Interview with Becket Mahnke, MD [Podcast]

Show notes:
[00:00] Intros 
[02:20] How a Telemedicine Project Sparked an Informatics Career
[10:33] A Low‑Tech Solution to a High‑Tech Burden: Fixing Patient Messaging
[23:00] Culture Over Configuration: What Really Drives Burnout
[26:00] Listening to Patients at Scale: The Patient Voice Collaborative
[31:13] Achieving AMA’s “Joy in Medicine” Gold Recognition
[35:30] The value of coaching
[38:07] What the U.S. Can Learn from Practicing Medicine Abroad
[43:00] Dr. Mahnke’s favorite well-designed tool
[28:35] Outros 

Transcript:

Craig Joseph MD, FAAP, FAMIA:

You're listening to In Network, Nordic's podcast series where we explore healthcare and technology with experts from around the globe.
 
Hello, and welcome to the in network podcast feature Designing for Health. I'm Nordic's Chief Medical Officer, Doctor. Craig Joseph. On today's episode, I speak with Doctor. Beckett Mahnke, Chief Medical Information Officer of Confluence Health and board certified Pediatric Cardiologist. Dr. Mahnke shares his unconventional path from military medicine to leadership in clinical informatics.
 
We explore his organization's award winning work in ambient documentation, AI implementation, and reducing clinical cognitive burden while maintaining quality. Doctor. Mankey offers refreshing perspectives on making technology serve care delivery rather than the other way around.
 
And he shares insights from his international practice that reveal how documentation bloat obscures what truly matters.
 
For health system leaders navigating AI adoption and physician burnout, this conversation offers practical strategies grounded in real world results from a rural healthcare system punching well above its weight. Let's plug in.

Craig Joseph MD, FAAP, FAMIA:
Well, why don't you give us a little background about yourself? What kind of physician are you? Have you always wanted to become an informative? And are you happy about ending up in the state of Washington?

Dr. Becket Mahnke:
Very happy about being in the state of Washington. Didn't think I would return here. For background, I'm a pediatric cardiologist. Not many of us in pediatric cardiology make it into the informatics space. And honestly, I think I was doing this work for about ten years before I even knew what informatics was. My colleague and I have, having done a lot of this work in 2014, said, hey, look, there's this clinical informatics board certification thing.
Turns out that's what we've been doing this whole time with projects. So I spent the first 24 years of my medical career in the in the Army, retired in 2016 and was doing a lot of informatics at that time. But that's when I took my first CMIO job. So it's been almost ten years of being CMO for a couple organizations still practicing. And it's great, great fun. But spent a lot of my time in Hawaii, and Washington was the only state that I was probably willing to leave Hawaii.

Craig Joseph MD, FAAP, FAMIA:
Oh, that makes sense because the climate is so similar. No, it's not very similar.

Dr. Becket Mahnke:
Beautiful mountains. Beautiful. And, can't go wrong here.

Craig Joseph MD, FAAP, FAMIA:
Image is you get some, you get some snow up there from time to time.

Dr. Becket Mahnke:
We do. And in the last day, we've gotten almost an inch of rain. So definitely the typical Washington.

Craig Joseph MD, FAAP, FAMIA:
That's fair. So how did you kind of get into doing this? You had said you were you were surprised at some point when you figured out that there's a board certification for clinical informatics and you're like, oh, wait, I've been doing that. But you didn't train to do that. You didn't do a fellowship. Those things didn't exist back in the day.

Dr. Becket Mahnke:
No, they did not. But in 2003, I finished my cardiology fellowship. I had been assigned to my duty station in Hawaii, and my boss and friend and mentor, who was the department chief, came in. I'd been there probably a week and said, by the way, 10% of your time is going to be spent on doing some research projects.
Oh, and by the way, here is the grant you're going to apply for. The deadline is in a week and you're going to do a telemedicine project with me. So I started for years in the telemedicine space. First until a cardiology actually developed an FDA approved tele cardiology device. Then went into broader telemedicine in the Department of Defense and just kind of kept getting deeper and deeper into what is apparently informatics, which is, you know, using our health IT tools to improve the care delivery.

Craig Joseph MD, FAAP, FAMIA:
I love the fact that you were volun-told. It's amazing how many people there their lives, their, their life work has kind of just been like, yeah, I was working with this person and they either suggested or told me that I was going to be doing this, and I liked it. And if you didn't, I guess that's one and done.

Dr. Becket Mahnke:

It was my good friend, Colonel, Chuck Callahan. And when the colonel tells you you're going to do something, you do it
But it was great fun. It slowly grew from 10% to 20 to 30, and when I got out of the military, I was about 50, 50 doing informatics and beats cardiology and decided to maybe flex the informatics muscles even more by taking a CMS.

Craig Joseph MD, FAAP, FAMIA:
Okay. And, where are you today?

Dr. Becket Mahnke:
So I now work for Confluence Health. We are a rural health care system in central Washington. It's actually seems silly. I'm going to tell you that Hawaii and central Washington are very similar in the fact that we have a population that is widely distributed and transportation becomes an issue. Also, access to specialty care because of the population density is a challenge. So we say similar problems. When I got a sick baby, when I'm practicing clinically, and I got a sick baby up on the Canadian border and there's no storms, getting that patient out as a challenge, just like it was if they were born on a different island. When I was living in Hawaii.

Craig Joseph MD, FAAP, FAMIA:
Okay. And are there’s. Well, obviously there are some challenges. And you just you just mentioned one of them in working in a in a more rural area than in if your area of responsibility is just located in some place you can drive within an hour or two. You're some of those problems don't kind of pop up. Well, let's talk about let's talk about confluence.

You've been doing some award winning work, and these are not awards that I have given you. These are, real awards. And so some of them are, you know, as you mentioned, kind of making things better for clinicians and for those that are treating for the patients. And, and so what happened at your organization that made them a kind of want to hire you and then be let you loose to do some of these exciting things? Was there was there a particular problem they were trying to solve, or do they just want to grow?

Dr. Becket Mahnke:
Well, I think for some time now, we have convinced executives and leaders that a healthy workforce is important, not only to ensure that we have folks that are working for our organization so that we can provide care, but also that the quality of care improves if you've got a healthy workforce, right. You know, from the technology side, I kind of I would say a lot of times I can care less about the technology because, again, the technology is in the support of us providing care to the patients that live in the communities we serve. And my approach has always been, you know, when you are with a patient or when any clinician is with the patient, that it's sacred time.

And we want to ensure that as much of the brain power, the CPU that is in our heads is dedicated to delivering health care, which turns out to be kind of complicated, right? We went to school for a long time to learn to differential diagnoses, and the best treatment plan, and also how to connect with a patient to form that trust and collaboration.

So now there's things that we have to do to make sure that we document and we get paid and we can continue to improve our quality. So we do need some record keeping if you will. But how do we minimize the cognitive burden. Right. As we talked about the cognitive burden all the time. And honestly health care has a high cognitive burden.

This is difficult work that we do. If I'm staring at a screen trying to figure out where the button is to click. That's cognitive burden that I would say is probably not value added cognitive burden. Right. So my team and I focus on minimizing that non useful cognitive burden so that our brains, as much of our brains as possible, is focused on the care delivery process and the medicine.

Because that's hard enough. Like we don't need to add more and it turns out that's what our clinicians want. That's clearly what I want. But it is what our clinicians gave up a lot of their life studying for and getting to medical school and working hard. That's what they want to do. And if they're enjoying what they do, that the benefits cascade throughout.

Craig Joseph MD, FAAP, FAMIA:
Okay. I love it. Let me pick up on what you one of the things that you just said. You said you don't really care so much about the technology right? No, I'm just.

Dr. Becket Mahnke:
I don't.

Craig Joseph MD, FAAP, FAMIA:
No, no, you will not regret that. That's a great statement. And, well, I'm going to give it I'm going to give you a specific call out. So I've seen you speak a couple times, and I'm going to, talk about some of the things that that you've talked about. And so one of them was patient medical advice requests.
And so in the, EHR vendor that you're using, they we call that MyChart, messages, but it's basically patient portal. The, the patient's sending messages to their physicians as you and probably most of our listeners know, the number of messages that was going to physicians kind of exploded with the pandemic starting in in 2020. We've seen so many more messages than we had before.

However, that's not true at one organization. At your organization, you would thrown out some data that showed that your the number of messages that are sent, kind of stayed flat since 2021, whereas everyone almost everywhere else, they've just kind of gone, up high and, and many of us would think, well, that's well, that's not good. You know, we want our patients to be, have an easy way to communicate with their physicians.

But on the other side, we also know that we were overwhelming the clinical teams. And so my question is, hey, how do you do this? It sounds like it was maybe a little bit of technology and also some expectation setting. How do you kind of decrease the unnecessary noise, yet still keep an avenue open for patients who need to communicate with their doctors?

Dr. Becket Mahnke:
So one totally like we want our patients engaged. And I do challenge my colleagues sometimes that if a patient is reaching out to this, that's what we went into this profession. But you're correct. We have been able to keep that flat while growing our MyChart usage overall, both in the percent of patients that are using the portal and all the other activities you can do there

.
Yes, there were some technology pieces, but the biggest piece was really expectation setting, right? So we did this crazy thing, right? So in my office, and I suspect when you were practicing in your office, patients were not allowed to go walk in the front door and immediately into your own.

Craig Joseph MD, FAAP, FAMIA:
That is.

Dr. Becket Mahnke:
It's not.

Craig Joseph MD, FAAP, FAMIA:
That is accurate.

Dr. Becket Mahnke:
Correct, correct. And it's not because you know, you're the king like on your high chair. You know, it's because we had team based care, right? So that we could efficiently deliver care to our communities. Patient portals. We designed that so you could go immediately from the patient directly to the doctor and but why would we have designed that?

Like we talk about design all the time. That's silly design. We had to think about. Okay, let's break that down and set expectations for patients and providers that unfortunately we don't get paid. And we're not staffed and resource to provide concierge medicine. Right. That's a separate thing that maybe you can go directly into your doctor's office, but we won't.

We don't want that digitally. So we set expectations with patients a lot within a couple days of signing up for my chart. And we did this retrospectively for our patients as well. But you get a signed, digitally signed a letter from our physician CEO and our chief medical officer saying, welcome to my chart. Right. We and we want you to engage this way.

But part of that is setting the expectations that we prioritize scheduled in-person care. And we will typically respond within two business days, typically. Right. That's not you know, we'll get to you right away if you go to submit a message. We actually made it a little a little bit more friction there and not necessarily friction. But the picklist is schedule.

An appointment is right at the top because we know that's what a lot of those messages are for refill or medication. Symptom checker. Right. I need to just check my symptoms. I can do that on my own, which is even better for the patient because they're not waiting for us to reply. So they get their serve faster. We remind them of our kind of response times when they go to submit the message.

But one of the things that we did, and I think you'll appreciate this from a design perspective and to be clear, we stole this from very smart folks at University of Utah. Is the initial or the default design for the message submission is two doctor mainly in my case. Right. So it's just two colon and still on the physician.
We changed it to the office of Doctor Blank. Right. And by the way, that's now become the epic standard of it. You know, in the old days you didn't.

Craig Joseph MD, FAAP, FAMIA:
Nobody.

Dr. Becket Mahnke:
Just quality right now, people.

Craig Joseph MD, FAAP, FAMIA:

Always said, that's exactly right. I called my doctor and they said, and if you really kind of. Well, actually, you called the office someone you talked to, nurse maybe, or some sort of medical assistant. They took a message. Sometimes they were able to answer that question immediately. Sometimes they had a kind of, standing order or protocol that they followed.

And then sometimes that was a message that was delivered to the physician, and either the physician replied directly or indirectly through an intermediate. So you're absolutely right. We've forever said, I'm calling my doctor, but, never, almost never are you actually doing that? And I'm just I'm fascinated by that change from send a message to Doctor Mahnke’ versus send a message to the office of. Right. Just that that sends a little bit. And I just know kind of the expectation that, yeah, this is going to go and going to be looked at by someone because the doctor is probably a little busy and it's going to be faster and better for you.

Dr. Becket Mahnke:
But it sends and it sends a message to my provider colleagues as well. Right. So we did a lot of expectation setting of my provider colleagues. And there's this twice a year we bring back of providers that have been hired in the previous six months. And I get an hour with them to talk about things. And one of my favorite things to talk about is what are the expectations of responding a patient medical advice request?

And I say, listen, nobody's watching to make sure it's within two days. We trust your judgment. If you think they need to come in and be seen in person, that is the right thing to do. You're smart. We've hired you because you're smart. We're empowering you, and I don't expect you to check these on nights and weekend because that's not the care model that we have.
I also challenge them that I can only help so much. And I love the story of my office mate is a general pediatrician, and she got a message one day when I was in the office and she said, look at this. Can you believe this message and the message that I'm this is almost word for word. Hey, doctor so-and-so, I'm on the way to the pharmacy.

Make sure my refills ready in 20 minutes. And I would say that that is unfortunately not the service that we can deliver on our health care system, but the easy button. So but she empowered herself and set expectations so the easy button would have been hit the refill button. Right. But she said, I'm going to close this. I'm going to take time tomorrow to respond to the patient so that I don't set expectations.
So it took more of her time, but she'll get that reward in the future. And then her nurse happened to come in like a minute later, I was still in the room and she said, by the way, she goes for future messages like that. You can forward him to me, but you can also just respond to the patient that we will get to these when we can.
We expect at least a two day turnaround. So if you're running out of medication, don't wait until 20 minutes before to ask for that refill. So empowering their staff because all our messages go to the staff pool. But then empowering the staff to handle them often?

Craig Joseph MD, FAAP, FAMIA:
Yeah. When I was practicing a gazillion years ago, a common a common question that we would get, this is back in the day when we used antibiotics for ear infections. More, more, voluminous sleeve than we do today. Pretty much every infection got an antibiotic. And, it was always one antibiotic. It was amoxicillin.
That was always the first antibiotic that we used. And, you need to refrigerate that if it's in a liquid form. And if you don't, it loses its potency. And, often it would be left out overnight. And I would get a lot of requests at the office to call in a refill again before electronic health records. And so my staff was now I enabled them because it was a two doctor practice mostly.

And, we didn't have a committee that I had to go through. So we said, hey, if someone calls in that they left out the amoxicillin, just call in for more marks or sell them. This is not a drug of abuse. They will not be able to sell this, liquid amoxicillin at the high school and make some money off of it.
There's really no risk there, and I didn't I found out about it at the I did find out about it, but I found out about it at the end of the day where there was a message waiting for me, and I initialed it to say, oh, I'm aware that they did do this. And

Dr. Becket Mahnke:
 I might argue, though, that remember that bubblegum flavored it was that was it was horrible.

Craig Joseph MD, FAAP, FAMIA:
It was horrible. Oh, I loved that. And I don't think it's changed. I think it's the same thing. I had a bad reaction to that. I just in the taste of it as a kid, and it's just, it's scarred me. I will tell you a story, though. I did something so your colleague and I encountered almost the same thing. It was a Sunday, and I was on call and I got a call from the pharmacy and they said, Mrs. So-and-so is here, and she needs a refill on her child's fluoride. This was, Right? I'm glad you're laughing. Good. I thought you might castigate me. She needs. And this. So they live where I was practicing. A lot of our patients were on, well, water, and they didn't have any fluoride, and we gave them a supplemental fluoride. And I think everyone knows, no matter what your level of medical education, fluoride is not a medical emergency.

If you're out of fluoride for a day or two, your child will be fine. This is not an, you know, an anti-epileptic medication. This is just not that important. And, the pharmacist said the patient, the mom's here, and, but we don't have any refills, so can you give me an order for the refill? Much like your colleague, all I needed to do at that time was say, okay, like I didn't even need to. I didn't need to figure out what the dose was or how much to dispense in the bottle. I all this pharmacist wanted me to do was say, okay. And I, like your colleague, said no, no, this is a Sunday afternoon. I'm not available 24 hours for, non-emergency. I am available 24 hours a day for emergencies. But this is not one of those.

So, just tell her to call the office in the morning, and we will be happy to call in that prescription, later that day. Right. And, because we'll do that the same day. We don't we don't we didn't need more time than that. And the pharmacist says to me, but she's here right now. And I said, I, I said, I appreciate that, but the message is the same.

And, he said she might get angry. I think he was afraid. And I said, well, that's fine. If she's really angry, tell her to call the office in the morning and just tell us the name of her new physician, and we'll be happy to forward the charts to her new physician. You know, if you want to get it, because.
That's fine. And if you want to leave us over this, you can. She didn't, she was fine. And but we've just saved ourselves now. And that parent, you know, has kind of now understands better what an emergency is, what's not an emergency. And I think it's really important. And you thought I was going to castigate you over the lack of technology.

I agree with you. I think often we over we over, index on the technology and like, well, how can we solve this problem of too many, patients reaching out all the time to their physicians? And, sure, we can say it's a team based thing, but I love the fact that your CEO, CMO, and others, at the very top of the organization, send an email kind of setting expectations and, and then you reinforcing those with new physicians to the organization to say, hey, you're not going to get in trouble for answering these messages in 2.3 days, if that's what you're averaging.

And in fact, you might get in trouble for answering them all the same day, right? Like, if, if you're going to, if you're going to air, because we don't want you to burn out and that's a, that's an easy thing to do. So I, I love that fact. And I really want to kind of jump up and down on that. It's a leadership and an expectation setting.

Dr. Becket Mahnke:
Well, and, and a quick way to index on that is, we, we now with that, obviously, but we routinely look at what percentages, what percentage of messages come into the provider's office that are handled without the provider ever touch. Yep. Right. So we're at we're at 59%. I know that because I look at that regularly. I have some departments that are pushing 90% right.

And those departments have great team based care protocols. I have departments at 15%. And it's fascinating to it's really just a team dynamic issue. But when I see family medicine clinics close to 90%, that means that is possible, right? That in a well oiled machine that is very possible. And it's just wonderful to see that they've actually shared with other parts of our organization how they've gone.

Craig Joseph MD, FAAP, FAMIA:
And you've proven the point. That's not a technology solution, which means it's also not a technology problem. And sometimes it's a call. It can be right. It can be if the messages automatically go from the patient to the doctor without going through the team, that that's a technology problem. But a lot of it's culture and training and expectations.

Dr. Becket Mahnke:
Right. And I think, you know, it touches on, you know, the issue of the EHR as a cause of burnout. And I challenge folks, is it the cause of burnout? And let me be clear, we have some poorly designed tools that clearly contribute. Right. But when you say that H.R. is the cause of burnout, my question is, is it causing the burnout, or is it the thing you are looking at when you become frustrated because of billing rules in the United States, let's say? Right. So oftentimes I think we get frustrated and whatever we're looking at the moment becomes the cause. And it's just a side effect.

Craig Joseph MD, FAAP, FAMIA:
Well, and yeah, 100% I can't agree with you more. Sometimes it's, operational. I, we I've certainly seen a clinic that, you know, leadership was saying, hey, can you come and look at this clinic? They really they really are getting burned out, and they really hate the electronic health record, and something's wrong. We haven't figured it out because it's configured the same way as all of our other clinics.

And we're really getting a lot more complaints from them. When you look at a high level, it's hard. It just all you see is, yeah, a lot of those messages are getting directed right through to the doctor. Why are the why is the care team not engaging. And sometimes it's culture in this case though, it was one clinic where they did a lot of that for the organization.

They trained their Mas. And so they constantly had new Mas coming through. Right? Right now you're laughing. But let's let me explain a little more. So someone who may not understand exactly what the problem was. With New Mas, you're not able to get, that kind of physician, medical assistant or physician nurse sync going on right where they're like, oh, yeah, no, I know what his answer is going to be.

I don't I don't need to ask. I know in my office it was, no, I don't need to ask the doctor if he'll call in an antibiotic because you think your child has an ear infection. That will never happen. And so I can just short circuit this right now and let's just make an appointment. And so with new again the culture was fine.
It just that they were by the time the medical assistant or nurse became, good. They were they were farmed out to someone else and then a new person came in. And so that's not the technology. That's definitely burnout on the physician part. But that's not because of the technology that was decisions that they had made from an operation standpoint.

So, it's important to look at that and not immediately blame the technology. And I agree with you. Sometimes the technology is horrible and we do need to make it better, but not always. All right. Speaking about technology, you all, have I think it's called the Patient Voice Collaborative is that okay that that's a group of patients obviously that you that the system has put together to kind of give you advice.
And so I'm interested in specifically how that how that works. I just want to get on that committee. And then what kind of questions do you bring them and how do they help you?

Dr. Becket Mahnke:
Well, let me correct that please. Here. So the patient voice, the patient voice collaborative is a collaborative that we participate. So I know you're familiar with the Arch Collaborative, which, is an initiative by our friends at class. And what a concept, right? What if instead of looking at chime awards, which have value, or epic gold stars which have value, why don't we ask the end users if we're serving their needs?

Right? So the arch Collaborative is let's ask clinicians, are the EHR tools serving their needs? I was one of the arch collaborative members that harassed class for some time to say, why don't we do the same thing for patients, right. Let's ask patients as we expect them to engage more with digital tools. And they want to, frankly, are we meeting their needs?

Right. So we did our first patient voice collaborative survey earlier this year. We have a new one kicking off in about two weeks. And we were targeting 500 responses from our community. We got almost 8000 responses. So boy they had lots to say. It was a way for us to assess what their needs were, what tools they were using, which tools were meeting their needs, what tools were garbage, and where they wanted us to go next.

Some was a surprise, some wasn't a surprise, but it was. I mean that again, as the end users like we can pat ourselves on the back like we did recently at epic CGM, where at the five diamond level. And we're pretty proud of that because we've enabled this functionality. But the real value is are the patients getting value.
So getting that information, and we've committed to doing this regularly. Compared to the traditional patient family advisory Council, which has been useful. This allows for a much broader, approach. And again, are the digital tools for providing you are they meeting your needs and what do we need to do better and what do we need to do next.

Craig Joseph MD, FAAP, FAMIA:
So you answered. So, thank you for correcting me. That is one of the problems often that I've seen from organizations that do have we have patients who come and meet with us once a month and which I think is great. That's better than nothing. But oftentimes those the people who kind of are giving you their time, have a have an agenda. And I, I totally get as and often that they have either they have chronic, problems or they have highly acute kind of problems where they're either they're involved very much so with your hospital or health care system or someone that they're caring for. Is involved, and that input is very important. However, you've totally lost the input also of the people on the other side of that, of that, spectrum who hardly ever come in or come in three times or four times a year and, and have, sometimes competing needs.

And so I love it that you kind of expected 500, and you got, thousands and thousands of, of responses. And so that's going to be I'm assuming that's going to be a bigger cross-section with, with different kinds of patients.

Dr. Becket Mahnke:
And allows us to really look at the results in a more meaningful way and, and look at different demographics based on age, based on payer, based on health needs. Language was a big piece of this, right? We have a large Spanish speaking population, and we want to make sure we're serving their needs as well. So we could target that group, which isn't always represented on our FAC. I think those surveys on a regular basis are helpful. Classes allowed us to then benchmark those results against some other health care organizations, which is helpful because sometimes you may only be doing something well 50% of the time. That might actually be good compared to other organizations. So, we're all type A's that want 90% or better, but that benchmarking adds a lot.

Craig Joseph MD, FAAP, FAMIA:
Enamored with the idea that you've won awards at you. I mean, your organization, and you have won awards for technology. So you're the vendor epic has given you kind of, good marks. You've gotten good marks from your patients and again, benchmarked against other organizations. Also, the physicians are giving you good, good marks. So the American Medical Association has a Joy in medicine program.

And, it's first of all, from a commentary standpoint, it's sad that the AMA needs to have a Joy in medicine program. It's just the state of affairs that that's out there. But what they're trying to do is bring back some of the kind of anti burnout, right. Some of the things that the reasons we went into medicine, I think if we all wanted money, we should have gone to Wall Street.

That's what we were really looking for. We were looking for some other things I think that were more important. And that's what that Joy and medicine program is about. And you moved from your organization, moved from bronze to gold. That seems like a good direction to go. And how did that happen? Now, I'm assuming one answer is, hey, our CEO and CMO send out a letter when you sign up for MyChart. That's one. But yeah, at a higher level, both technology and not technology. What do you think you've done to win that award?

Dr. Becket Mahnke:
Most of this credit goes to my wellness leader, Doctor Shambaugh, who introduced me to the Joy medicine program back in 2021. And I will paraphrase something she told me, which is something I agree with 100%, which is I don't care about a stick, an award, but I do care about and what is really the value is provide me a well-defined pathway to success.

Right? So here are the criteria. There are six criteria. Here are the levels for bronze, silver and gold which you recertify every two years. And we've kind of nicely moved up the ladder. But that gave us a framework to follow that we probably could have figured out a lot health, but it was stamped with the AMA and said, listen, if you follow this path, you are likely going to increase the joy medicine, increase the wellness of your providers.
By the way, here's the calculator that shows you what the ROI is by decreasing. By decreasing burnout from x percent to y percent, you have likelihood to leave decreases. And we know that a physician leaving an organization costs roughly half $1 million in lost revenue. So on our last survey, our family medicine burnout was down to 26%. Right. And it was in the mid 40s, not that long ago. The structure has given us a pathway to follow. It's a it's a recipe, right. And it's nice to have recipes versus just making stuff up. It also kind of give something back to the organization that they can be very proud of. And we can use it for recruiting and retention.

So they get value out of that as well. And honestly, Doctor Shambaugh and I get to lead our wellness team for informatics and IT teams along this pathway to support it. Right. There is no magic bullet. The work that I am most involved in is efficiency of practice section and teamwork section, because both of those have a lot of Dr. related measures, right. Wellness probably decreases if you're working till midnight. Right. So how do we routinely use our data to diagnose challenges. Right. And we try to to phenotype our users into those that need skill set help and those that need mindset help. Right. So, you know, as an entire motivation, I have one treatment which is let's send the trainer out to help them

But I think we both know that that treatment does not always work right. And it's probably because there's a couple different phenotypes underlying. So I've done some work with a colleague of mine of using the signal user action log data to kind of say, listen this this person needs a trainer because they have a skill set challenge. This person needs a coaching resource because there is a mindset challenge

And both of those, you know, neither of those are negative. But let's make sure we apply the treatment that is appropriate for the challenge that someone is going through. And I and I use that diagnosis and treatment language because my colleagues, we all understand I find that very helpful.

Craig Joseph MD, FAAP, FAMIA:
Yeah. I'm, I was just going to comment on that, you know, diagnosing and treating is, you know, as the as the chief medical information officer, you have often I always I, I always thought I have two hats, I have my clinical hat and my it hat. And, it's important to know what hat you're wearing at what time.
And it can change from minute to minute. So with that clinical hat on saying, hey, this is not a technical problem, it's not a learning problem. It you understand how to do the thing. You're just, you've got either your expectations are wrong or the culture that you're setting in your, in your clinic is wrong. And so who do you send?
So I totally understand if it's a technical like, hey, they don't seem to ever press this button and this button would really help them. That's a learning problem. Hey, you didn't understand why it's important to press this button. It'll help you. And you send a trainer who understands workflow and technology. Who do you send for the coaching side?

Dr. Becket Mahnke:
So we're also very lucky. Our medical group invests, in a program that allows any of our providers access to coaches. So we tend to take the front end approach of sometimes open interview. I will tell you, my diagnostic tool of choice is the signal report, which is the usage of the EHR report that we get from epic. And often it doesn't take long to look at that, kind of like a hematologist looks at that CBC that has all those readouts that you and I don't never understood. Right. But I can pull up a signal report and say, oh, you know what? We need a trainer or I might even send a specific trainer based on the fact that some trainers may be better in that mindset fair area.

Some are better at making sure that the team works together. Right? Is this a team problem or is this a person? I don't want to say problem, but is that is that the issue that we need to address so often? As you said, the trainers, the trainers do a whole lot of mindset work as well. But is it the individual? Is it the team? Is it skill set? Is it mindset? And then kind of figuring out who the right person versus the old days, which, you know, the first time I got a call from my boss years ago, which is so and so is having trouble, I would send a trainer and the trainer would show up. These are before we had good audit logs and they'd say, Hi Craig, I'm the trainer.
I'm here to help you. What can I do today? And they're like, I'm great. And you tell me, right? You tell me. So now we have the trainer or the whatever the resources comes in with a good idea of listen, here's where I think the challenge is based off this data. And I always engage with the data because it's actually really it's well presented. We're almost jumping past the hoop and jumping right into the assessment

Craig Joseph MD, FAAP, FAMIA:
Yeah. No, that's great. And that's exactly where to go. And if, anyone from the American Board of Pediatrics is listening, I do know all of the parts of the CBC and just for the record and the mix is my favorite. That's my favorite. Just again, for, if anyone's listening, who can, you know, decertify me.
I want to make sure. All right, let me give you one more question. You've practiced. You were in the military then. So you often move around when you when you're in the military, you've seen patients on four different continents sometimes using advanced electronic health record, sometimes using paper. What have you learned from kind of seeing how medicine is practiced all over the world? And are there any kind of high level lessons you wish we could take back here in the US?

Dr. Becket Mahnke:
American health system is over complicated, right? A lot of what I get to do when I'm in a developing country is the kind of medicine we all want to practice, which is going in and maybe not checking 27 boxes, but getting to the problem, right, I can I've seen up to 50 patients a day in, very remote island settings in the Pacific, because you can remain incredibly focused. I've gone back year over year and turns out I can write a three line note that my future self understands what my past self thinking. So we have generated these a long, long, long notes for a long time. That is a lot of noise. So the signal to noise ratio gets much better in those areas. It's also just interesting to see new organizes or organizations going from paper to computer now, because we've all done it quite a while ago.

But I also notice I said paper to computer, right. And that's largely what we did as well. We took analog processes and we put them on the computer. Right. People said we want digital on like, no, we did. We just went on the computer that we failed to leverage the value of digital for decision sharing and quality improvement and patient engagement and all the things. So it's fascinating, you know, as a I don't know how many chemists get to practice on paper every year, but I still do. I was in Bolivia just a few months ago, and one my handwriting has gotten there and a lot slower, but it really helps focus on what is actually the important part of documentation, at least from a clinical perspective.

Right? Because you right. From a clinical perspective, the documentation should serve your colleagues and your future self to make decisions in the future based on past information. And we we've put a lot of employees, into the system.

Craig Joseph MD, FAAP, FAMIA:
Yeah, I love it. I remember as a medical student working with this, I, we all call them the dean of pediatrics. And in the Detroit area, he just been around forever, and, I watched some spend 20 minutes with a six month, six month old and their mom. And then he documented it, and he wrote, six month old.
Check. Mark, six month check. P colon negative. Normal physical exam.

And he wrote plan shots. That was it. That was the his entire note. And of course nowadays you couldn't get away with that. That was a note to future self. And he knew that he asked about he didn't document anything about diet or elimination or development. However, I was in the room, he asked all those questions and he would tell me if anything was, if I needed to check anything or anything were abnormal, or I was a little concerned that I would document that documented by exception. And so he knew that when he saw that child for a nine month checkup, if there was nothing there for the six month, that meant there was nothing he was concerned about.

Dr. Becket Mahnke:
But I would challenge you know, that the idea that we can't get away with that now, right? Lost during the pandemic when we were all rather busy, was the CMS changes to documentation requirement preached? I will tell you. Preach. Yeah. My notes today. And I don't mean this in a bragging way. My notes now are 75% shorter than they were before. And I have not had a bill. Yeah. And I mean, I feel guilty whenever I see our lovely head of coding. I'm like, oh, God, she's going to tell me that they're too short and none of my colleagues have told me that they're too short. My future self goes back to those notes that everything's there. So I think we've not leveraged that that gift that we were given.

And I mean, there was an epic study that said, since those changes, notes of actually gotten longer. So we owned up to that. And it is possible, I was fortunate I joined the organization right when that happened. I was setting up my templates for the first time. I said, all right, let's see how far I can go.

Craig Joseph MD, FAAP, FAMIA:
Well, it's all based on medical decision making is, you know, I'm telling you what you know and correct. And so you don't even really have to document a physical exam, but you're going to and as a pediatric cardiologist, you're going to be focused in one area, and with a couple other things that you are concerning. Oh, that makes that makes complete sense. Again, getting back to me, agreeing with you, aggressively agreeing with you that it's not technology all the time and that you shouldn't care about the technology, at certain point. All right. We have run out of time, and which means I only have time for one more question. And I we always ask the same question, which is, is there something in your life that is so well designed to brings you joy whenever you use it? Do you have something like that?

Dr. Becket Mahnke:
There's a lot of things. But I and I'm actually going to go with a company that produces a products that I have purchased too many and that's that company is Peak Design.

Craig Joseph MD, FAAP, FAMIA:
Okay.

Dr. Becket Mahnke:
They started in they started in the camera business largely or camera, bags. They're now in luggage. And I love pulling my peak design bag off my out of my closet pack for a trip. I've got my own case right here in front of me. You'll notice this. This little notch, which is, like, two millimeters deep and yet is a rock solid connection to my bike every stitch and I geek out.

Sometimes I'll go look at the videos of how to use our product video, and literally everything on this has been done for a reason. And if you take the time to actually tell you the reason, and it's often for a functional fit, and I can't tell you how, I've never been disappointed in one of their products. I tried really hard not to buy all of them, but they are incredibly thoughtfully designed and everything, has a function, and they're actually quite lovely to look at as well.

Craig Joseph MD, FAAP, FAMIA:
Yeah. And they're, they often folk do they, they don't focus on Apple products exclusively, but they do a lot. Oh no they don't. Okay. I just know they do a lot with Apple products.

Dr. Becket Mahnke:
Correct. But you can get them for your Android phone and other things. But they are, remarkably well done. And actually I had this is a new phone case because I had a small issue on one last week when I was traveling and they said, I am so sorry, and they said, wow, wow. They said, that's cover.

Craig Joseph MD, FAAP, FAMIA:
All right, peak design. We will definitely try to put a link in the in the show notes. Well, thank you so much. This has been a great conversation really like I said, aggressively agreeing with you, which makes me a little bit irritated. Doctor back at Mackey. Thank you. And look forward to all the great things that you're going to you and Confluence Health are going to do in the future.

Dr. Becket Mahnke:
Great. Thanks. I enjoyed it.

Craig Joseph MD, FAAP, FAMIA:
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