Focus on the Medicine, not the Minutes

Vital’s Director of Nursing Dr. Stephanie Frisch recently spoke with Dr. Ameer Mody, Associate Director of the Division of Emergency and Transport Medicine at Children's Hospital of Los Angeles (CHLA). The discussion ranged from using artificial intelligence to help patients to have more productive conversations with their clinicians to how the emergency department can be a proving ground for new technologies like ERAdvisor, which CHLA launched last month.

Stephanie: So, Dr. Mody I have to ask, I know with all of your experience in pediatric emergency medicine that we have experienced, even in our lifetime, this evolution of how patient experience has become an integrated part of care and everything that we do and everything that our patients and their parents expect just at baseline for excellent care. How do you think that this has evolved over time?

Ameer: Yeah, I mean, I think the evolution of patient and family expectations, you know, in a sense it's been somewhat of a double edged sword. And I think that we have tended to sometimes confuse quantity of care with quality of care. But I think that the pendulum is swinging back towards a focus on quality.

And, you know, in our understanding of what quality care means and what our patients and families’ understanding of quality care means, I think things can get confused. Again, I think we need to do some work, clarifying that sometimes the quantity of care that you receive is not necessarily related to the quality of care that you receive. But that needs to be communicated. 

And the tools that we use to communicate is another area where we, I think, can leverage technology, you know, making sure again that the parents and patients, parents and families understood what happened to them during their medical journey, right? And then being able to be empowered to recognize that, you know, not everyone needs labs for you to make the diagnosis for them. Not everyone needs an X-ray. The clinical expertise, as long as it's backed up by a forged therapeutic alliance with the family, I think is something that's important.

But again, the expectation of patients and families, I think, is ultimately something that is driving us towards better care.

Stephanie: Do you think that having that technology potentially in your hand on your phone, has influenced that at all?

Ameer: Absolutely, right? I mean, everyone knows about Dr. Google. But, you know, I think when we talk about the pendulum swinging, right, I think that the amount of people who I think understand that Dr. Google has its limitations and that we have these tools now to also let patients see and do research. You know what I mean? And see the way that we think. You know, when they're able to read their medical records, when they're able to see their labs or their x-ray reports. I think that again, patients have a higher expectation of what they can have and what they are going to receive during a visit. But then also, I think, they have the ability to have more informed care as well. And so, yeah, Dr. Google did not graduate from my medical school class.

Stephanie: Yeah, I know. It's very interesting sometimes when Dr. Google comes into play and how we get that conversation with patients.

Ameer: I wish that... We all have to do a better job of recognizing the magical place that an emergency department is. We sit at the crux of health care and if there is a problem in our society, the emergency department plays a role in it.

And so I guess it's a little bit of self-promotion, but I think if people know, if our communities realize how many different places that we impact it and where we sit. So, if you talk about any problem, whether it's homelessness, whether it's disparities in health care, mental health, gun violence the emergency department sits in every single one of those things. You know, access to care, the uninsured, and all of those things. And when all those things funnel down and they all end up in the same place, you can understand why we can be a little bit busy.

And so, that is macro communication. And we have to balance that with the right micro communication, also realizing that for most patients and families, their emergency department visit is one that they're going to remember forever. Right? Not necessarily, you know, not in a good way. It's going to be a core memory, not a core positive memory necessarily. But, you know, the burden and the honor that we share with those patients and families and being able to hopefully have a positive impact on that core memory that day that they're going to experience.

Stephanie: Can you tell me a little bit about what steps your team has taken to ensure parents, caregivers and the patients obviously feel like they're being heard or reassuring them?

Ameer: So, you know, the things that we have done historically are really focused on — particularly, work coming from a children's hospital emergency department —  are focused on staff. So being in a pediatric E.R., from the positions that are seeing you, those are board certified, specialty trained pediatric emergency physicians who go through extensive training. The nurses are specialists in pediatric emergencies, specifically.

And the way that we design our hospital has been toward that sense of comforting a child and their family when they're in distress. We have child life specialists — people who are some of my favorite people in the universe — who dedicate their lives to helping children and their parents through some of the most stressful times in their lives. Social workers, the respiratory therapists, we have an extensive staff that's trained specifically on pediatric emergencies. And you know part of what they do is making children feel comfortable, putting them in an environment so that we can do accurate assessments. And then also, making parents feel comfortable as well. 

And so, the difference — and I'm stating the obvious — is that with pediatric medicine is that you basically have two patients. You have a parent and their child. And there are situations where they're both anxious. There are situations where just one of them is anxious. And in trying to navigate that, our focus historically has been on having the best trained staff. The newer work is going to be in some of the tools of technology that we can use to help them.

And so our child life specialists use things like iPads, things like distraction techniques. You know, we've looked at how the rooms and how we layout our rooms to make sure that they're done in the most child-friendly way possible. There's, I think, a lot of work still to be done in doing those things to allow us to both efficiently and effectively do our work.

Stephanie: What additional things are you doing to increase transparency for what we're doing as medical professionals, and then making sure that the patients are, like you said, and their parents, caregivers, whoever is with them on that particular day to make them feel informed.

Ameer: This is, I think, where there’s so much wonderful work and so much potential to be done. The understanding of what I like to call a “therapeutic alliance.” For patients and parents, I think that the historic model — almost hierarchical — where there's a doctor and the patient and the relationship was one-way, right. Meaning that you're the giver of the care. The other person is the receiver of the care. There's time for questions and things like that. But, you know, I think that was our history. But that's just not what medicine is today. And I think that doing the work with transparency so patients have access to their medical record, patients having access to their labs, those things that empower patients to actually be more participatory in their care.

And so things like the work we've been doing with the patient portal and letting patients actually see their clinical notes, I think, is just a wonderful accountability tool as to what we document. And our patients can see it. And also, I think it helps empower them in their own health. So being able to see your labs, to pull them up and not just be on the receiving end of it, not having to go through 52 different steps of asking for your medical records like they're not your own I think are things that help with health literacy, that help with communication, that actually also let patients and families participate in their care.

I think also gone are the days of a single patient and a single doctor. It's rare when you go see your doctor that you are going to see the same person time and time again. It's going to be a team that's going to be taking care of you. That's particularly true in emergency medicine. I often will tell families, if we have a really good interaction... They're like, “Do I get to see you again?” I'm like, “If you're lucky, you will never see me again in your life.”

Yeah, but allowing families to have control of their information and their data so when they see a different provider, they can say, hey, these are what my labs were before, these are my chronic medical problems. I think that level of transparency — I mean, it comes with with with a lot of lift and concerns about privacy and things like that — but when it's done right, when patients have a role in the ability to see what's going on in their care behind the curtain, I think ideally it forges that therapeutic alliance a lot stronger.

Stephanie: Yeah absolutely. I agree with you. Are you using technology to keep patients and loved ones up to date on specifically their emergency department journey?

Ameer: You know, I think it's true in health care that we kind of lag behind a lot of other industries for a variety of reasons. But we do tend to lag behind other industries with regards to how they use technology and how they might reform or improve processes. A lot of what we're doing with technology is behind the scenes.

So, using data. One of the things that I love about emergency medicine specifically is that I think of the fields in medicine, it's the most like a factory. Meaning that when you look at processes and throughput and things like that, there's a lot more predictability in that model than you think. Everyone talks about emergency medicine — you never know what's going to come in the next day. Yes, that is true. But the patient journey tends to be fairly typical. I mean, it tends to follow a certain number of steps. And so a lot of the work that we have done so far has been on looking at data with regards to those throughput steps and modernizing them. Using timestamp data to improve our processes. The next steps are going to be getting patients a little bit more informed about those things. And so that is work we, specifically at Children's Hospital, are embarking on.

Stephanie: So let me ask you this. Do you think there's benefit in potentially automating redundant potential questions that we get asked a lot in emergency medicine we know are going to come, just to let that patient know about the next steps and expectations within the emergency medicine world?

Ameer: Yeah, I mean, I think without a doubt there is a huge role for that automation, you know. And what you're hitting on is really important, right, is that families oftentimes, particularly pediatric medicine, come in with a higher state of anxiety. But then once that, you know, once they hear from someone or they have spent a little bit of time or their pain has been addressed or their fever has been addressed, and when their child gets accustomed to their environment. And it goes from being scared to all of a sudden maybe reading a little bit or playing a little bit on a device or something like that. Once the anxiety level drops, then the expectation of “what are we going to do next” and “what's next up” and “how long is it going to take,” are very common questions and very understandable from the perspective of a parent. And actually from the perspective of the team as well.

We all want to know what the next step is and how long it's going to take. And so I think there's a huge role for automation for even building in scripts for laying out the path for people. And to the earlier point, being transparent about the steps that you're going to go through in an emergency department journey. And then being clear to families or at least a little bit more clear to them about what's what. Sometimes some of the roadblocks are — we know about the national problem of boarding. Boarding is patients waiting to be admitted. And sometimes it can be an hour — sometimes there's places where it's more than a day.

Those are huge and multifactorial problems of which the average emergency department pays almost no role in. We're completely passive to the problem of ED boarding because if you're waiting for an inpatient bed where, for the patients and families it's not on them, but it can be a significant source of anxiety, stress, and frustration. But communicating to them, being able to communicate to them that this is the next step and maybe even being clear that your team has done everything that they can. They've done their work. We're just waiting for someone else for the next step, you know, might help allay some of the frustration that families feel, the frustration that is taken out on our staff. I think that can affect our staff's level of job satisfaction, their wellness, and the rates of burnout. And so again, I think that transparency can be empowering. 

And then automating those steps in communication so that when a patient finally does get to ask a question, the question is not, “what's my next step?” We've already covered that, right? It’s then that we can focus on the medicine as opposed to focusing on the minutes.

Stephanie: Exactly. Really just taking kind of, like you said, taking medicine to that next level. And then instead of it being a what's next conversation, it's an empowering conversation with patients to really get them engaged in their care and have that open communication that we all — I mean, I know I do and you probably do, too — crave that interaction to make sure that that patient is getting their needs met in a timely manner at the right time. What do you think we should adopt in healthcare? Are there certain things that we should be adopting? And then what impact do you think that these technologies can have on patient outcomes?

Ameer: You know, the big answer probably has a lot to do with some of the work that's being done with AI and large language models, you know, utilizing some of those things in a safe and effective way to to really reduce the amount of time that the providers have in doing some of the non-clinical work that they do and focus on on the on the clinical. One of the biggest drains, I think, for nurses and for physicians in practice is the amount of time they take documenting. Whether it's documenting in the EMR or doing redundant work with regard to referrals and paperwork and prescriptions. And a lot of those tasks can be, I think, addressed utilizing AI technology.

So I think an exciting new field is going to be using AI as scribes. Scribes started maybe 15 or 20 years ago. And some of the places where the scribing process was innovative was emergency medicine. And, just as a side note, one of the things I love about emergency medicine is our ability to grow, adapt. A lot of the emergency department is really all of health care in a little crucible — its own little health system. And so it's a great lab for research, it's a great lab for development for testing ideas, for piloting ideas. And so scribing is one of those things.

I think that having a room that's set up for a kind of a scribe where it listens to your interaction with the patient and, and their family. And then when you leave the room right, you have part of your documentation or most of your documentation done. And when you're telling a patient, when you're educating them about something, when you're talking about their prescriptions, those things can happen on the back end. And I don't think that it's a huge technological leap for AI — a large language model-guided system — to be able to do that and to reduce the amount of time that providers spend typing that stuff and letting them spend their time doing what they love doing.

When I'm having a conversation with a family about a fever, there's a lot of details in there that are extraneous to what needs to be put into the EHR. And so to be able to pull out the signal from all that noise I think is going to be a huge area of potential. And it's one of those things that lifts all boats. So, it will improve, I think, the patient experience because I think half of half providers will be on a computer while they're talking with patients. Half of us don't and interact with it outside of the room. But we know for a fact, patients and families crave that face to face eye contact. We do a better job of communicating, of receiving information. And then if it improves patient care, if it improves efficiency, if I'm able to see a couple extra patients because I'm not spending my time... And then if I'm able to go home at the end of my shift with all my charting done, it actually impacts patients and impacts the process and it impacts providers in a positive way. So, exciting stuff!

Stephanie: This is exciting stuff. I see it helping patients as well on their side because I potentially could see something along the lines of, if we are able to record and capture that conversation we're having, I think maybe, like you said, people are a little anxious, their caregivers are anxious. If we could take those large language models and generative AI and actually make it so succinct and actually give them key bullet points out of everything we just talk to you about, because — I don't know about you — patients don't remember a lot of things we tell them. And it's not their fault, right? It's, “I'm not at the phase right now in this situation, things haven’t been relieved yet, so I'm not really listening to you. I'm not in the phase where I can learn.” So just having it more as a notebook that literally is taking notes for you and then you're able to reference that notebook later on.

Ameer: You know, I think another huge area, particularly in emergency medicine, of both patient education or after care and one that, again, I think meets patients where they are. Exactly. You know, when someone is discharged right now from the hospital, they get a huge stack of stuff. You know, anywhere between 5 and 15 or 20 sheets of paper.

Stephanie: It might be called a discharge summary? It’s a “discharge novel.”

Ameer: Yeah. And it's full of a lot of noise — something that’s not important to families. And so, if someone comes in with their child with a broken arm. Obviously a lot of worry, a lot of stress. And then, you know, then things get better. But, you know, there is pain control afterwards, what to look out for, cast care, how to take a shower, when to see ortho, and all those pieces that we hand to them in a book. If we're able to create, either through their portal or through a chat bot, something that allows them when they get home, when they're in a more receptive place to receive some information or when it becomes important to them.

So, you don't think about any of that stuff and then you get home and you're like, “Well, how am I going to get this kid into a shower?” And then I guess I can look through this novel that they sent home with me. Yeah, if you can find it. And so I think it’s such fertile ground for improved care. 

Stephanie: Yes, it's, “What do I need to do when I get home? Who do I need to follow up with?” Like you said, pain control specifically, “When do I need a follow up or orthopedics specifically for this case? When do I need to come back to the emergency department? What do I need to do? What do I not need to do?” And that's a lot for someone who just had a traumatic event, knowing their kiddo just broke their arm.

Ameer: Correct. And if it's done in a patient-specific way, utilizing all the pieces of information that are there. So I get home and my kid is having pain after their fracture reduction, a generative AI app or bot that is able to communicate with the family can actually maybe even pull the last time that they received the pain medicine so that their care is informed. So, “Your son or your daughter received ibuprofen 6 hours ago. It's time for more.” I mean, as opposed to just reading this paper and then not knowing when the last pain medicine was received, what the last pain medicine was, all those pieces of information are already out there. It's not like it's a huge mystery. This needs to be harnessed the right way and then repackaged so that patients get more personalized care and ultimately better care.

Stephanie: Speaking of LLMs and generative AI and patients really trying to understand things, do you think that that potentially could help with the 21st Century Cures Act in patients understanding and things being released to them in real time, like their imaging reports and potentially their physician notes?

Ameer: The answer is yes. I think that translating the amount of words and the complex jargon I think can be daunting to families. We have to understand that we do a lot to meet patients where they are. There are language barriers and maybe some education. There are definitely educational differences. And without addressing them specifically — by treating all patients the same — you actually can end up exacerbating disparities in care. And so I think that fertile ground for improvement is using a large language model translator. Something that takes into account the family’s reading level or language and things like that, and is able to translate what's going on in their medical record to meet them where they are. I think it’s just a fascinating area where it empowers families and lets them form — I keep on using the word therapeutic alliance — but form that therapeutic alliance with their health care team.

Stephanie: Well, thank you, Dr. Mody. I really appreciate it. It was great speaking with you today. Thank you for sharing all your wisdom and knowledge with us. We really appreciate it.