Designing for Health: Interview with Dr. A Jay Holmgren [Podcast]

Decades after their introduction, EHR capabilities continue to expand. However, ease and functionality can still be challenging hurdles to overcome. The ‘productivity paradox’ shows that doctors spend quite a bit of time working on something that isn’t actual patient care. Real-world datasets are essential for discovering actionable insights for optimizing the clinical use of applications.

On today’s episode of In Network's Designing for Health podcast feature, Nordic Chief Medical Officer Dr. Craig Joseph and Head of Thought Leadership Dr. Jerome Pagani are joined by Dr. A Jay Holmgren, assistant professor in the Department of Medicine at UC San Francisco, and the Center for Clinical Informatics and Improvement Research. He has spent his career studying real-world use of EHR applications, trying to shorten the ‘digital use divide.’ In this podcast, Dr. Holmgren discusses how he gained access to a treasure trove of EHR activity log data and how he used those data to gain valuable insights into how clinicians use their software. Those insights help him narrow the productivity paradox and reclaim clinicians’ focus on patient care.


In Network's Designing for Health podcast feature is available on all major podcasting platforms, including Apple PodcastsAmazon MusicGoogleiHeartPandoraSpotify, Stitcher, and more. Search for 'In Network' and subscribe for updates on future episodes. Like what you hear? Make sure to leave a 5-star rating and write a review to help others find the podcast.

Want to hear more from Dr. Joseph and Dr. Pagani? Request a copy of their upcoming book, Designing for Health, by filling out the form here.

Show notes:

[00:00] Intros

[01:12] Dr. Holmgren’s background

[06:26] Dr. Holmgren’s business-minded approach to healthcare and policy

[09:50] U.S. versus non-U.S. use of EHRs

[17:34] How non-U.S. healthcare providers can think about maximizing the use of the EHR

[21:30] Barriers to surveillance reporting

[25:47] Researching mass data in EHRs

[31:19] Adversarial billing structures in U.S. healthcare

[38:38] Things so well designed they bring Dr. Holmgren joy



Dr. Craig Joseph: A Jay, welcome to the pod. How are you?

Dr. A Jay Holmgren: Great. Thank you so much for having me. I'm excited to be here.

Dr. Craig Joseph: We are excited to have you here. You're kind of famous in our world. And so this is going to be a lot of fun. So to start off with, I just wanted to say that, you know, it's good to understand your origin story, you know? How did you get here? We find it very interesting so that we can, you know, learn, and maybe we can get to where you are if we're interested in kind of going down those lines. As you explained it to me, you were a young man returning from college. There was a pool party at your house, and you were taken aside by a friend of your father’s who was telling you what the future was. And he said the future is three words: Ph.D. health policy. And your plans, they changed dramatically after that. And you knew that was your future. Did I get that exactly right, or was I off just a little?

Dr. A Jay Holmgren: You know, I think that might be paraphrasing a little bit. So let me give your interested listeners the real story, because this is obviously a podcast, but it's really also a gritty biopic of my journey to this point. But the real story is that I had finished college and I graduated into the post-2008 recession, and I realized I needed a job and I could show older executives how to do math in Excel. So I ended up doing data analysis for a health insurance company for a while in Michigan, where I'm from, and I got more interested in the technology side and I wanted to work closer with clinicians and patients and technology. And so I ended up deciding to do a master's degree in health informatics where I thought I got really interested in these concepts around electronic health records and data interoperability and thinking about how people use technology in a healthcare setting. I thought you know, to your master's that I should probably be able to figure out most of these thorny questions out over two years. And it turns out I was a little bit slower, but I liked doing some research. So I decided to do a Ph.D. in health policy and management at a program that was co-located between sort of a health policy division and a business school, which I thought was the ideal spot to think about, you know, how do organizations play a role in how we use technology. And since then, I've really built a research agenda thinking about coming at thinking about technology from a social science perspective that is informed a lot by sort of the disciplines of economics and management and clinical informatics. That's sort of where I sit at this weird little intersection of those three fields, and I use sort of a quantitative toolkit most of the time to think about how can we make technology work better for clinicians and for patients and for organizations. That's really my overarching goal. For those of you who like buzzwords, sometimes I say I want to resolve the productivity paradox in healthcare, which is, you know, a really famous sort of economics version. Bob Solow used to say this, you can see the impact of the computer age everywhere, but the productivity statistics. And I think that's true in hospitals too. You can see computers everywhere except for how productive they make us. So that's my short little spiel on how I got here, my background, and this was completely wild. I went to music school first, never tried to be pre-med, never did math, and was never a math person before this. So never too late to totally change your entire life and work career.

Dr. Craig Joseph: That is interesting. And now that I think about it, I think I was confusing the beginning of the movie The Graduate with your history. So that's on me. So I'm fascinated by this, you know, social science and business school kind of, you know, background and then that leading you to healthcare policy and technology. And it seems like you focus a lot on the electronic health record. Was this a plan or does it kind of like slowly evolve over time? You know, you were interested more in policy and then somehow you made a wrong turn somewhere?

Dr. A Jay Holmgren: Yeah, you know, interestingly, I think I came at it originally from being interested in the technologies, my master's degree and my first dipping a toe into this field of healthcare, you know, I thought I was going to be a technology person, an informaticist, someone who purely did design work or something like that. But then when I thought about it and I learned a little bit more, I thought the big problems are not necessarily the technology. It's sort of this world that surrounds and shapes how we use the technology because none of these things exist in a vacuum. And so when I got to graduate school, I started learning about meaningful use. For those of you who are veterans of the HITECH era. I thought a lot about, wow, this is some very prescriptive things from the federal government. Can you imagine if federal government set out 20 different regulations about how Twitter was to be used? Now, I actually think that could be maybe a little bit useful at this moment. That would be a course correction where the private sector has failed. But I just got so interested in this policy angle, especially, of thinking about how there's laws and regulations and incentives to change how we use technology, they change how organizations think about technology relative to users thinking about technology.

Dr. Jerome Pagani: A Jay, how we train influences a lot about how we think about things. So, for instance, those with professional degrees like Craig, you know, spend a lot of time thinking about how to ply their trade. Those of us who are academics think a lot about the really interesting questions and the best way to answer those questions. And you mentioned that you grew up in a business school. Does that influence the way you approach problems and the practicality of the questions that you ask?

Dr. A Jay Holmgren: I think definitely. So one of the things that I'm always thinking about when I come at these types of questions coming from someone who is trained primarily by the types of economists that sit in business schools is, what is, one, the role of incentives doing here? So when we think about how much time a physician spends working in the electronic health record and where they spend that working, what is, asking them, what is their financial or non-financial incentive to spend time in documentation versus messaging with their patients? And how does that change based on the clinical value of those things? So I think you'd get a lot of physicians who say the importance of much of the documentation I do clinically is not very significant. I document much more than say what the next physician needs to know to think about this patient. On the other side, the financial incentives are significant because they would like to not get their claims rejected. And when they're documenting in this sort of multi-payer environment that a lot of fee-for-service clinicians work in, you know, they're sort of incentivized to document maximally towards the most sort of litigious, most rejection-worthy payer who says, all right, I need the most documentation. And so they sort of build those skills to be sort of maximally conservative, which means they're sending a lot more time and something that is perhaps less valuable to their patients sort of building their health than, you know, messaging with them might be because there's simply no financial incentives to do it. I think the second part about growing up in a business school is thinking a lot about different layers of where interventions sort of succeed or fail, by which I mean, so let's say we want to make EHR use more efficient for our clinicians. How do we do that? Do we target the individual with targeted training that says, okay, you're doing this wrong. Like, here's a way to be more efficient with different tools. Do we target sort of a team level where I would say, okay, maybe, you know, the way that your MAs are rooming patients. They could be getting vitals while doing that and entering that documentation into the EHR so that you don't have to do it. And we can maybe think about team workflows a little bit here or adding another member of the team like a scribe or a front desk person to do some of the additional documentation or do we think about it on an organizational level where they say organizationally we are going to change the requirements for what you need to document in the EHR for quality improvement or research purposes? And then finally, this sort of big overarching level of what is the policy environment, what does it look like to think about malpractice or payment or sort of getting all your boxes checked for whatever CMS program that your organization is participating in now? I think those two things really influence a lot of my thinking around technology and design, which is sort of what are the incentives and then sort of what level are we thinking about right now? Is this a person, is this a team, is this, you know, a firm, whatever that means? And sort of the country as a whole.

Dr. Craig Joseph: So, Jerome, I like the term that you used, plying my trade. You know, some people say taking care of patients, but we'll go with your reference. A Jay, you're the first author of a pretty important paper in JAMA Internal Medicine from 2020 wherein you compared each our use between U.S. and non-U.S. systems. And you found, and I'm going to quote from, I'm quoting your article here, U.S. clinicians versus non-U.S. clinicians were found to spend more time per day actively using the electronic health record, receive more system-generated messages, write a higher proportion of automatically generated no tax, and spend more time using the electronic health record after hours. And so I thought, that's all good, right? Like more is better. USA, USA we rock. However, some people have interpreted that as potentially these are bad things. I know that it's not your job. It was to kind of find these facts and present them not to give us your opinion. But now it's just you and me and Jerome. No one else is listening. What do you really think about these findings?

Dr. A Jay Holmgren: Well, I think importantly, you know, you're both right and you're both wrong, which I like to tell everyone. Ideally, as much as I possibly can give a little compliment sandwich there. So I think, you know, when we originally did this dive, we were really curious because we thought this would help untangle this productivity paradox. These are clinicians who are working in the same software essentially. And yes, I know Epic and various electronic health records get customized a significant amount by each individual system that is using them, but fundamentally, they work the same way. It's just that they're practicing in different policy environments where you have in the U.S. a very prescriptive health IT policy in HITECH and meaningful use. And in other countries you have sort of a mixed mass of different policies. But for the most part, nowhere near as sort of hands-on as the HITECH program was. And so what we found coming into this was, wow, non-U.S. docs use their EHR way less. And the first line, I think, and I think what a lot of people took away from this is, you see, it's U.S. policy that is driving all of this burden of the electronic health record. So what is burdening our physician workforce with all these onerous documentation requirements? Well, it must be something about U.S.-based policy. A lot of people took this as sort of a big win for single-payer as a way to sort of reduce administrative burden. A lot of people took it as you look at to sort of this unique malpractice situation. You know, all of these things that make the U.S. a weird little outlier on every single graph you've ever seen in every health policy primer about, we spend the most money, we don't get the best results. These are all of our weird little quirks of the United States system. And they saw that, you know, people read things as through the lens that they want to read them as, and they saw this as a big vindication. And I think in some parts that is true. We did a little bit of qualitative work on the background. We talked to some CMIOs at non-U.S.-based sites, and they did say things like, I only document what the next physician needs to know to treat that patient. I never care about anything else. I never worry about anything else. I know that there is no enforcement on the back end. No one will ever come to me and say, you need to add more documentation for us to get paid for this. And this is a Canadian CMIO who I thought was just really insightful there, and I think that's very different than the U.S. case. I think that's a clear case of where policy really is imposing an administrative burden on American physicians. On the other hand, what we also saw was sort of your interpretation, which is if you look at so e-prescribing messages which says, you know, your prescription was successfully transmitted or the pharmacy has a problem or something like this to physicians in other countries, you see they receive far fewer than the U.S., but that's not because citizens are more efficient. There's no additional gains from lack of policy burdens there. What happens instead is those countries just don't have a very robust e-prescribing infrastructure. Pharmacies aren't set up to receive them electronically. There isn't sort of a SureScripts alternative in Canada. And so what you get instead is, well, electronic health record activity logs are really deep, rich resources to understand how people interact with technology. What we found there isn't a lack of work. It's that work was happening on paper and we couldn't track it using a computer. So physicians were still just writing their messages or writing their prescriptions, excuse me, on a piece of paper. And so all that work still happened. And I think most Canadian physicians would say, I wish we had sort of robust e-prescribing that you had in the United States, because I think it has generated benefits. It's more convenient for patients, for physicians, for pharmacies, but they just don't have that yet. But it looks like in the data they have way less prescribing work to do. Sort of similarly, in Europe, we found far fewer patient messages to their physician. And, you know, it's really hard to interpret that because on the physician side, the sort of big increase in messaging work and portal work has been a real burden to that over the past year or two. On the other hand, you know, these are sort of cultural differences or sort of a lack of the service being available or broadly known in other countries where we also have a good amount of data that suggests patients really value this sort of asynchronous messaging with their physician, and they really enjoy the ability to have additional touch points. And there may be health benefits of being able to check in with your physician more often than sort of the times you see them in the four walls of the office. So I think it's sort of a mixed story where on one hand, the U.S. is pretty far advanced in our health IT capability. On the other hand, the way that we did that through a lot of financial incentives, through HITECH, the Meaningful Use program, meant that we had to be a lot more prescriptive about what these functions needed to be in a way that has really sort of burdened our physicians and constrained sort of the evolution of health IT and chronic health records. And I think there is a definite true fact to the U.S. system is uniquely burdensome for its documentation. That said, I think there's some pluses to that as well we can get into a little bit later.

Dr. Craig Joseph: So it's not the design of the EHR itself. I think it's a popular thing to blame the EHR vendor in the United States specifically for a lot of the burden. And I think some of that's fair, but apparently, a lot of it is not. And you were looking at the same year our vendor data in the U.S. and outside the U.S.?

Dr. A Jay Holmgren: Yes, that's correct. And I will say, you know, there's an excellent paper in, I believe, NEJM Catalyst by Ted Melnick, who is a physician at Yale, who asked people’s sort of rate on a usability scale that people use for consumer applications, how usable their electronic health record was. And I think it does pretty poorly. You know, it compares to a sort of consumer-facing apps, a lot of the apps that I use on a day-to-day basis are nice and smooth and streamlined. And the EHR is perhaps not at that level, but I think, the example I use a lot is first-year consultants at McKinsey don't think that PowerPoint is the reason they work so much. It is simply the tool by which they do their work in. The same is true of the electronic health record. The reason you work so much as a physician is not because of the EHR, it is the mechanism by which work is delivered to you, and you are told you have to do this output. So I think that's definitely a big part of it. While EHRs are not perfect, when we looked at sort of the same EHR, even within the United States, we see big variation in clinicians across the country in the same specialty, the same subspecialty, and sometimes even within the same organization. And obviously, we see this huge difference between the U.S. and non-U.S. clinicians.

Dr. Jerome Pagani: On the U.S. side, we've seen how prescriptive requirements contribute to partially to the amount of time that physicians spend in the HER, and then we also have things like the ability to message physicians, which, you know, is one of those classic cases where it really solves a problem for one side, you know, pushes the wall smooth on the patient's side, but, you know, the brick is sticking out on the physician side. And that's a great example of how the process at least or we're not thinking about the process, designing the process in a way that works for the people giving and receiving care and strengthens that interaction. And then, as you mentioned in the Canada and European side, they are still coming into sort of the fullness of the use of their EHR, so there are some capabilities that could be expanded on that side. So is there a rubric for how those parts of the world can think about maximizing the use of the EHR to support that physician-clinician interaction without making some of the, we’ll call them mistakes, but really they're sort of unintended consequences that we've made here in the United States.

Dr. A Jay Holmgren: Yeah, absolutely. I do think that there are some difficulties whenever you kind of compare national health systems, you know, the way that countries think about healthcare, think about the delivery of care, think about how care is paid for, is just so wildly different in a lot of ways. It's really difficult to do these sorts of comparisons, and it's really difficult to overlearn from the U.S. story because a lot of what happened here is, you know, thinking about both the HITECH program, which is a very prescriptive thinking about how electronic health records should be implemented, but also how that interacts with our very sort of unique multi-payer adversarial payment system and adversarial legal system. So if you were thinking about electronic health records in the context of the UK and the NHS, you have a lot more levers on the UK side to say, here is what we are going to require for documentation, we want to make documentation for it and not a thing here. And so we're going to be very specific about what is required and what is not required. Whereas in the U.S., obviously you're sort of at the whims of sort of every payer, which is an independent private organization relative to that. But on the other hand, you know, I think we can learn some things. I think in some ways HITECH was perhaps too prescriptive around some of the things that we may not need to know anymore. So in a design way to thinking about this, how often have you recorded smoking status, for our clinician listeners, for a 12-year-old? And the reason you do that is because smoking status was one of the fields that HITECH decided needed to be in there and needed to be recorded. And it's always in one of these quality programs that you record smoking status for all of your patients. And it's really possible that was maybe too prescriptive. That's something that we didn't really need to include in everything. On the other hand, perhaps we were not prescriptive enough on a few things around data interoperability because the U.S. really took a first we need to operate and then we will interoperate perspective on interoperability, and I think back in 2009, that was probably a justifiable thing to do when we really didn't want to constrain how sort of these networks were going to get built. But I think looking back with the gift of foresight, we probably should have mandated some more data interoperability between of health records there because it ended up being really a big challenging problem now we've got all these disparate systems. How do we build them? That's really been a big focus of 21st Century Cares Acts and future legislation, and we're not exactly knocking it out of the park now. I think interoperability has been really the slow boring of hard boards to borrow a Max Weber quote of making any progress at all. It has been well over a decade, and we're maybe halfway there at best.

Dr. Jerome Pagani: To touch on that point, actually, and to zoom out to sort of the macro level where we're looking at the way health systems interact with each other and with the public health system. You also have a really nice paper on some of the barriers for surveillance reporting around COVID, for instance. Can you tell us a little bit about that and ways in which we could look for some improvements on that side?

Dr. A Jay Holmgren: Absolutely. And I think, you know, since I wrote that paper, which is really at the onset of the COVID pandemic, things have improved. But I think it really, once again, this paper reflects policy choices that we made. And I think it reflects policy choices that we made, not thinking too deeply about it. And so, you know, for those of you who aren't familiar, the HITECH Act passed in 2009 as part of the American Recovery Reinvestment Act, put a ton of money into modernizing our nation's healthcare IT infrastructure. But for the most part, almost all of that money went to incentivizing buying electronic health records for acute care hospitals and primary care physician organizations. You may notice there's one organization that is not in there that became pretty important in around March of 2020, which is state and local public health agencies. And so when we did that, we used survey data from the American Hospital Association’s annual survey. So they're putting this out, and this is the 2019 survey. So COVID was not a thing yet when these organizations were responding, and the most common barrier when they ask hospitals, you know, what are the barriers to you reporting data electronically to your public health agencies, which is one of the things that they did say they had to do in the meaningful use requirements for this, that you need to report things like syndromic surveillance and vaccination status, was hospitals said, listen, we can report it, we can send it, but public health agencies cannot receive it, or cannot regularly receive it and ingest that data in usable ways, which is to say they may have that technical capability or did it one time. But as those of you who work in technology know, enterprise-level IT Is not a set-it-and-forget-it type of thing. You need someone on the back end is to interpret that data to aggregate it from all the hospitals you're receiving it from to make sure that those data uploads continue to work, that any of these set of standards are not deprecated, that you're not maintaining a bunch of legacy interfaces that you don't use anymore. And so where we sort of missed was interoperability requires people on both the sending and receiving side. So we gave all this money to hospitals, and they were able to sort of successfully adopt these advanced systems that were able to send data to public health agencies. But we didn't give any money to public health agency, to staff up to buy these systems, to have big IT staff. So especially at the local level, we're seeing organizations that are doing the absolute best and heroic things, especially in the COVID pandemic, on the public health agency. But they just didn't have the money going in and the resources and sort of that investment at the organizational level to be able to really handle this. So that's when you started seeing us rely on fax machines again, or people were building websites that aggregated all of this data from different hospitals, sort of ad hoc, rather than relying on sort of a government system or their local or state public health agencies, because those organizations just didn’t have that sort of IT capability. So I think from a design perspective, we should think about when we design policy, who is left out and what are the potential negative impacts of that, because I think, you know, at no point were we thinking, oh, there'll never be a pandemic. A lot of the thinking around public health agencies and reporting was informed by actually the anthrax scares of the early 2000s. After 9/11 and post-2001, all the anthrax scares really encouraged a lot of public health agencies to staff up a bit. But by 2020, they sort of lost all of that additional funding. And so, you know, thinking about these things, design in policy as well as design in technology is really important and a real focus of my research.

Dr. Craig Joseph: Well, I'm glad to hear you say that there will not be another pandemic and we need not think about public health or technology and that you've gone on the record. So definitely appreciate that.

Dr. Jerome Pagani: Shh, the monkeypox can hear you. Shh.

Dr. A Jay Holmgren: Well. And this one went so well. I think we pretty much got to figure it out for the next time, I think everyone's on the same page.

Dr. Craig Joseph: Yeah. Oh, yeah, for sure. And all of this is real, and I'm we're not being tongue in cheek in any way. Let me pivot a little bit to ask you to explain how you got these data, where you're looking at specifically electronic health records. I'm quite confident that when these vendors were putting their EHRs together, they were not thinking about making it easy for folks to judge the outcomes of some of the policy and legal frameworks that they work under. And so you have managed to get a treasure trove of data from one of the largest EHRs vendors in in the world. And is it true that you've stolen all of that, that you were walking around in Wisconsin, found someone that didn't log off their terminal, and you sent a spreadsheet to yourself? I heard it. That might be false. I'm not sure.

Dr. A Jay Holmgren: Well, it's obviously much more heroic and daring than that, more like National Treasure. You know, I found obviously, the map to this was located on the back of the Declaration of Independence. No, you know, the data is very interesting. And I think the origin story of it is interesting. So the basic story of what our EHR, some people call them audit logs or activity logs is these were required by the meaningful use program to be part of all certified electronic health records for privacy and security reasons. I'm sure most people are familiar with HIPA requirements. One of the requirements is that you not access anyone's private medical information or private health information for non-approved reasons of treatment or operations or research. And so every activity, every keystroke, mouse, click, etc., is logged in these are really, really long, difficult-to-interpret database is that were primarily for security reasons so that if you had someone break in, you would understand what user it came from, what terminal it came from, what they did, who they looked at, so you could properly alert everyone that there was a HIPA breach. You know, do whatever it is that your organization has to do to sort of fix that problem. But sort of coming through that, we realized, you know, sort of as a field over the past ten years, that having a time-stamped very detailed setup of how every single clinician interacts with their electronic health record is a really amazing data set for research. And so Epic built this platform. It's called Signal, and it does some aggregation of those very granular, fine-grained audit logs into some categories, like how much time you spend documenting, how much time you spend sending messages, and how do you document, is it, do you type manually, do you copy and paste? Do you use templated texts? Often those doc phrases or smart phrases, and they originally marketed this as a platform for health system leaders operationally to find out, okay, who are my users that are struggling? Who are my docs, my MPs, my PAs, my nurses who are spending a lot of time after hours? You know, they're not getting it. They might need additional training. And so they had this data and they had this sort of platform. It sort of got a gooey graphical interface that is sort of the main the main look. And then people realized, hey, I can just download all this as a sort of CSV file as a spreadsheet. And it's sort of interesting for research, and so I sort of thought of this question around, you know, what about what sort of variation do we see across organizations and across countries? And the simple question is, you know, the simple answer is how I got the data was I asked them. More specifically, I had Chris Longhurst, who is now the CMO over at UC San Diego, who was at the time the CIMO and their chief digital officer, who knew a lot more people at Epic than I did. I got him to ask them because I knew Chris. And so they said, Sure, why not? And truly, it was one of those things where I think we had to put together a little pitch. We said, you know, I think there's going to be something really interesting about comparing different health systems. No one had ever done at that point, like a multi-site study, because that's, you know, in the pre-audit log era, really difficult. It's so manpower-demanding to do a time-in-motion study across hundreds of physicians and a bunch of different sites, you'd need millions of dollars and to hire an army of people with stopwatches and journals and notebooks to record everything that was happening. And you still wouldn't get as granular as this. So yeah, they thought, cool, cool idea for research and see how it's going to hurt us. And then, then they just sent me the spreadsheet file that they had found to do finding the back of the Declaration of Independence.

Dr. Craig Joseph: Well, that is still an amazing story. And, you know, I love it that it really just ends with, so we asked them, and they said yes, that's pretty terrific. I would not have guessed it was going to go in that direction.

Dr. A Jay Holmgren: Yeah, I think the EHR vendors are often the target of some scorn and ire in the same way that I yell about Microsoft whenever PowerPoint or Excel crashes on my end. But I will give a shout to Epic for being a pretty good data partner. They've never asked me not to publish anything, and they've always done their best to try to figure this out because I think they're also really invested. We think about incentives. They would like people to think well of their electronic health record and not poorly. I think they're very aware of the perception of their role and documentation burden and physician burnout. I think it behooves them to do this research.

Dr. Jerome Pagani: A Jay, you've mentioned the term adversarial billing structure and used it to describe how the U.S. functions with respect to paying for healthcare. So what do you mean by that, and how does that contribute to the usability of the U.S. healthcare system?

Dr. A Jay Holmgren: Yeah. And so I'm borrowing a term here from sort of the legal nomenclature. We think about differences between court systems and how cases are adjudicated in, say, the United States, where we have an adversarial structure, where we have a prosecutor and a defendant, we sort of go back and forth to try to convince a judge versus some of the systems in continental Europe, for example, where things are much more of a fact-finding mission. And there's one lawyer who deals with everything. And so when I think about how the United States pays for healthcare relative to many other countries. So first off, we have a multi-payer environment which is different than, say, kingdom, where everything is billed for one national health system, NHS. And so there's only a single-payer, and now a lot of other European countries also have some sort of multi-payer environment. So if you go look at the German system, they have more than one payer there. There's a government system. There are private insurance on top of that. I think what's unique about the United States is the level of multi-payer complexity that we have and sort of this going back and forth, the check that we have as a country on healthcare costs are individual private insurance companies and what they will cover and what they will pay for. Whereas sort of the comparison in the UK would be what they call NICE, which is they have, you know, a more formal cost evaluate cost-effectiveness evaluation system, and they say anything above or below the threshold is what we choose to pay for or don't pay for. And they've sort of made these concrete decisions as a society, much more transparently, whereas in the United States, we sort of operate under a system where hospitals and physicians would bill for unlimited amounts of medical care services if they were allowed to, and the sort of backstop and check against them doing this is payers insurance companies say, hold on. No, no, no. You have to prove to us that you need this, that the patient needs this in order for us to pay for these systems. And sort of the way that this ends up influencing sort of the administrative burden on our clinician workforce, where I think a lot of our documentation burden comes from is when you are a physician practicing in a system like UCSF Health, where I am sort of on the campus side, we have patients of a ton of different insurance companies and many of them have multiple insurance companies. You might have Medicare and a supplemental plan. You may have your plan and your spouse's plan that will cover sort of secondary expenses. And so all you have to do as a clinician is simply know what every single patient you interact with’s very specific insurance status, very specific plan details, and then just document exactly what the payer needs to know, which you definitely know from your background knowledge. Obviously, that's an impossible task. And so what ends up happening is we train physicians to maximally document whether sort of explicitly in medical school and residency or implicitly when the billing person calls them all of the time and says, Hey, in order to bill for this, you need to make sure this is documented, and this is documented, and this is documented. And so even if one insurance company, say, let's say Blue Cross Blue Shield of California, we're like, Oh, this is really bugging everybody, let’s drop all these documentation requirements or something. If the other insurance companies don't do that, most physicians don't know, you know, especially specialists. So people who are seeing people in the hospital, you know, that they're on Blue Cross Blue Shield versus Medicare versus state Medicaid versus United or Anthem. So you end up in a situation where everyone is working to please the most sort of onerous set of requirements at all times. And these can vary all over the place. And I don't think it's specifically one insurer that does this, but small tweaks around, oh, well, this insurer is really getting into level four or five E&M codes, and we need to really justify those because we keep getting rejections for those claims or, you know, just sort of organizational level not wanting to get claims rejected. You end up in a situation where the work falls back, the physician and the clinician who's doing that documentation. So that's really what I mean about how the sort of adversarial multi-payer system has generated a lot of this documentation burden.

Dr. Craig Joseph: Yeah, well, you know, we love it from a physician perspective. You know, we love being held to the account of the most onerous payer. And I never really thought of it that way, but that is true. We do go to the lowest level and figure if, hey, if we can document for them, everyone should accept this. And it's almost like even if 98% of payers decided that you don't need to do this thing or jump through that hoop, that doesn't really matter that much because there's still 2%. As you pointed out correctly, I don't know which 2% you know, which insurance my patient has, even if I have that information, they don't always trust it. And so it's easier. We've certainly seen this sometimes with physicians who say it's just easier for me to put everything in there, which leads to some of the findings where you see very large progress notes that have a lot of words. But from a clinical standpoint, actually don't say anything.

Dr. A Jay Holmgren: Yeah, I think that's definitely true. And then the other thing that I want to talk about with documentation burden is, is we've really never had this conversation explicitly, but documentation drives a lot of things in the U.S. healthcare system. It drives a lot of billing, which we've talked about at length, and I think gets a lot of focus, and it drives your ability to guard against malpractice suits, which is where that adversarial legal system comes in. But it also does a lot of things that we don't think about as much on the clinician side, which is how do we do a lot of our quality measurement and quality improvement efforts with data from the EHR? How do we do all of our research these days when we want to do observational studies or cohort studies of patients with data from the EHR? How do we think about measuring organizational performance? Where is our finances going? How quickly are we able to turn patients over, how full are our beds with data from the EHR? And so all of these things sort of feed into what we need clinicians to document, what we need to write down somewhere, what we need to store electronically. And it has created a system where we can do research that was impossible to do before at scale. And it has created a system where we can do quality improvement measures to say we're really going to think about patients with sepsis this year because we had bad sepsis measures last year, and it's important for us to improve our processes and being able to use real-time EHR data really facilitates that. But somebody has got to write down everything that's happening. Somebody's got to document what patients had sepsis and which ones did, and so that all ends up flowing down to the clinician level. And I think that's where we've really got this tension that some of the state is really useful. It facilitates important things, but we haven't really said is it useful enough for the costs that it imposes on our clinical workforce?

Dr. Jerome Pagani: A Jay, we ask everybody this question towards the end of the podcast, which is what are two or three things that are so well designed that interacting with them brings you joy?

Dr. A Jay Holmgren: Yeah, I think there is a couple of things, and I'm going to go a little bit analog here and not talk about digital technologies, but two pieces of my life that I thought about immediately when you asked this question, the first is my espresso machine. I love coffee. I'm a big coffee guy. When people tell me they're somehow academics or researchers that don't consume a lot of caffeine, I’m immediately skeptical, like they have some sort of superpower. And I could never be that way. But there's something really, you know, I have not the most fancy espresso machine in the world. It's a, you know, a mid-range Bravo model. But there's something very soothing about how tactile the responses feel when I turn the little knob to start the milk froth or when I tamp down the espresso, it makes a lot of noise. It's really become like a nice morning ritual. And it works well in every way. And it appeals to my little scientist brain where I can think I can really precisely adjust one variable. I'm going to change the grind on these beans, or I'm going to change the temperature of the milk froth. So I really dial in that perfect espresso or that perfect sort of cappuccino that I'm looking for to get the right amount of foam and, you know, having those little buttons, that little ability to change just a single thing a little bit really appeals to me because it's something I do every single morning so I can keep a little notebook where I think, yeah, for these beans, this is my grind setting. So it really just makes my morning every day. The second one for you who are pet owners, you may get this, but my dog's harness, which is sort of an odd one, but I have a Hungarian villa. He's four years old now. He doesn't need this anymore. But when he was a puppy, I was training him to walk nicely on leash on a normal dog collar, and he was just such an excitable dog. They're a very high-energy breed, and he would get so excited when he saw anything. We were in the block of the dog park. He would start choking himself, almost as puppies are wont to do, because they're, you know, not thinking through the long-term ramifications of what's it going to be like if I drove myself every day until I get to the park? And so I started doing some research about this, and I tried all sorts of different things, you know, until I found, you know, essentially this woman who had made this harness that had a front clip on it, and she had just engineered it for the perfect little ability to when they pull from this front clip, it turns them around instead. And so, the first day I put this on, I hooked him up to the front clip, and I took him for a walk. I’ve heard a lot of advertisements for miracle products in my life. This is the only one that actually worked. It was a night-and-day situation. All of a sudden, he thought, “All right, well, if pulling just turns me around in the wrong direction, I guess I won't pull anymore.” And it fixed his walking issue immediately. And this is such a small little thing, and it was just a clever little design to have the weight of where the front clip harness is in just the right position. So it sort of turned them around when they didn't want to go, and they pulled, and I, you know, my willingness to pay to borrow an econ term for that at that point would have added you could have sold me that for $1,000 and I would have bought I would have said this saves me so much anxiety and stress and worry. And it sort of made walking with my puppy from a nightmare to fun and enjoyable. And so that's really when I think about it, and it's so well designed but so simple that I can buy it for $18 on Amazon. You know, it really blew my mind. So that's one of my favorites.

Dr. Jerome Pagani: And what's the name of that?

Dr. A Jay Holmgren: It's called an easy walker harness, so free advertising. They're on Amazon, and they have their own website as well. Genius stuff. I can't recommend it enough for those with rambunctious dogs.

Dr. Craig Joseph: Now, does that work, as a pediatrician, is that, does that work for humans? I'm just asking. I'm not making a judgment.

Dr. A Jay Holmgren: You know, I don't have kids yet, but I'll report back, come back to me in five or six years, and we'll see. We'll see if I can jerry-rig up the baby version of this.

Dr. Jerome Pagani: Craig, I'm sensing a business opportunity. If we stand outside theme parks in the summer and sell these.

Dr. Craig Joseph: No, we stand at the, yeah, before people go in, not after they come out.

Dr. Jerome Pagani: At the entrance, right. Or actually, after a full day in the amusement park with your kid on a leash. You may be willing to pay a lot more money for one of these and then going in.

Dr. Craig Joseph: I like it. Let me just comment that we do not recommend leashes for children. And I, I don't want to hear from the American Academy of Pediatrics, of which I am a member. Well, thank you so much for this. This was great.

Dr. A Jay Holmgren: Great. Thank you so much for having me.

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