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Featured topic and speakers
Our guest is Reggie Lyell, MD, medical director of informatics at Baptist Health. Dr. Lyell discusses the near-death experience that caused him to retire and the opportunity that inspired him to return to work. He talks about his new role as a leader focused on improving clinical workflows and his current project to improve the in-basket experience. AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Reggie Lyell, MD, medical director of informatics, Baptist Health
Transcript
Unger: Hello and welcome to the AMA Update video and podcast. Today we're talking about one physician's unexpected journey from working on the frontlines to becoming a physician leader and an expert in in-basket efficiency. Our guest today is Dr. Reggie Lyell, medical director of informatics at Baptist Health in Corydon, Indiana. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Lyell, it's a pleasure to have you with us today.
Dr. Lyell: Thank you, Todd. I'm glad to be here. Thanks for the opportunity.
Unger: Well, before your current position, you worked as a family physician at Baptist Health all the way up through 2022, and then something happened that changed everything. Why don't we just start there? What was it?
Dr. Lyell: OK. Well, going back to 2021, February of 2021, I had been visiting a daughter and grandson for his first birthday in the DC area. We had traveled Super Bowl Sunday, actually. And during the night, I woke up with a seizure and was taken to a local hospital, a community hospital, and had a seizure workup that was normal. And while I was undergoing a workup in the ICU, I had some prolonged pauses and some pretty profound bradycardia. I was transferred to a tertiary care center and had another episode and underwent an emergency pacemaker placement.
They originally thought it was sudden cardiac death, that I was a survivor of sudden cardiac death. It turns out it may have been, or it may have been a seizure and a prolonged postictal period. They're still not sure. So anyway, my wife and I stepped back and decided we wanted to look at other options. I was 62 at the time, coming up on 62. We decided to leave clinical medicine and to spend more time with grandkids.
Unger: Let me just ask—when you started talking about the timing, I thought this would be a COVID-related story, but obviously really serious. And I'm sure that experience would make anyone in your position really rethink how things were, maybe consider retiring, a change of pace. But you got offered a new opportunity that you couldn't pass up. Tell us more about that.
Dr. Lyell: Right. Well, my father died at 57 when his grandchildren were three and one. Never got to spend any time with them. So we prayerfully considered what we wanted to do and decided that I would start cutting back on what I was doing. One of the things I was doing, I was a medical director of quality for a medical group that now has 1,800 providers in it, so I cut back on that and started transitioning out of it. But before I could transition out of it, we decided that we would just leave clinical practice altogether.
In the six-month transition period after that, when we were leaving clinical practice, Dr. Isaac Myers, who's our Baptist Health chief integration officer and president of the medical group, and Dr. Brett Oliver, who is the chief medical information officer, got together and they offered me a position that utilized my deep skills, my tech skills, my history of work with quality, and my clinical experience to combine for a unique role that could be done mostly virtually. So it allowed me time to travel and spend time with grandkids, work early in the morning and still get the work done and be able to spend time with the grandkids. So that was an opportunity that they gave me back in 2022.
Unger: Now, this is interesting because you're the second physician I've talked to in the past week that is now in the informatics world. Just for folks out there, basic what does that mean your day looks like? What kind of things are you doing?
Dr. Lyell: Yeah. Right now, my main focus—Dr. Oliver asked me to focus on in-basket and the burden it was already providing before COVID, the In Basket. I don't know if it's generational or what, but with MyChart and other in-basket opportunities, patients feel they have 24/7 access to their primary care, especially. And so they're messaging 3, 4 or 5 times a day, wanting symptoms taken care of, things that require medical decision-making, and they just disrupt workflow.
So you're trying to see patients in an office and most of our providers are getting at least 100 messages per day. So you add that on top, it's an overwhelming burden for primary care providers. It's something I'm passionate about and working with it, so I began focusing on everything Epic and In Basket starting back in 2022. So I worked, followed different organizations.
I've been working with a really good team, trying to put together some efficiency optimization and looking at it more from an operational standpoint now than truly a tech standpoint. We've just about reached all we can do from a tech standpoint. I mean, AI is going to change it a little bit, but still requires some medical decision-making and some workflow and workforce issues that have to be addressed to optimize In Basket and help improve work/life balance for providers.
Unger: That makes a lot of sense, I think, with any new technology. I don't think the expectations are quite set there, certainly with patients, in terms of response time and not really realizing just what that flow looks like on the other end of the physician. In your work that you've been doing so far, do you have any insights or success stories that you can share with us based on what you've seen?
Dr. Lyell: Yes. One of the biggest insights I've had is that this is not unique to any single organization. This is an issue that has been created by several different factors. And probably one of the big ones is a decision that's been pushed on us by payors over the past several years, that we are now data-directed—not just using data to support what we're doing, but we are being directed by data.
Goodhart's Law is an economic law from Charles Goodhart back in the '70s, who talked about—I'm paraphrasing, but he said that anytime you take a metric and tie a reward to it, it immediately becomes a bad metric. That's what's happened. We created a set of metrics and then tied the reward. Our payors tied rewards to those metrics. So now we chase the metrics.
So the ultimate goal of a health care system, in my opinion, is that we optimize the provider-patient encounter and that experience to promote the health care of that patient. Well, what we've done is we've taken data and metrics and overwhelmed the providers to where they can't do that. So they end up chasing the metric and chasing documentation and can't really take care of the patients, and the patients are the ones that are suffering.
Now we're hearing terms like "moral injury" and "burnout" and things like that, and that's all a direct result of the immediate access and texting, and primary care access plays a part of that. If you've got a patient, it's really easy for me to sit in an office and say, that's something you need to come in and see me for. But if my next appointment is six weeks out, that doesn't do them any good. So how do we address that? So those are some of the things we've been working on, how do we fix those issues?
Unger: Yeah, these kinds of administrative burdens that you're talking about directly result in physician burnout. We know that a lot of physicians are spending significant amounts of time at home. They call it pajama time, doing things like reviewing notes and working in the EHR, probably responding to email messages like this. The day just kind of continues. When you have analyzed this and you're looking for solutions, is there anything that you've come up with that is helping?
Dr. Lyell: Well, there are several things we're working on, and we are in touch with organizations across the country, mostly Epic shots because that's what we use. So we work with our Epic teams, but we're also working on—the thing that I'm most excited about, we're starting the pilot this season, is a program we're calling Daser, D-A-S-E-R, which is a virtual acute and subacute encounter resource which allows, at the provider level, the decision to be made about whether or not in-basket messages are handled by a virtual team or they handle them themselves.
In an ideal world, the primary care provider knows the patient and best should take care of those messages. But sometimes your son has a basketball practice at 3 o'clock you need to get away from, or you are up on-call all night, or something comes up that you just can't handle any more messages today. Well, we're looking at putting together a safety net where you can just, on a dime, turn and say, "Hey, I can't see anybody else today. I can't handle any more messages."
And it gets sent to a team, a virtual team, that has options for medical decision-making. Has a provider embedded. It has more advanced staff. Medical assistants are not part of that. It's LPNs, RNs. We're also looking at moving in case managers for social issues, as well as pharmacy for taking care of the INRs, medication refills, things like that that can be handled at a remote location.
So our organization has six different markets. We have 1,800 providers, 450-something that are primary care providers. So we have different markets and they have different needs. And some providers want to see every message that comes to their in-basket. Some don't want to see any. Part of the challenge was to make it where the provider level could be where the decision was made.
And if they chose not to take care of the message, one of their advanced practice clinicians, or another provider in the department or the group, could see the patient that day. So it could be shuffled there, and if not, then to the virtual major team, what we're looking at. We're starting to pilot that, hopefully by the first of the year. We're getting on some of that setup.
The other thing that is important, we live in a world where budgets are important, and especially in the ambulatory world. I talk about the three-headed beast of health care these days, and that three-headed beast is that even though we talk about quality, we still live in a pace of productivity, or work harder based world. So the more patients you see, the more money you make.
So we've got that, but we also have a portion of our income and it's related to the clinical side. And then we had thrust upon us the patient experience part, which many of us, years ago, knew that that was going to be very difficult to navigate. And so when you put those three things together—you've got to keep the patient happy, you've got to hit quality metrics and you've also got to see more patients—what do you do?
That's where we have to come up with some innovative solutions to help our providers so they don't get burned out so we can attract more primary care providers. We have a large portion now that are nurse practitioners that are moving into primary care, which is going to happen. They feel a need and they're very good. The ones we have that I work with are excellent at providing care, but even they are burnt out. Just what do you do?
So we're trying to figure out ways to limit that burnout from that, and also try to help the organization understand that they can't set this scheme up and make it make us money. It's not going to make us money. It's going to prevent us from losing providers.
One of our regions recently lost three primary care providers, and when they did an offboarding survey, the number one reason was the in-basket. I mean, it's real and there's a lot of data out there now about that, but again, I want to use data to support what we're doing, not to drive what we're doing.
Unger: Absolutely. And just for folks out there, too, there is a lot of information and resources related to in-basket management and AMA Steps Forward section on the website, and I encourage you all to check that out. Dr. Lyell, just in closing, any advice? You mentioned that you're working with a lot of folks across many different systems. This is not a system-specific problem at all. In fact, we hear this from lots of different physicians out there. Any final advice to folks who are dealing with this situation?
Dr. Lyell: Yeah. I think from a system perspective, listen to your clinicians that have the clinical experience and work. It's easy for us to rely on MBAs and people with Health Care Administration degrees that don't have much clinical experience. That is important, but again, listen to your providers that have clinical experience and what they're living through and let them help you work through solutions, because there are solutions out there.
Also, try to stay out of silos. Find physicians that can be champions, that can cross silos in different areas within your organization to give a better perspective, especially those that have owned their own practices in the past. Although I think we're becoming dinosaurs, those of us who have owned our own practices and had to deal with all of this on our own without organizational help, we're becoming dinosaurs. But just listening to them, listening to them when they ask for resources and not make it all about, is this project going to make us money?
Unger: Thank you so much, Dr. Lyell, for that perspective. Really, really important. We'll be keeping an eye on your work, and we're going to look forward to hearing more about it as it progresses. Reducing physician burnout and improving practice satisfaction are top priorities for the AMA. We encourage you to support that work by becoming an AMA member at ama-assn.org/join.
That wraps up today's episode, and we'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-ass.org/podcasts. Thanks for joining us. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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