A Physician's Perspective: How Healthcare IT Bridges Gaps and Helps Patient Care

Host: Today on the podcast, we are delighted to have Dr. Austin Fredrickson as our guest. Dr. Fredrickson is a board-certified general internist, and he practices medicine at Salem Regional Medical Center located in his hometown of Salem, Ohio.

He received his medical degree at Northeast Ohio Medical University also known as NEOMED. Then completed his residency and internal medicine at Akron city hospital, and completed his primary care fellowship at NEOMED where he currently is an assistant professor of internal medicine.

Dr. Fredrickson, you have grown up in Ohio, studied medicine in Ohio, and treated patients in your hometown, and helping train the future of physicians at your alma mater as well. That’s really unique.

So, thank you for joining the podcast today.

Dr. Fredrickson: Well, thanks for being here, and thanks for all the support for the small community hospital in my hometown, taking care of all of my neighbors and patients.

Host: Oh, that's tremendous. Let’s just start out a little bit about yourself and your background. Have you always wanted to be a physician?

Dr. Fredrickson: I basically did. I was lucky in that where Salem is -- it's kind of rural, northeast Ohio. It's about halfway between Pittsburg and Cleveland on the map.

We're the top of Columbiana county about 100,000 people. It’s a rural, mostly white, non-college educated county, and actually, the recent train explosion and derailment occurred right next door to us.

So, that kind of put us on the national map currently. I always did. We were lucky in that I was able to train within an hour of our hometown, even though we're rural. We're within a couple of different metropolitan areas that have good training programs, especially for primary care, and my medical school—right down the road—is where I always knew I wanted to be.

We went there and then after graduating from residency came back. As soon as I started working in my hometown as a primary care physician, I started teaching up there as core faculty in the department of internal medicine. So, it's been very cool and we're very lucky to live where we are that there's such great programs right here.

Host: That truly is fantastic. To not only have the opportunity, but then to take advantage of it and make sure that future generations have that same opportunity that you had as well. That's great information. Our paths crossed—our organization and yourself—during our recent EHR implementation where Salem Regional moved to the MEDITECH Expanse platform, and you were involved as part of the physician advisory committee or the PAC. Can you talk a little bit about the PAC? How you've seen it work, what's your involvement was. Any sort of insights as it relates to the effect that the PAC had on the EMR implementation and just setting that up for success?

Dr. Fredrickson: Sure, and just to sort of encapsulate my viewpoint where I'm coming from is I'm a practicing PCP. I was asked by the hospital administration, who ultimately decided to convert our professional corporation to MEDITECH Expanse to help try to guide some of the clinical questions that were coming up in terms of who needs access to what, how are we going to configure this or that.

Our hospital is one of the only last freestanding community rural hospitals, and because we're independent, we're a small hospital. It's a lean team, and we had been on MEDITECH as an inpatient hospital for several years. But our outpatient employed physician group, roughly 40 to 50 physicians, probably roughly 40 to 50 bed hospital now, status post COVID, we were on a different system. It was not meeting the expectations of anyone and it was apparent. Essentially, yeah, you had to keep buying more and more for less and less product each year.

A few years ago it was decided—let's try to get the entire health system on one platform. Since the inpatient world was working well enough, they said, let's convert the outpatient. They started with MEDITECH Expanse for the hospital side about 6 months prior to the outpatient side. The hospital side was pretty straightforward, because they were very familiar with the MEDITECH system.

Outpatient, it was a new system to most of us. Now, some of the physicians worked inpatient so they were enough familiar with that. For others it was brand new, they're completely ambulatory, completely in different locations.

At least 6 months before implementation, which we launched December 1st of 2022, a group of us were invited to start giving feedback on the main questions MEDITECH had as we built the system.

First, what do you need from us? What are you expecting from your current system that we absolutely need to make sure exists in MEDITECH Expanse. And I think that's where we as physicians were most helpful, because in our lean hospital, our administrators don't typically practice clinically anymore.

They understand what quality metrics are required for reporting purposes, what they need for order entry, what they need for collaboration with other healthcare systems, what they need for their own internal tracking, but they don't have a clear idea of boots on the ground—what we need to take care of patients every day.

That combination of administration and representatives of the physician team formed a physician advisory committee chaired by our chief medical officer, who basically met, I think weekly or every other week, for quite some time, answering all of those questions.

And then, as we got really close to launching, making sure we had training schedules available for everybody, making sure that there was going to be adequate staffing available, making sure that the team that was coming in for the live launch was prepared as well.

Host: That’s fantastic and certainly something that we always advocate for which is that collaboration across the organization. It's always great to see an organization who truly takes that to heart and builds that sort of feedback mechanism, not just in a one-time environment or situation but ongoing throughout the project. Certainly great to see, and I believe it definitely has benefited Salem as it moves forward.

Maybe talk a little bit about that. You all have been live now for a little bit of time. You've practiced medicine now for a couple of years. Maybe talk a little bit about what you have seen as it relates to the evolution of health IT, particularly as it relates to your function and your area in the ambulatory side of things. And then how and what you've seen change just over the past several months as you have moved into MEDITECH Expanse.

Dr. Fredrickson: Sure. Of course, health IT was evolving and then COVID came and really pumped it a lot faster. Suddenly we were quickly trying to use this system for telemedicine, and we were trying to keep up with the inundated messages from patients who were accessing their care remotely. We're trying to use a portal to interact with physicians in numbers that had never been seen before.

Rural America generally were less connected, were less online. And so, these patients did have some troubles. We can come back to getting in touch and finding all of their healthcare information technology, especially when they were quickly made virtual, and they couldn't quickly run into their PCP’s offices or see their specialist.

I think the biggest thing that I've seen in my relatively new career is sort of a manifestation of starting to really think about how we're approaching care to the patient in a population model but also in a team model.

So, it used to be, you'd show up at your doctor's office once a year, and that doctor would go over whatever you had to go over, make sure your cancer screenings were up to date. Your vaccines were up to date. See if you have any major questions or other issues. And then for patients who had chronic medical conditions, check in with whatever frequency was mutually decided to make sure they were in check. So, you might go back and manage your diabetes or your heart failure, cirrhosis, or what not.

What health IT can do is really take that sort of one off and change it in a really good way into a more population-based model to say I want to see all of my patients with diabetes. I want to know right now —in real time—what their last A1C level was or their measurement of their glucose for the last 3 months.

I want to know right now which of my patients have had a blood pressure reading that was too high and I need to see when their next appointment is. And if they don't have an appointment in the next month, I want you to schedule one.

Those things have been really, really cool. And they've also shifted the burden from the doctor having to know what to do at every visit to the system providing kind of like Atul Gawande’s book The Checklist Manifesto that they talked very much about in surgery.

Primary care, preventative care, chronic care, thinking, okay when was the last time we screened your urine for protein? When was the last time we did a toxicology screen? It's right there. It's able to graph to track and then to plan forward.

So, at its best, I think it is improving or has the availability to improve patient safety, patient care, up-to-date guidelines. And if done algorithmically, systemically can be offsetting so that the physician's not the only one making sure patients are moving forward with their progress of health goals, but that the patient can see it online. They can actually look at their chart and see what's going on. And the team— staff members, other asynchronous or more virtual players—can get in contact and set this stuff up as well. That to me is the best and most promising feature of this recent evolution of health IT.

Host: That’s certainly fantastic. As patients, we rely on the physician community a lot. It's a big burden for you all. So, to be able to have the tools and the capability to help in that effort and to enable then the rest of the team—because it isn't just the physician—but it truly is that health team, inclusive of the patient, to be able to be active and knowledgeable participants. Really, it certainly raises all levels inside of the health care setting.

Dr. Fredrickson: I couldn't say that better. Honestly, I think that is the goal. And then living in the real world, especially in a world of rural health, where things are a little bit more segregated in terms of those who are able to connect to their technologies, those who are able to connect with their physicians, take time off work, transport to their local hospital or their PCP.

Unfortunately, there's a lot more health disparities in that realm. But at its best, this should help to change that social determinant of health, and hopefully with increasing access and more time spent getting everybody online actually improve what they can get out of their physician's office.

Host: Oh, absolutely agree. One of the largest audiences for this podcast to date are CIOs and IT directors and so I'd love to get your take and your perspective. From the physician standpoint, what advice would you give other CIOs, other IT directors as they are looking at an EMR implementation or an upgrade, or quite frankly, even new technology that impacts the physician community.

Dr. Fredrickson: So, I think marrying, as we did in the PAC—somebody who is in the trenches with someone who's on the sidelines or in the C suite is so important for each of these conversations.

The C suite has very different goals and thoughts than the guys in the trenches. The guys in the trenches, unfortunately, are the ones who daily have to interact with the system. So, things that make complete sense to the C suite are so detrimental to those of us in the trenches. I can think of 50 examples off the top of my head where there was a disconnect between what was intended versus the actual issue.

For example, we would want to make sure that patients have their height and weight recorded in the system. Right? So, every patient would have a little block, or a pop-up come up if they didn't have their height and weight recorded.

Except that pop-up actually occurred with patients when you were just refilling a medicine, or if you were not seeing the patient, or if it was a virtual visit, where you're not recording that information. So, we created a lot of speed bumps with good intentions by not knowing.

The biggest piece, I think, when we're converting systems (which is what we did) is not just thinking about what the new system can offer. In this case, what can Expanse do. How great Expanse can be which is really cool and important. But what we're doing is not starting a brand-new practice on the system, we're converting a practice. And what they were able to do in their old system, whether it's paper charting or whether it's an actual system.

I think that was the biggest piece that we were helpful to share as physicians to say, hey, wait. You know, in our old system, we were able to have reminders pop up when we opened the patient chart. In this case, we may not have that functionality. What can we do if we've relied for years on pop-ups to tell us—Hey, by the way, make sure we order an annual lung CT screening. How do we convert that? How do we find that information? Because it changes the way that we think as clinicians if we rely on tools that either aren't there or changed in shape.

And so, a lot of our medication management, the way we approach flow sheets, the way we approach some of our internal processes, weren’t just how to do it in MEDITECH. But it was, how were you doing it? And are you missing cognitively something in that bridge.

So, that's where keeping the physician in the room, even though the physician may detest being in that room so often, for all that time, keeping them in the room, and then conversely taking the guy in the margins. And honestly, I have my COO follow me around on my computer seeing patients so that they can visualize each of the processes we're discussing. Quickly by marrying those two components it can make all of those issues go away so much faster and alleviate a lot of stress in the transition.

Host: Okay, so you touched on a number of gems right there that I do want to at least drill in a little bit more on. And I'm going to start with the one about physicians detesting the engagement involvement. I know for a fact, every CIO’s ear just perked up. And they want this question asked. Which is —okay, we all know that physicians really don't have the time and they do detest getting involved and engaged.

So, what is the best way for a project team or an administrative team to approach that and to win over the physician base to get that sort of engagement? And then, my follow up question to that is going to then be, what is the benefit to the physician on the back end? What do you consider to be success at the end of that implementation? Because I think the two go hand-in-hand.

Dr. Fredrickson: I agree. They definitely do. By trying to bring unwilling physicians on board— that's tough. And usually in any group there's two cohorts, right? And it's a small Venn diagram of people who really want to improve the system and invest and spend time on committees and make their system better for the benefit of all.

And then the other side basically says, leave me alone. I've got enough on my plate. I can't get there. I can't do anything. Really, utilizing without overtapping the first set would be key. But then the other thing is changing the way—the mechanism—in which we train. Like I said, in the trenches things look differently.

And so, instead of inviting a group of physicians to meet at the convenience of the C-suite, at the C-suite headquarters, when they have busy offices, etcetera, one, can we use virtual technology to actually help these meetings? Can we actually just log into zoom wherever we are?

Or conversely, could we bring the C-suite out into the clinic? You know, can we bring these guys out to say, hey, sit down and we're going to run through what you're doing now and we're gonna do it piece meal. I think in PAC we got a little bit lost in just all of the things that had to be decided in terms of this is the list of things that you got to do. You gotta decide in what order you want these things listed on a widget. You want to decide who's getting access to what documents? And at what time? Who's cc-able and who's not.

And instead, if we take maybe more project based to say, what is a workflow that makes sense for a surgeon? Very different than a physician who's in primary care versus the neurology specialist trying to do EMG’s all day and think very specifically about that group.

If we get them out—this is my experience in my small little hospital system—by exhibiting just a smidge of servant leadership in this way, by asking for input, advice and help, there's that psychological —Oh, my God, I actually have the opportunity to make it better. Most physicians may be able to jump on board. If someone's coming out to you, holding your hand, saying, “I want you to succeed.”

Then for the physician, if you actually choose to take that step, and many won’t, many will just complain about it the whole time, drag their feet along the way, and then complain thereafter and save it as a reason for burnout, etcetera.

But if you can lean in, just a little bit to it, then you actually can find ways —and I personally have found ways—to make my system more efficient because we're building it from the ground up. And I'm building it with my end goal in mind. So, I know that if I need to fill a whole bunch of medication refill requests, I need to develop a mechanism that makes that as streamlined as possible.

Everything that I'm complaining about in the current system—can I make it better in a new one? By building it, and especially with Expanse, by being able to have all of the individual controls for discrete options, without being too granular, because each doc might want something a little bit different from the other docs.

But, by the physician leaders actually leaning in and being designated—hey, we want you as champions, we want you to make this as good as possible for yourselves and your patients—the payout is tremendous. It's a ton of time upfront, but the amount of time you save down the road does end up boosting the RVUs, boosting your productivity, getting you home at night a lot sooner.

Host: I think you're spot on. You have to meet people where they're at. You have to understand where they're coming from. And then you truly listen and understand what those positive outcomes are going to be, and need to be, and then keep them involved in that process.

You made another comment earlier too, where yes, it's easy to say—Well, here's what we do today. But there is a knowledge gap when projects like this start. What's there or what will be there that we don't even know about? Certainly, have to take into consideration all of those components in order to achieve the success you were talking about.

Dr. Fredrickson: Honestly, the health maintenance features in the new system far supersede what we had before. In such a way that we're still not fully using them, because it's such a cognitive change in how we practice.

We are catching up slowly, but we didn't fully understand what was before and what is to come. Sort of doing that Ebenezer Scrooge in between to marry these different versions—you might be able to optimize the whole workflow. The trouble is health IT doesn't exist as a singular event in the life of the health system. Right? So, it's not the only thing going on. Unfortunately.

Host: Exactly.

Dr. Fredrickson: We're all privy to these same issues that fall on IT. Hey, we don't have enough staff. Hey, we don't pay our staff enough. Hey, patients are complaining about this or this or this. And so, it's very easy for us to blame the first variable that comes to all of our minds—what changed recently.

Oh, it's the fault of the EMR or the implementation of the EMR. But the EMR really has to lift the burden of the rest of the team by saying, we understand that healthcare is not outstanding. It's not all lollipops right now.

So, it's a tough time to do anything. And when you're making more changes to a relatively burned-out team that is trying so hard to just take care of patients. It's a big, big, big ask.

That's why, if you can show up and actually be arm and arm, an elbow buddy or whatever the near peer terminology that you want to use, but as much servant leadership as possible from above, I think, is maybe the only antidote that you can use.

Host: Empathy, for sure, that needs to be there. You touched on the fact that you are in a rural setting, and you've talked a couple of times about the engagement from a patient standpoint. And so certainly, Covid was a big starting point for us beginning to touch base with the patient community electronically via IT as it relates to telemedicine and tele-visits and so on and so forth. It was one way during the pandemic, and it's changing a little bit, but certainly, there's a future there where technology is going to be playing a large role between the patients and you as physicians in the hospital and health setting.

I'd love to get your take and perspective about what that journey has looked like for you in a rural setting and your State of the Union about where technology exists today. And where it needs to go in the future. To really not only help provide that connection on an ongoing basis from the patient, but then also help really support the physician community and the workloads and everything else that's on your shoulders today.

Dr. Fredrickson: Well, honestly, before the pandemic, I hardly ever dabbled in telemedicine. It was rare. It was confusing. I would have to call IT to get a program loaded, see if my microphone worked, if my camera was on. It just wasn't done. And then, suddenly, when you had to do all your visits that way, necessity makes you pretty efficient at it. For me, it's a little bit different because I'm rural medicine and I also practice you know, a mile away from where I live. I take care of all of my neighbors, and my kid’s teachers, and coaches and the town. It's a little Lake Wobegonian. You just know everybody, and you've seen them all.

And so, I have sort of been morphing my own practice. I don't even want to say telemedicine but increasing access because on my way home from work, I'll stop at a patient's house to check on them just because I've known them my whole life, and I want to make sure that they're getting better, and I don't have to send them to the ER.

So, what telemedicine is for me is just a better way to reach out to more of my patients that don't happen to necessarily live in town. The trouble is those patients—we know that our rural areas in healthcare are going to be older, poor, sicker, more likely on Medicaid, more likely to have chronic health conditions, worse health outcomes, and decreased access to the Internet by very significant margins.

I've done a whole podcast episode specifically on this plight of rural America. So, it's tough if my patients can't afford a smartphone, let alone a phone. Some of my patients don't have a mailing address. You know, they're truly off the map. There's a camper somewhere. Whole parts of the county don't have cellular or Internet access.

So, I became good friends with McDonald's saying, hey, McDonald's gives free Wi-Fi and if your nephew can meet you at McDonald’s for lunch once a month, then we could do a quick check-in that way. That has been a godsend for me. Meeting people at McDonald's and that they can use whoever's smartphone is pretty much the common script I give my rooming staff when they were setting up telemedicine. Whose phone is it, what number, what time? And then, for me, I sometimes get behind. But you can't get behind at McDonalds at lunch hour, because they're gonna lose their seat. I get some angry people with them.

Honestly, to me, we rely so much on the portal, and we're graded on the portal. What I'd like to see the next iteration of telemedicine or virtual technologies offer. Unfortunately, just like before where you're not always in the silo, tying it to compensation for me. I have to have someone collect a copay and I have to have someone set up a chart for me.

Instead of really being able to, at any time have on my app, all of my patients—look them up and boom, ding, virtual. Okay, here you are. What do I need —great. I can quickly Tweet my big response, which is patients feeling much better. Does not need further antibiotics at this time. Okay to stay at home or patient here ordering chest X-Ray. And, allowing the structure to just morph into what we do for any other component of life, which is just order it on the go. Apple Pay it—Apple Pay your copay, or quickly access the patient. To me, that level of functionality—I haven't seen any system be able to do that.

But when it does, it will replace the stopping by your house on your way home from work, or calling the patient directly, or meeting them at the gym. There's just so much that patients could be getting if there was access. That's separate then from the doctor being available to meet all of those needs. But having the option could really facilitate a lot more of those relationships.

Host: You're spot on and it's the same thing, right? Rules get made at the top level that they think will apply to all. But what you're talking about is that localization. Putting it into practical practice. It's a fantastic reminder to everyone. Well, what overarching rule might sound great. There's always that localization that needs to take place and tweaking and really understanding your community. I really appreciate that insight.

Dr. Fredrickson: We make every medical student stand up and vow in their first week of med school to say the patient is why I'm here, in addition to several other oaths. But just trying to maintain over and over again—the patient is why we're here.

And ultimately, will medicine change to more of a subscription model, or more of a model where everything's bundled and you can just connect how you need to, without all of the documentation?

Hopefully, we get there. In which case, a lot of what we're doing changes specifically to what does the physician think that the patient needs and what does the patient desire from the physician?

And if you can do that and meet it, whatever modality that you have available to you, hopefully in a decade, we're having a very different discussion about it.

Host: Agreed. Well, I always like to wrap these things up with an open call for insights and wisdom. As I mentioned before, most of the listenership, at least so far, has tended to be IT professionals inside of the healthcare arena.

They always love hearing insights, particularly from those that are in the physician community. So, what are the top two or three things that you would want an IT professional inside of a health system, or a single hospital to know, from a physician’s perspective, just about anything from an IT perspective in general.

Dr. Fredrickson: I think most really good IT professionals know these things and practice them, but what separates from a physician's perspective the really good IT professional, CIO's, CMO, whomever, and even the guy answering the help desk phone — the biggest thing is really spending the moment to reassess and remind ourselves —and this is a physician duty as well, but the physicians, they're not very good about it either —we're on the same team, right? The patient is why we're here and IT is only here for that patient.

There was a CEO I had at one time that said your job is either to take care of our patients or is to take care of the people who are taking care of the patients. Remembering that for IT is so helpful, because I see so frequently this dismissiveness—of God, this guy is an a-hole. Because he's so lazy, or he's complaining, or he’s critical or he's late or he’s not doing it right.

It's so easy to distance with negativity, specifically on physicians, because they're nasty to deal with. They call, they complain. You're not allowed to yell back at them, and they get more leniency than the IT world does, and that's not fair. A lot of that's driven from frustration and stresses beyond the physician's control.

In which case, if we could just check those negative impulses, we have. Those—this guy's... a real piece of work or whatever, those negative things that are reflexes. We just think them. We talk about people differently.

If we can change the language, even for just a half day and say, I will think nothing negative of whoever complains about whatever and legitimately pause and go out there to find out what they're doing. If we're in the world, if we're actually in the clinic, if we spend time —not in the IT basement or the C-suite—but with the physicians, we find out so quickly, they're the opposite of lazy. They're the opposite of uncaring. They're caring so hard and so often that they're just exhausted by the time they finally pick up the phone or send off a nasty gram to us on email.

And we are there to fix in real time, instead of trying to meet all these other responsibilities that the IT world has thrust upon it—the regulations and cybersecurity and keeping up with the revenue cycle —the physicians have no idea. We don't think about those things. We don't care about those things that you spend most of your day doing. We are just trying to order crutches for a patient and there’s no order for crunches in the EMR.

As much face-to-face time as possible, I think it's ownership from both sides. So, to me, I would say, just kind of what you said before—that localization—by actually having elbow support, by being face-to-face with people, by being on the team, by showing some servant leadership, some appreciation. I think reinvests many fold the engagement that you get from your physicians.

Host: One last question—a follow-up to that. You had the physician advisory committee as part of the implementation. What are your thoughts about the life cycle, lifespan of that sort of committee on a go forward basis? We've mentioned that technology isn't stagnant. We mentioned that while a project might officially end, the relationship can't end, and there's always optimization. So, I'd love to just kind of wrap up with your thoughts on how do we, maybe, from a programmatic standpoint—do we keep that PAC going in perpetuity? Is there another method? Just love to get your thoughts on that.

Dr. Fredrickson: Well, it's something I recently gave feedback about at my own hospital, because you're right—a standing committee is a dangerous thing to have around. Because unlike sometimes administrators who block off an hour of their calendar, the availability of the physician might be much more tied up. So, if we have an agenda, and we know what's going on for perpetuity, do we have the same fire to get things accomplished?

One of the suggestions I made was—yes, let us continue. But let's consider a different form. In that, we would have standing either work groups or one-off retreats. So, instead of meeting hourly, once a week, or once a month, let us instead take 90 minutes, two-three hours on a specific issue. Whether it's medication management and reconciliation, whether it's the facilitation of transitional care documents between extended care facilities in the hospital, pick the issue and dive deeply into it.

And set up essentially a series of three with the players in the room who need to be in the room, because I don't need to be in on the OR discussions. Like, I don't care about labor and delivery. This is not necessarily where I'm most valuable. But my colleagues are certainly wanting to be in the room in those situations.

I don't know what they'll decide, but if I were in charge for a day, I think that I would continue the relationship, but change the format such that it is much more focused on a specific issue. Because it gives everybody a win at the end of it instead of another meeting on the calendar. You know at the end of this meeting or the follow up meeting, you've actually addressed and fixed the issue. You've gotten buy-in from everybody, you've shown success, so that you're more likely to gain traction on the next one.

Host: That's fantastic. Some wonderful insight. Dr. Fredrickson, really appreciate your time today, and I thoroughly enjoyed our conversation and insights. I have no doubt that our listeners will enjoy it as well.

So, again, thank you very much for not only your time, but your partnership throughout the project, and we look forward to great successes to come.

Dr. Fredrickson: Well, thank you for coordinating it, for offering me some virtual therapy, and giving all of our listeners just a taste of what one physician’s small humble perspective is. If it makes anybody have any questions, feel free to reach out anytime. I'm happy to do anything I can to improve patient care wherever you are.

Host: Oh, that's fantastic. Well, thank you Dr. Fredrickson, really appreciate it.