[00:00:00] Dr. O’Connor: With us today on the show, we have Dr. Michael Davis. He is the director of inpatient systems for the department of medicine at Tufts Medical Center. Dr. Davis was a chief resident of a 76-resident program for internal medicine at Tufts from 2019 to 2020. So he has a lot of experience and passion around improving the creation process for physician and resident schedules. And we are really happy to have him on the show today. Welcome, Dr. Davis.
[00:00:31] Dr. Davis: Thank you. Thanks for having me, Will.
[00:00:33] Dr. O’Connor: Really glad to have you here. Tell me a little bit about your background as a chief resident at Tufts.
[00:00:38] Dr. Davis: I guess to, uh, start at the beginning. So I don’t consider myself too much of a tech person. I tend to break things when I pick them up. And, uh, I’m always relying on my brother to fix the things that I break. But in between undergraduate school and medical school, I did a gap year down at UT Southwestern in Dallas, Texas, part of their information systems department.
[00:01:00] And I essentially became an Epic analyst. The Epic EMR down there that they had already been using. So I went out and got trained at Epic and, you know, still wasn’t great with technology, but I really fell in love with the intersection of information technology and the healthcare system and the way that we deliver healthcare to patients. And sort of fast forward, I went to medical school and residency ended up in Boston.
[00:01:22] And so I sort of became the defacto information system, chief resident. So you had mentioned that we had 76 residents in the internal medicine program. And we had three chief residents. So each of us sort of took on a class of about 24, 25 residents. And before the chief year even begins – so sort of at, at the, you know, in the early spring, is when the rising chief residents are responsible with creating schedules for every single one of the 76 residents.
[00:01:50] And that process was terrible. And it was really like a process that prevented really good chief candidates from taking the job just because of the horror stories that they had heard before about that. And so we literally spent like hundreds of hours working through and building a smart wheel essentially in Excel for all of the residents in coming up with, you know, all of the different combinations of schedules that we needed for the residents, to sort of staff them in all of the rotations that we have them doing. But then also taking account their preferences and their vacation requests and and the different rotations that they wanted to do to further their own personal careers.
[00:02:30] So all of that put together, you know, like I said, it ended up being over a hundred hours of work, even before you started your chief year. And then once you got into the chief year, uh, you were constantly taking new schedule requests and accommodating those requests and, and uploading and updating the system.
[00:02:44] Dr. O’Connor: Yeah. I remember some schedule creation. We had a much smaller program and it still was, uh, a nightmare. I still remember trying to get it right. You know, and then, you know, when you have changes to it, then it can become, very, very complicated. That’s interesting, it actually kept people from becoming chief residents. I’ve never, I’ve never heard that before. It was that big of a nightmare of a process.
[00:03:09] Dr. Davis: Yeah, I think that, and that’s, that holds true across different programs that I’ve, you know, talked to that, that the beast of creating schedules for the residents is really a big downside to the job because a lot of it is administrative. And I think most chief residents want to take the job to focus on, you know, their clinical acumen and, and building that in education and getting involved in like the business of medicine and administrative stuff. You know, we don’t want to be typing away in spreadsheets.
[00:03:37] Dr. O’Connor: Yeah. Well, tell me about how your experiences has changed. You know, now you’re using, you know, automated and, and online scheduling. I know you’re using TigerConnect. Just tell me a little about what that experience has been like.
[00:03:49] Dr. Davis: Yeah. So thankfully, ever since chief year, I’ve been removed from really the nitty gritty of scheduling. So, I’ve become more of like an overseer of that process for all the different programs across Tufts Medical Center. Our relationship with TigerConnect began, you know, maybe a year and a half, two years ago, first with the implementation of the TigerConnect messenger app.
[00:04:09] And initially we rolled that out to primarily physicians. But ever since we went live with our new EMR this past April, pretty much everybody across the institution came onto the TigerConnect platform. You know, including messaging, but also we’re, we’re really picking up with TigerSchedule and getting people onto that platform.
[00:04:31] So the ideal state is having everybody putting their call schedules into TigerSchedule and then having those call schedules automatically feed the roles that we’re building in TigerConnect. So you can imagine having a single directory across the institution that somebody can access directly from the app on their phone.
[00:04:52] And so, you don’t need to know who the cardiology consultant is at any given time. All you need to do is pick your phone up and search for cardiology consultant, and then you can message them directly. And the person is fed into that role from the assignments we have in TigerSchedule. So that’s the ideal state and we’re really getting closer to that.
[00:05:10] Right now, we are only using the call scheduler, so we’re still anxiously awaiting the block scheduler. And I think that the block scheduler, in talking with the folks at TigerConnect, will more similarly, replicate what we were doing, you know, as a chief resident in creating these sort of blocks of rotations throughout the year for the residents.
[00:05:27] So it would be particularly helpful for trainees, whereas attendings and other faculty, it’s more important that we know their sort of week-to-week call schedule. So being able to use a software that, you know, keeps track for us, all of the different requirements that each program has. So, you know, at any given time, you need a resident on cardiology, on pulmonology, on GI – tracking that in real-time and making sure that we’re correct in our work will be extremely important. And so a software like TigerConnect schedule hopefully will make that happen.
[00:05:57] Dr. O’Connor: Yeah. You mentioned a few interesting things there. What are – do you get a sense of, just from a scheduled creation perspective, the magnitude of the time savings?
[00:06:09] Dr. Davis: I don’t think that I, I don’t think we have a great understanding of that until we get the block scheduler. I think that you know, just using the call scheduler where we’re, creating that on-call directory and automatically feeding those tiger roles. That can really dramatically reduce the amount of time that our program coordinators and our executive administrators have because they only need to put that information in once.
[00:06:34] And then it kind of becomes a decentralized process where you can arrange these swaps from provider to provider with sort of a final administrator being the signup person saying the swap is okay. And what we’ve found has been very nice is the fact that when somebody takes over a role in TigerConnect, that automatically then gets fed back into the TigerSchedule directory that the rest of the hospital sees to see who’s on call. So that bidirectional communication between the messenger app and the call scheduler has been very helpful.
[00:06:59] Dr. O’Connor: Yeah, I think you’re absolutely right. There’s, we’ve seen a lot of benefit of having messaging and scheduling on the same platform so that you can do that because, in a big institution, the schedules change so much. You have to be able to take over for someone, you know, at a, at a moment to notice. So tell me about the downline benefits. So, what is it like now for other physicians and, in particular, nurses, now that the schedules are online, what have the benefits been like for them?
[00:07:30] Dr. Davis: Yeah. So I think the number one thing is that everybody is gonna be using their phone at work no matter what, and whether that’s a work-provided phone or a personal phone, you’re on your phone regardless. And so we all in this new technology age are very familiar and comfortable with using your phone on the fly.
[00:07:46] Like probably too comfortable with it because you pass people in the hallway and they just have their head buried in their phone. But for, you know, high acuity clinical situations where you don’t have time to leave the patient’s bedside, especially if you’re a nurse doing a million different things at the bedside, you don’t have time to leave the room and to find a desktop, to log into the desktop, to send a unidirectional page to the on-call physician and then wait for them to call you back or hope that they just magically show up at the bedside.
[00:08:13] You can just pull up your phone, again, search for that role. So you can search for the physician on call. You don’t need to know who it is. You can message them. And then one of the greatest things I think of tiger, especially compared to pagers is the natural form of closed-loop communication. So you have those read receipts, you know exactly what state your message is in. You can see whether it was sent or not. You can see whether it was delivered. And then finally, you can see whether it’s been read, and that read receipt is, is hugely helpful in supporting this natural form of closed-loop communication.
[00:08:45] So I think that our nurses love it. The physicians love it. Uh, I think that having everybody very suddenly on the same platform, suddenly in a completely different fashion compared to paging has certainly presented some unique challenges. And so now the threshold for messaging each other about clinical communication is much lower, which is a good thing.
[00:09:04] I think a lot of the, you know, adverse events that happen in the hospital that we sort of huddle about and talk about, ultimately comes down to communication, and oftentimes there’s this too high of a threshold that the trainees especially feel to have when they need to escalate to their attending. Or when the nurses need to escalate to their supervisor or when the nurses need to go directly to the attending instead of the resident.
[00:09:29] And so tiger has really, really lowered that, that threshold for communication. So that’s great, but we, we found, you know, the challenge with that is that, you know, perhaps there’s some diluting of the clinical message and triaging the messages that come through. Because, if you’re an intern at night, you’re overseeing maybe up to 80 to 100 different patients. And so they need some form, of triage for figuring out which messages need a call back right now and which message can wait. And so we’re working through those challenges right now.
[00:09:58] Dr. O’Connor: Nice, Dr. Davis. One of the things I wanted to ask you about was how have you noticed any change in particular for the residents in their behavior and how they’re interacting with nurses and other healthcare providers on the floor and with their patients. I know Tufts has a philosophy around, especially in the residency program, you know, getting people up and getting ’em moving and getting them away from the computer and being anchored to the EMR. Have you noticed any change there?
[00:10:32] Dr. Davis: Yeah, definitely. And, and we, you know, we’re, we’re certainly passionate about that. We want our trainees, especially, to be seeing patients for as much time throughout the day as possible. And we don’t want them tethered to their desktop or to a landline. So you know,, our program director has been really, really excellent in this regard and, and taking initiatives to make sure that the residents are up and moving and seeing patients rather than just sitting at their desktop typing. So I think that having that application on your phone where you can message on the fly with really valuable in high-quality type of clinical communication, has been hugely valuable in, in accomplishing that type of initiative.
[00:11:10] But having said that, you know, there’s gonna be a certain amount of time throughout the day where residents do just need to be at their desktop, typing their notes. And what we’ve found now were the residents in their charter rooms have a, like a dual monitor setup, has been great because now they’re utilizing their TigerConnect desktop app on one screen while having the EMR on the other screen.
[00:11:31] And so, you know, as an attending who rounds with them for about an hour or two on any given day, it’s really been fascinating to watch them utilize that desktop app and message consultants sort of immediately and instantaneously in getting a message that we need to hear back before we’re able to make a decision about a patient. And so our hope is that over time we see early discharges increase, and sort of the the need to wait for an answer from a consultant before we decide about what to do with the patient, hopefully, that all becomes much more, efficient process because of a system like TigerConnect.
[00:12:06] Dr. O’Connor: Yeah. Have you, have you noticed, even anecdotally, any change yet in discharge speed around, you know, sort of the increased coordination?
[00:12:17] Dr. Davis: Yeah, I would say anecdotally, I don’t have the numbers on it, and we’re definitely gonna be tracking that, especially now with our new EMR and all the reporting that we can do. But certainly like I’ve seen it happen during my time in the OR recently where, you know, an intern will sort of break off from the conversation so that they can turn around and message somebody on TigerConnect. And we instantaneously get the message back. And so that’s been, that’s been very helpful.
[00:12:38] Dr. O’Connor: Yeah. The other thing you mentioned that was interesting is that dual monitor setup. That’s the third time I’ve heard that now where it ends up being a very good reason, not to bury messaging in your EMR and use, you know, secure chat or something else like that because there’s a lot of benefit in being able to communicate and use the health record at the same time.
[00:12:57] Dr. Davis: Right. Right, exactly. And again, it’s a balancing act. Like we want the consultants to really be leaving their formal recommendations in the EMR. So that other parts of, or members of the care team can reference that. And so we don’t want too, too much information being only put into TigerConnect. So it’s finding that good balance.
[00:13:14] Dr. O’Connor: Dr. Davis, talk to me a little bit about, have you, have you noticed any impact on minimizing the noise for nurses or, or nurse fatigue. It’s been such a big issue lately with the cost of labor rising and burnout going up. Have you noticed any impact there?
[00:13:33] Dr. Davis: Yeah, I think we’re dealing with that right now on both sides. So I think that both the nurses, you know, could become frustrated with not hearing back from the trainees or the residents quickly enough. And I think that the residents can become frustrated when they feel like there’s just too much volume of messages coming through their TigerConnect. And so a lot of that, in my opinion, is just human education. I think that the system is behaving as it should be, or the software is behaving as it should be, but we need to sort of reassess the standards for communication and how to, as I mentioned earlier, really triage those messages both as a sender and the recipient.
[00:14:10] And so what we’re actually doing, and, and I’m in the process of planning right now, is putting together a work group with a few representatives from nursing and a few residents, and then a chief resident to kind of moderate it. And actually somebody from quality improvement to come up with these sort of standardized type of templates that we’re gonna be using for, for the clinical messages that come through TigerConnect.
[00:14:31] One really nice thing that we had in our old EMR that was directly tied in with the paging system was these templates that we had built. And you would just click on a button if you wanted to send off an FYI page, you know, from nurse to resident. And then that would pull in information about the patient and it would alert the recipient of the message that this is just an FYI page. You had the same button for an urgent page. You had the same button for a callback page. And so we’re hoping to leverage the quick replies that TigerConnect messenger has to create some form of that standardized messaging.
[00:15:05] Dr. O’Connor: Excellent. Well, Dr. Davis, it has been a pleasure having you on the show today. You all are doing an amazing job, you know, with your healthcare information technology platform overall, but you know, really, the work you’ve been doing with TigerConnect, in particular on the physician scheduling, has been excellent. You’ve been great to partner with, so it’s, it’s been a pleasure having you on the show today and thanks so much for joining us.
[00:15:30] Dr. Davis: Yeah, I appreciate it. It’s been a very exciting partnership and I look forward to what’s to come in the future. Thanks, Will.