues at Advisory Board, we like to say that we're in the flip phone era of AI because there's just no way that any of us would've known in 2004 when we got our first phones that what the iPhone could even do for us today.

(34:17):
I wonder if each of you can take a moment and say, when it comes to some of the challenges that we've discussed so far, what can generative AI do? What can new innovations, new technologies do to alleviate some of those challenges today? And what are you most excited about in the next say five years?

Dr. Nele Jessel (34:31):
Okay, I'll start. I think generative AI in particular has real potential to put the care back into healthcare by moving the technology in the background. We've all leveraged traditional AI for many, many years. Machine learning, it's heavily used on the administrative side, document management, insurance claims and so forth. Generative AI is different because it's in the clinician's face. For the first time, the clinician today actually sees the AI that has been in the background for many years. That's both an opportunity and a challenge because clinicians are optimistic.

(35:05):
I think the AMA survey showed this, but they're also understandably skeptical that it's going to turn out to be yet another thing they have to deal with. So how do we go about not repeating the mistakes of the past where development marches full steam ahead without taking clinical workflows and clinician into consideration and make sure we develop AI first and foremost with patient safety in mind, and second, all was clinician workflow in mind and make sure we involve clinicians every step of the way to ensure that the solutions we design actually meet their needs and are viewed as an asset and are trusted because nothing is worse than, and Tina alluded to this earlier, than losing physician trust.

(35:48):
If you have experimented with Gen AI, you know that it makes a lot of mistakes and it loses physician trust pretty quickly. It behooves all of us to proceed cautiously and make sure we involve clinicians every step of the way.

Dr. Jesse M. Ehrenfeld, MD, MPH (36:01):
I think that's right. 40% of US practices use AI today. It is unsexy, back-end administrative office things. There are definitely lots of opportunities, and we need these tools. Certainly all of the stuff that's happening in terms of patient engagement using large language models, I think is really exciting as we try to help consumers regain control of their healthcare because the time that they interact with us sitting on the stage is just a tiny little fraction of their lives. Then there's the rest of everything that they do. The way that we can use these tools that I think will be transformative to help patients manage chronic conditions, engage with their care, I think we're only scratching the surface of that, but there's obviously a lot of potential out there.

Rae Woods (36:43):
What are you most excited about when it comes to the nursing workforce and the rise of these new technologies?

Dr. Syl Trepanier (36:49):
It depends on who you quote, but it really doesn't matter the source. At the end of the day, it doesn't matter how good we all are about hiring and retaining nurses. We're just never going to have enough. If we keep on working the way we work right now. I would argue that we've never had enough since I've been a nurse for 35 years, but that's a whole different conversation. As I think about the future, I'm excited about AI where it will actually give us the ability to leverage the brain trust and all of the knowledge that people can bring much better so that we can, to your point, do all of the administrative stuff and really help prioritize the work perhaps, and even help guide and support the practice.

Rae Woods (37:36):
And frankly, extend the reach of the clinician, not just extend the reach of the clinician, but perhaps improve the supply of clinicians that we have. There's a couple of questions that we've gotten about how we can leverage technology and otherwise and how we extend that supply, and I appreciate that you're naming that now.

Dr. Tina Shah, MD, MPH (37:51):
I guess to kind of close off the perspectives on this, sitting in a generative AI company, there's the immediate relief. There's the promise of the immediate relief. I work in the ICU every month and it's a battle. As soon as I show up at 7:00 AM, the clock is ticking and I'm just waiting for the next chaotic moment. After I finish all of that, I still have to write my notes. I still have to comb through and try and curate data. There's the promise of relief of what can generative AI do right now, which is helping to take the exponential number of data points that a clinician has to put together in her head and curate that so I can see what's actually important and cut through the noise, and then help me too with all of the routine tasks that I have to do so I can focus on my patient.

(38:37):
When I look into the future, you know what I want? I want the ability to practice medicine in a fundamentally different way. Why is it that you're a nurse and you're over there and I'm a doctor and I'm over here, and the promise of generative AI is to completely disrupt how we organize the delivery of healthcare so that we can hit patient safety goals that we haven't hit. Because by the way, spoiler alert, we actually haven't made any gains on patient safety since we started working on it in the 90s. This is the promise of generative AI.

Dr. Syl Trepanier (39:08):
You mean actually working as a team?

Dr. Tina Shah, MD, MPH (39:10):
It's novel. I know.

Rae Woods (39:14):
I will say for all of the excitement, for all of the practical kind of positive change that we can make and frankly can make quickly, the reality for leaders on the ground, and I'm particularly talking about hospitals, health systems, medical groups, is that they have to make very real trade-offs about investments. They need to understand how quickly can I get to ROI knowing that their margins are razor-thin at absolute best. What do you say to that leader that might not see the ROI from some of these investments for many years to come, but they're clearly important investments to make? How do you help them kind of weigh that very real challenge?

Dr. Tina Shah, MD, MPH (39:51):
I want to offer something slightly different as a response, which is that I really feel for the decision makers in health systems and in healthcare, because for years, decades, they've had to make decisions based off of limited data. Our industry has such low expectations of proving how technology works before it's implemented, before it's purchased, before the contract is inked. We need to raise the industry standard and have rigorous research on the impact of generative AI on clinician experience, on patient experience, on patient outcomes. And because of how fast generative AI is iterating, we can produce those studies in days to months. We're not talking about years. We actually need to inform in a much better way. If I was a health system CEO, I would say, show me the data.

Rae Woods (40:42):
Part of showing the data, showing that things work, is not actually just focusing on the technology itself, but making sure that those technologies are actually implemented used by today's clinicians. Something that I often say is I don't actually care how good your tool is. If it is not easy to use, it is not going to be used. What do you have to say about the larger system around some of these investments to ensure that they're actually effective for today's clinicians, and to your point, Tina, so that we are not repeating the mistakes of the past?

Dr. Jesse M. Ehrenfeld, MD, MPH (41:12):
We have to make sure that the tools actually work, and what level of evidence ought to be required before something's brought in the marketplace is an open question, whether it's a regulated product or not. We also need transparency. That does not mean explainability. It means that if I walk into an operating room as an anesthesiologist, I turn on the ventilator, there's an AI algorithm that's doing something, I ought to know that there's an AI algorithm that's influencing what's happening because that's the only way that I'm the human in the loop that can control and correct if there's a problem.

Dr. Syl Trepanier (41:39):
And what's its impact and interfaces with all of the other widgets and digits that we might have? Quite frankly, another thing that we need to challenge each other is if we're going to be introducing one more thing, what are the 10 other things that we can remove by adding one thing?

Rae Woods (42:01):
Yes. Yes, yes, yes, absolutely.

Dr. Nele Jessel (42:05):
I would also argue that in addition to producing data and showing what's possible, we have to reprioritize what's important. I mean, the sad truth is that today data exists that shows that, for example, ambient note generation is a true physician pleaser and reduces significant number of hours, but there is an extra cost to it. I hate to be the naysayer here, but those extra hours that physicians spend outside of their clinical face-to-face hours are "free." So there's very little incentive today to pay for technology whose only ROI is to improve physician satisfaction and reduce the number of hours they work.

(42:46):
Because guess what? That time is free until that physician picks up and leaves, then it becomes extremely costly. But up until then, it's fine to just cross your fingers and hope that doesn't happen. I think unless we reprioritize what's important in healthcare or perhaps change our payment models to move from an RVU fee-for-service model to something different, what could that possibly be up for debate.

Dr. Tina Shah, MD, MPH (43:11):
The regulators know that well-being should be a priority because we have unequivocal evidence on how it can cause patient harm and actually add costs to US healthcare. What we're starting to look at now is how do we design the right incentives through regulatory means and accrediting means to then make sure that people don't just try and find a workaround, but we actually can prioritize up technologies that help the workforce.

Rae Woods (43:36):
We could have this conversation all day. I want to thank you for being part of this panel. Before we close, I'm going to ask to do a quick lightning round. Go ahead and look out at the audience, think about the listeners at home, and I want you to give them one takeaway, one action item that you want to take back to their organization when it comes to addressing the workforce crisis and doing it in a meaningful way. Nele, we'll start with you.

Dr. Nele Jessel (43:56):
I would say collaborate. Collaborate on curing complexity and making the healthcare system less fragmented.

Dr. Jesse M. Ehrenfeld, MD, MPH (44:03):
Elevate the voice of the clinician as you're designing the tools that you're going to expect us to use.

Dr. Syl Trepanier (44:08):
Let's deconstruct and blow it up.

Dr. Tina Shah, MD, MPH (44:12):
How do I top that? I'm going to say urgency. We cannot think and think and think about this. We must act now. So let's do and verify at the same time.

Rae Woods (44:23):
If there's a team that I would bet on, it is the four of you that I'm just happy to be a part of and the people in this room. So thank you again for coming to VIVE and for coming on Radio Advisory.

Dr. Jesse M. Ehrenfeld, MD, MPH (44:31):
Thank you.

Dr. Tina Shah, MD, MPH (44:32):
Thank you.

Rae Woods (44:44):
Sometimes I get worried that folks are still thinking about new technologies, particularly generative AI as the solution that's going to solve all of our problems. But I hope it's clear from this conversation that that's not actually the case. First, we need to look at the existing practices that we have. We need to make sure that we're solving real problems for our workforce and we need to address the technologies we've already invested in. Only then can we really start thinking about new opportunities and new solutions to support the workforce of the future. And remember, as always, we are here to help.

(45:45):
If like Radio Advisory, please share it with your networks. Subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Abby Burns, Kristin Myers and Atticus Raasch. The episode was edited by Katy Anderson, with technical support provided by Dan Tayag, Chris Phelps, and Joe Shrum. Additional support was provided by Carson Sisk, Leanne Elston, and Erin Collins. We'll see you next week.