How Clinician-Led Informatics Improves Patient Outcomes with Danny E. Lee, MD

You're listening to There's a Better Way, smart talk on healthcare and technology. If you're up for energizing and story-driven conversations with national healthcare leaders driving industry innovation across the country, then you are in the right place. What does it mean for technology to, quote, work in healthcare? And what does it mean in the exam room with a real patient in real time?

Today on There's a Better Way, we're kicking off our first episode of Season 5 with a guest who lives each day where healthcare and technology meet. Dr. Danny Lee is a practicing internal medicine physician and chief medical information officer at Johns Hopkins Community Physicians. He sees patients and he builds the systems these patients depend on.

So today we'll talk about friction, the delays, the gaps, the invisible processes that sometimes come between the doctor and the patient. We'll dig into prior authorizations, the inbox problem no one talks about at the executive level, ambient AI, and what it looks like when technology gets out of the way and lets people do what people do best? And we'll close with a question that I think sits at the heart of everything we'll be exploring this season. What should patients never have to think about again when it comes to their care?

This is a conversation about what's broken, what's working, and what comes next. I'm Melanie Marcus, and this is There's a Better Way, smart talk on healthcare and technology. So, all that said, a warm welcome to the show, Dr. Lee.

Thanks for joining us on our first episode. Well, thank you, Melody. It's great to be here. Well, let's start with our signature question, one that really draws directly from what you experience as a physician.

What's your better way in healthcare, and how does it show up for your patients when you walk into the exam room? Well, for me, the better way is reducing any friction in the care of our patients so that we can act on the care plane that we agree upon together while we're in the room. I feel like technology should be felt as something that provides better access to gear and not a barrier that you have to navigate around. Now, you still see patients regularly, right, while you're serving as the CMIO at Johns Hopkins Community Physicians?

That is correct. It's the only way for me to really understand the technology that we're implementing and how it impacts the care of our patients. It also gives me some gravitas with our other providers so that I'm in the trenches with them seeing patients and I understand the frustrations that they feel. And when things are working well, I can see that in action.

And when things are not working well, I can also witness that and bring that to our IT leadership and figure out solutions that make that better. For sure. Well, can you walk us through a little bit about how you got started and what brought you to combine medical practice and technology? Sure.

I mean, probably it started with frustration. We were slowed down by the tools that weren't really designed for us in mind. And then I became a certified physician builder and realized that I could address some of the hangups and the issues that clinicians were facing by working within the EMR and building tools to help take better care of our patients. Well, so then that leads straight to another question, like how does being accountable for patients face to face in the exam room shape how you think about technology?

Well, it keeps you honest, for sure. I mean, if things don't work the way they're supposed to and you're feeling that frustration, the patients can also express their frustration when things aren't working well. We want to make sure that we're building decision support and systems that help us take better care of our patients and not get in the way of that. In contrast to that question, how does your role as CMIO inform your approach to patient care?

Well, actually, I think it helps me be a better CMI by being involved in patient care as well, so I can understand what are the problems at the ground level that we're all facing, and then also understand where our systems are failing, if there are system-wide patterns that are something that are creating obstacles for our providers, as well as being able to then collect feedback from many of our providers and then raise those issues, elevate those issues to make the rest of the teams aware of the fixes that we need to implement.

Sure. Are you a super user? I am. Yeah, I would imagine.

I would imagine you are. Yeah. Yeah. I do a lot of listening.

So my inbasket's always filled with messages from providers who are frustrated by various things. And I try to read through the lines, right? Because some people read through my inbasket and Like, how do you do that? How do you take all this, what appears to be negative energy coming at you?

And I look at it as not negative energy. I look at it as they're telling me something and I need to understand what they're telling me. And do patients give you feedback on technology? Oh, absolutely.

I mean, we have patient committees that we try to include patients in many of our committees as possible. We have a patient representative. We also have a patient facing committee for each of our sites. so patients can give direct feedback of how things are working, whether it's the phone room or the MyChart messages or their visits with their providers or all of it.

We collect all of it and we listen to our patients to help us evolve our practices to make it more patient-friendly. What reminds you that healthcare is still deeply human, even with the promise of technology all around us. I go into an exam room with a patient. It is not about the technology.

It's about the patient and what problem are they coming to me with and how do we solve that problem? It's all about human to human interaction. The technology has to be in service of that, not the other way around. I love that.

That makes so much sense. So you talked about friction in healthcare. And one thing that seems clear to me is that technology can either nurture trust and protect the doctor patient relationship or sometimes quietly erode it Let explore a little bit more deeply by looking at the current friction points in healthcare and the impact it has on patients Friction is anything that inserts delay or uncertainty between the decision and the action plan that you have with the patient. For patients, that friction often means silence.

In other words, they don't know what's going on behind the processes after you've created a bunch of orders. And that silence really can erode trust, both from the clinician and the patient standpoint. Are there examples of where you see the friction being addressed that are going well? One area that we've had a lot of success has been in our ambient AI documentation.

That really reduces friction in the exam room. It makes the provider much more present during the visit with the patient. You're no longer focused on the computer. Instead, you're focused on the patient.

And that, instead of looking at the screen, what are you looking at, allows me not to look at the screen anymore. I can look at the patient, and then when I do look at something in the screen, if we're looking up something together, I will do it with the patient. So the patient is always involved in their care and what we're doing, and everything is transparent to them. Well, given that example, what lessons does it hold for us as an industry regarding how we solve the other points of friction in the service of patient care?

I think it's going to require all of us to work together to have these discussions, these conversations together to understand each other's point of view and then work collectively to solve these issues. One point I always bring up, and I do enjoy the opportunity to talk to SureScripts as well as talk at your conferences as well, because it gives me an opportunity to just not only talk to healthcare providers, which I do regularly, but also to gain the perspective of the pharmacy benefit plans and the pharmacies themselves.

And so having that collective conversation about understanding each other's point of view and what we're trying to achieve, and we're all trying to achieve the same thing. It's just that it's fascinating that we're all getting there by different means. And I think having that collective conversation will allow us to then figure out a path forward and offer strategies that I think will help all of us. Yes.

One of the themes that we always end up on in these conversations around technology and how to help healthcare heal itself is the way we talk about it at SureScripts is collaboration. Oh, absolutely. Right? We can't get this done any one segment of the industry alone.

So as we talk about this, is there a friction point that you bump into as a clinician that never quite shows up at the executive strategy meeting? Oh, absolutely. We're all dealing with the patient portals and messages that come at the clinicians. And the number of things that are coming into the in-basket aren't really something that is measured by RVUs or encounter visits and patient flow and all of that.

But we all understand that can be 50% or more of your job is just managing your in-basket and that will never show up on a balance sheet on any executive summary. We have triage nurses that will help triage the patient. And then that layer helps us then decipher, okay, when they're pulling me out of a room, when the nurse is pulling me out of a room, it's because they've reached the top of what they can do. And they're asking me to take over at that point.

But those are very few. So a lot of this stuff requires teamwork and collaboration in order for us to kind of get through our days. Oh, for sure. And I definitely am in my prolific use experience at being triaged, which I think is completely appropriate.

I actually feel bad sometimes thinking the doctor might see this. I'm like, I don't know where else to send it. And that's the other side. We want patients to engage in the portal.

We don't want them to be held back or to be quiet or silent. We want them to engage in the portal. And we try to actually do things to empower patients to do more for themselves through the portal. Let's take the friction a little deeper into the medication area, right?

We've talked about that friction is really when a patient is delayed in some way, shape, or form from getting their care. What do you see as the most common reasons medication doesn't move forward after a visit? Oh, there's so many, but probably the most common one are incomplete documentation, incorrect diagnoses, missed clinical content. Prioritization is so extraordinarily complex because the rules center around them are very complex too.

And that whole process of what it takes to get these medications approved for our patients is completely invisible to them. And yet there's so much work that happens behind the scenes every time that we sign off on one of these orders. And that when there's missing clinical documentation, then it triggers a whole manual review of filling in the gaps that were missed. So this happens, I'm sure, a lot.

The patient calls to say, I can't get my medication. What's happening behind the scene when you get that call? We begin a manual process review to understand, did we miss a fax? Did we miss a notification?

Did we miss something? And to understand why they didn't get it. And if they were denied, then to start, again, the manual process of appealing that decision after we learn that knowledge from our patients. I will say, in my experience, the majority of patients won't call us and tell them they never got the medication.

They'll just not take it. Oh, yes. Right? Oh.

They'll suffer in silence and not say anything. And which also leads me to my next point, which is when I know I am facing a prior authorization, for example, like a GLP-1, I will look the patient in the face and say, if you do not get this medicine in 48 or 72 hours, you need to let us know. I don't know if you were turned down or if you were approved unless you tell us, right? When you have medicine in hand, then I know you have it.

Closing that loop is sometimes often missing. And I don't find out until the next time I see the patient. And I'm like, wait a minute, you never got your Munjaro or you never got your Ozempic. What happened?

They say, I don't know. And you didn't call us or tell us or complain to us and say you never got it. And they don't. Most people will just live with it.

So let's dig a little deeper into the data, okay? It's got to be correct for one thing. It's got to be timely, right? And it's delivery.

So it strikes me that trust is incredibly important around the accuracy and timeliness of data. Does that resonate with you? Oh, absolutely. We all been on electronic health records now for decades Let face it this is not new stuff And we capture all of these things like diagnoses lab values prior medication histories as discrete values These are not like natural language processing things.

We know in the patient's chart what they've done, what they have, what their current problem list is, what their current therapies are, and what they've tried in the past. And that doesn't require reading a note. We just have this discrete data, but we don't send that anywhere, right? At the time of prescribing, what you want is to package all of this stuff that we have.

And we've been capturing for years in an EMR. And why does it have to be a person? Just package it together and send it out. And then from the pharmacy benefit side of things, they too have a process where they have to have a person who has to review it, et cetera.

And so what if we could just check all the boxes and then from the pharmacy benefit side, yes, they've checked all the boxes and just approve the medication. Because eventually what ends up happening is if we do a human-to-human review, they will approve it because we've already filled in the boxes and something was missed in the prioritization process. So let's talk about AI. We trust the data.

We can't have a conversation about technology and healthcare. data, anything without talking about AI, right? So from your perspective, where is AI genuinely helping healthcare right now? Right now in the ambient notes, it's been a huge burden reduction for our providers.

Hear from them regularly about how much this technology has impacted their day, impacted their lives, allowed them to go home on time, not log in on the weekends to complete notes. just the reduction in burden that they feel, that mental fatigue of carrying that in your head until you finally write the note has been alleviated. So that part has been good. The next part of it is with our implementation of AI is also AI-driven clinical decision support at the time that you're seeing patients as well that's offering you real-time clinical decision-making tools that are from a trusted source.

So for us right now, we have a partnership with our vendor as well as UpToDate, and we're getting that source of truth made present to the providers. So again, it's all of these little things that happen that really impact the care of our patients, but also deliver the information that is actually relevant to the visit because it's using the ambient conversation to drive the clinical decision that's being put in front of the provider. So it's not some arbitrary best practice alert that fires when you don't want it.

You don't even understand why it's firing for you. Instead, it's tailored and it's curated to the conversation you're having with the patient. And that has been a huge boon for our providers. What the Ambient AI allows you to do is have a more human contact with your patient so you're not typing away and not looking at the patient, right?

So when we're having this conversation, you want to maintain eye contact, You want to make sure the person's listening and you want to give feedback as they're talking, right? The patients feel heard. They feel like their discussions are taking place in the way they want to. And the other thing that's happening is because providers are no longer worried about writing the note.

You never feel time constrained, right? So when the patient says, I have, oh, one more thing. And as a clinician, you often sigh and say, okay, I have to one more thing and get back on the computer, start typing again, et cetera. Instead, you can just listen to what they have to say and then keep going with the conversation that you have.

I want to like put a pin in it because, I mean, I've done a lot of reading and work and as we all are in AI. And one author, I wish I could tell you the name right now, but talks about technology overall has evolved to a place before AI where it has taken the human out. It's just like we're all working on technology and AI actually used right can put the human back in. That's right.

And allow it. And you just gave the best use case for bringing the human back using AI. So that was great. Absolutely.

Absolutely. And then maybe this comes with age. But when I was younger, I used to felt like I had to know everything before I went in the patient room. And the last thing you ever wanted to say was, I don't know.

but I frequently now say I don't know in front of my patients. If they're asking a question about an area that I don't know very well, I don't have a problem saying, hey, let's look that up together and find out what that answer is. With the introduction of Ambient and then the clinical physician support, if I'm asking that question out loud, it starts pulling up that reference for me. And then I can show the patient about what we talked about and the clinical references and show it to the patient.

And it gives the patient further feeling of trust that we're talking about what they want to talk about and we're addressing their concerns. And that we're not just pulling up something from Google, right? We're not pulling some arbitrary social media site where this thing is coming. We're doing cited information that have footnotes to journal articles and that they can understand that we're giving them really good, grounded, evidence-based answers.

Well, we've talked a lot about the potential impact of technology on patients and those who care for them. We've brought the patient straight into the discussion, but let's even bring the patient back in more closely. When technology's working as intended, it helps keep patients' care on track. But when care doesn't stay on track, patients feel it right away.

So after a visit ends, where do you see patients struggling right now to follow through on their care plan most? Oh, that's a variety of things. I mean, I can start with access to specialists, right? That's often a delay in care.

We all work as hard as we can, and I'm not pointing fingers or blaming, but there aren't enough specialists for some areas of the country, and it could be long waits to see somebody. And that could be a struggle. And then finding alternatives for that person while they're waiting is, it can often be very frustrating. We talked earlier about prior authorizations.

Sometimes the things that are visible to patients is what we call step therapy, the thing you have to fail before you get to that thing you want to do, and making that transparent to patient can be tough for patients. And not understanding where they are in the prior authorization process can be really frustrating for patients. I've often wanted to, and I've said this in a number of venues, both in Epic and with SureScripts and with anyone else who listened to me blather on I often use the interface of DoorDash right Or an order You place an online order It tells you where you like a Starbucks order You put an order in Starbucks.

It tells you somebody's working on your drink and now your drink is ready for pickup, right? Like you're never in the dark about where your order is for your latte. And we need to do something like that with the prior authorization process. We need to say, okay, your medication was filled.

The PBMs have it. Here's the decision that they made. The pharmacy now has it, and now it's being dispensed, right? Like everybody wants to be, like there's all these stages and none of us know what the other one is doing.

It's completely opaque to the patient as well as the provider. I completely agree. We call that, I don't know why we call it the pizza tracker. I think the latte tracker is much better, but we call it a pizza tracker.

Pizza tracker, exactly. But we have this interface right now in a variety of things that we do. We online order things. We order an Uber ride.

It tells you when the driver's coming. You know the status of all this stuff that you do. From watch them row. Exactly.

And so we need more transparency on that. Right, right. So where do the handoffs, because we talked about collaboration, about different is really key to being able to solve some of the issues in healthcare. And collaboration comes in the handoffs too, right?

So where do the handoffs between clinicians, pharmacies, payers create the most friction for patients trying to move forward? Oh, there's a variety of places on that. I think we can all share a level of blame on that part of it. And I think to what I said earlier, the ongoing dialogue between all parties involved is an important process to help knock those down as much as possible.

But I don't have a simple answer for that because it's complicated. If you did, we would have fixed it by now, right? Exactly. If it was easy, it would have been fixed.

Yeah, if we could Just pinpoint one thing. Yeah, I hear you on that. Well, looking back, what's one thing the system could do better to help patients actually complete the care plan you agree on together? Again, what I said earlier, just being more transparent in the process with our patients, having patients get a better idea of whatever order or medication or referral that we've placed is where it is in the process.

Also, getting back to medications on appeals, too. After the appeal process going on, let patients know that, hey, we hear you, we're appealing, you know, and this is where we are. Right, right. Well, I love how you've de-centered technology.

We've put technology in the center, but we've also de-centered it because it's always, that's the magic of the role that you have and the work that you do is you put the patient in front. And we did that from the very beginning of the conversation. So usually in these kinds of conversations, technology takes the front stage because we're talking about technology, but really it's about the patient. It's all in service of the patient.

So let's end our conversation today with a little more of that. When you imagine the patient experience in the years to come, what's the one thing you hope patients never have to think about again because technology got it right? Oh, it'd be great if we could get rid of prior authorizations. and just know instantly and being able to, honestly, I mean.

Absolutely. I would love to be able to look a patient in the face. And when it works, I will say this, when it works and you go through the e-priorization process and you get an answer back before the patient leaves, it is the best feeling to let them know it was approved, the pharmacy has it, please talk to your pharmacist about when you can pick it up. That's great.

Awesome. Well, thank you, Dr. Lee, for grounding us in what really matters, the patient and the clinicians who care for them, and building what comes next so that we can keep patient care on track. It was really a pleasure to have you on the show.

Well, thank you. that was dr danny lee a physician and chief medical information officer and one of the most grounded voices i've heard who lives and works at the intersection of health care and technology what struck me most is how consistently dr lee came back to the exam room for dr lee's smart talk about healthcare and technology doesn't focus on the strategy meeting or the conference keynote or the slick sales pitch. It's focused on the actual exam room with the actual patient, and he called this his truth.

And in this time of great enthusiasm around the potential of AI, it's good to hear a voice remind us that technology is only as good as what happens in the exam room. A few things really landed for me in this episode. First, his idea of friction not as a technical glitch, but as silence. When a patient doesn't know what's happening with their prior authorization, their medication, their referral, the silence that results is a sign of system failure.

And it's invisible to everyone except the patient. Often, as Dr. Lee told us, what ends up happening is the patients just don't take their medication. They suffer in silence.

That's the human cost of friction. Second, we talked about AI. There's a notion that Ambia AI is just another productivity tool. But it's more than that.

When the doctor doesn't have to type, when they can look the patient in the eye, when they can listen to understand without worrying about charting later, that's putting the human back in healthcare, as Dr. Lee put it so well. So I'll leave our listeners with this. The best technology is the technology patients never have to think about.

That's the better way. Thank you for listening in today. If you've enjoyed this podcast, please rate, subscribe and review. There's a better way.

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