December 2025 Dallas Medical Journal

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December 2025

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08 HOUSE CALL

When the Chart Becomes the Challenge

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Riva Rahl, MD Anil Tibrewal, MD Articles represent the opinions of the authors and do not necessarily reflect official policy of the Dallas County Medical Society (DCMS) or the institution with which the author is affiliated. Dallas County Medical Society does not endorse or evaluate advertised products, services, or companies nor any of the claims made by advertisers. Claims made by any advertiser or by any

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PRESIDENT’S PAGE

A Legacy of Unity and Advocacy: Reflections on a Year of Leadership and Service Shaina Drummond, MD, FASA 2025 President, Dallas County Medical Society

AS MY YEAR AS PRESIDENT OF THE DALLAS COUNTY MEDICAL SOCIETY comes to an end, I am filled with gratitude for what we have achieved together. This year has reminded me of the strength, compassion, and leadership that define our community of physicians. It has truly been one of the greatest honors of my career to represent nearly 9,400 members who dedicate their lives to healing, advocacy, and service.

When I first joined DCMS, I could not have imagined how deeply it would shape my journey as a physician. Through advocacy, mentorship, and community, I came to understand that organized medicine is not simply an institution. It is a living network that connects us beyond our hospitals and clinics. Each of us cares for individual patients, but together we care for the health of our community and the system that allows our work to thrive.

Over the past year, I have seen the strength that comes when physicians unite across specialties and practice types. Together, we supported one another, advanced the needs of our patients, and stood firm in defense of our profession. We advocated for responsible use of artificial intelligence, protected the patient-physician relationship, supported physician wellness and mental health, and worked to ensure that public policy reflects the real-world challenges of medical practice. Our efforts also focused on improving women’s medical care, advancing prior authorization reforms, addressing the corporate practice of medicine, expanding access to telemedicine, and strengthening the physician workforce.

Several of our members went even further by submitting formal resolutions to the Texas Medical Association House of Delegates, demonstrating how local leadership can spark meaningful statewide change.

Dr. Lauren Fine authored Resolution 104, Providing Actionable Clarity for Physicians and Hospitals Caring for Complicated Obstetric Cases in the State of Texas, addressing the uncertainty surrounding complex maternal care.

Dr. Shawnta Pittman Hobbs introduced Resolution 402, Hospice Benefit Coverage and Network Adequacy for Private Insurance, which highlighted the barriers many patients face in accessing quality end-of-life care. Their dedication reflects how advocacy rooted in daily practice can lead to tangible improvements for our patients.

December 2025

DCMS continues to serve as a trusted and balanced source of information, collaboration, and connection. In an age when misinformation spreads quickly, our society remains a steady voice of unity. We value every member’s perspective, regardless of specialty, practice model, or political affiliation.

My goal this year was to focus on physician unity and to remind us that while our opinions may differ, our shared mission to care for patients and to protect the integrity of medicine binds us together. That shared purpose is what gives organized medicine its strength.

This year reinforced an important truth: if physicians are not part of the conversation, decisions about our profession and our patients will be made without us. That is why staying involved matters so much, even in small ways. Joining a committee, attending a book club, going to a social mixer, participating in an advocacy day, or simply connecting with a colleague through DCMS can make a difference. Every voice matters, and every act of engagement strengthens our ability to care for patients and to preserve the profession we love.

It was also a year of looking toward the future. Through the DCMS Foundation’s Campaign for the Future, we are building not only a new headquarters in Uptown Dallas but a lasting home for the next generation of physician leaders. It will be a place where our history, values, and vision come together to inspire those who follow. From our developing and future K–12 outreach initiatives to our established physician leadership programs, DCMS is investing in the pipeline of advocacy and service that will sustain organized medicine for decades to come.

To our members, board, and dedicated staff, thank you.

You have shown that leadership is not defined by titles but by showing up and making a difference. To our Past Presidents, your guidance and steady wisdom have been invaluable. I am especially grateful to our CEO, Jon Roth, and the outstanding DCMS staff. Without their tireless work and behind-theDALLAS MEDICAL JOURNAL | 3

PRESIDENT’S PAGE

scenes dedication, none of our success would be possible. Their professionalism, creativity, and unwavering commitment keep this organization running smoothly and allow our volunteer leaders to focus on advancing the mission of DCMS. I also want to acknowledge the medical students, residents, and fellows who participated in DCMS activities throughout the year. You are the future of medicine, and your enthusiasm and curiosity inspire us all. Stay involved, ask the hard questions, and never stop learning. Even attending one meeting or one event connects you to mentors, advocates, and colleagues who will shape your path in ways you cannot yet imagine. The future of our profession depends on your curiosity, courage, and integrity.

As a first-generation college graduate and physician raised by my grandparents, I understand the profound importance of mentorship and support. Having advisors, mentors, and sponsors has shaped my journey more than I could ever express. I am deeply grateful to those who made space for my voice and encouraged my growth as a leader. My hope is that each of you finds purpose and connection through DCMS. Whether you testify in Austin, mentor a student, or attend a local event, your participation matters. When physicians stand together, we strengthen not only our profession but also the communities we serve.

The challenges ahead are significant and complex. They include workforce shortages, scope of practice expansion, the growing influence of private equity, an increasing number of physicians entering employed practice models, persistent issues with network adequacy, declining reimbursements, and expanding administrative burdens. Yet I remain confident that together we have the strength, wisdom, and unity to overcome them. Organized medicine is not an optional part of what we do. It is the foundation that protects our ability to provide patient-centered care and to advocate for our profession. Staying engaged, even in small ways, keeps that foundation strong. The future of medicine depends on all of us lending our voices and our time to this shared mission.

Thank you for allowing me to serve as your President, and for your trust, partnership, and unwavering commitment to your patients and to one another. This year has reminded me that leadership is never the work of one person but the result of a community of physicians united by a shared purpose. The success of DCMS belongs to every member who chooses to show up, speak up, and contribute to something greater than themselves. Even in challenging times, our collective voice continues to shape the future of medicine and strengthen our profession. Thank you for your ongoing commitment to organized medicine, for the many ways you serve, and for being part of the story that makes Dallas County physicians stronger together.

As my term comes to a close, I hope you will join me in supporting our 2026 President, Dr. Gates Colbert. I am confident that under his thoughtful leadership, DCMS will continue to grow, innovate, and build upon the strong foundation we have established together. DMJ 4 | DALLAS MEDICAL JOURNAL

December 2025

EVP / CEO LETTER

Holding the Line: A Year of Progress and a Call to Vigilance Jon R. Roth, MS, CAE

AS I CLOSE OUT MY FINAL EDITORIAL OF 2025, I find myself reflecting on a year that has tested our profession in ways both familiar and unprecedented.

The pages of this journal throughout the year have chronicled not just medical advances but the evolving challenges we face as physicians committed to science, evidence, and the well-being of our patients. As we look toward 2026, I write with both pride in what we have accomplished and deep concern about the threats to evidence-based medicine.

This year began with our January focus on physician wellness and burnout, a topic that remains as urgent today as it was twelve months ago. We highlighted the groundbreaking work of physicians like Dr. Sarah Chen at UT Southwestern, whose peer support program has become a national model for addressing the mental health crisis within our profession. The Dallas County Medical Society has continued to provide re6 | DALLAS MEDICAL JOURNAL

sources for our members, recognizing that you cannot care for others if you do not first care for yourselves.

In the spring, we turned our attention to healthcare access and the persistent inequities that plague our communities. Our April issue featured Dr. Marcus Williams and his team at Parkland Health, who have pioneered innovative approaches to reaching underserved populations through mobile health units and community partnerships. Their work demonstrates what is possible when physicians refuse to accept that zip code should determine health outcomes.

DCMS members have rallied around these initiatives, understanding that our professional obligation extends beyond the walls of our own practices.

Summer brought our focus to technological innovation, with August's exploration of artificial intelligence in medical practice. Dr. Priya Patel at Baylor Scott & White shared her experiences integrating AI-assisted diagnostics while maintaining the irreplaceable human element of clinical December 2025

EVP / CEO LETTER

judgment. Her insights reminded us that technology should enhance, never replace, the physician-patient relationship that remains central to healing.

Yet as I review these accomplishments and the dedication of our physician community here in Dallas, I cannot ignore the storm clouds gathering on the horizon. As we enter 2026, we face a crisis of confidence in the very institutions that should be the bedrock of public health guidance. The erosion of science-based policy at the federal level threatens not only public health but the trust your patients place in you as their physicians.

We are already seeing the consequences in your examination rooms.

Patients arrive armed with misinformation and recommendations that contradict decades of rigorous research, guidelines that prioritize ideology over evidence, and policies that seem designed more to sow confusion than promote health. A number of physicians have shared with me their frustration at spending increasing portions of patient visits correcting false information about vaccines that originates from sources patients have been taught to trust.

This is not a partisan issue; it is a scientific one. When federal agencies abandon evidence-based approaches in favor of political expediency or fringe theories, they undermine the foundation of modern medicine. We have spent centuries building a system of peer review, rigorous clinical trials, and evidence-based guidelines. To see this dismantled from the top down is truly disheartening.

What concerns me most is the burden this places on individual physicians and your relationship with patients. You are asked not just to be clinicians but also constant fact-checkers, correcting misinformation that should never have been legitimized in the first place. This takes time you do not have, erodes trust when patients feel caught between their physician, and contributes to the very burnout we work so hard to address.

So what is our path forward? First, we must acknowledge the reality we face without surrendering to cynicism. The Dallas County Medical Society and organizations like us have never been more important.

We must be a reliable source of evidence-based information for your patients and our communities. DCMS is already working to develop resources to help our members address common areas of federal misinformation, such as tools grounded in peer-reviewed science and presented in ways that respect patient autonomy while guiding them toward evidence-based decisions.

Second, we must advocate for the restoration of scientific integrity in federal health policy. This means engaging with our elected representatives, submitting comments on proposed guidelines, and using our collective voice to demand that public health policy be guided by science, not politics. We cannot be silent when evidence-based medicine is under attack. Our patients deserve better, and the profession should demand it.

Third, we must support one another. We should look for spaces where physicians can discuss the challenges of practicing in this environment, share strategies for navigating difficult patient conversations, and remind each other why you chose this profession. DCMS will conDecember 2025

tinue to facilitate these connections and provide the support our members need.

Finally, we must remember that our members are also educators. Every patient interaction is an opportunity to model critical thinking and evidence-based decision-making. When we take the time to explain not just what the evidence shows but how we evaluate evidence, we equip our patients to navigate an information landscape.

I remain optimistic about the profession and our purpose. The physicians I have the privilege of working alongside in Dallas continue to demonstrate extraordinary dedication to their patients. From the emergency rooms to the specialized clinics of our academic medical centers, our physician community shows up every day committed to the highest standards of care.

But optimism does not mean complacency. The year ahead will require vigilance, courage, and unity. We must hold the line for evidence-based medicine even as federal institutions waver.

We must be the steady voice of science in a chorus of confusion.

As I look ahead to 2026, I am reminded that medicine has weathered storms before. We have overcome pandemics, shifted paradigms, and constantly evolved while keeping patient welfare at our center. We will weather this storm too, but only if we stand together, speak clearly, and refuse to compromise the scientific principles that make our work possible.

To our physician members: thank you for your unwavering commitment this past year. The challenges ahead are real, but so is our resolve. Together, we will continue to serve our patients with integrity, defend evidence-based medicine, and work toward a healthcare system worthy of those we have pledged to serve. DMJ

Jon R. Roth, MS, CAE DCMS EVP/CEO

DALLAS MEDICAL JOURNAL | 7

HOUSE CALL

WHEN THE CHART BECOMES THE CHALLENGE

A national survey reveals how EHR usability—and the tools meant to fix it—shape physician satisfaction and burnout.

by A. Jay Holmgren, PhD, MHI1; Nathaniel Hendrix, PharmD, PhD2; Natalya Maisel, PhD1

8 | DALLAS MEDICAL JOURNAL

December 2025

HOUSE CALL

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HOUSE CALL

Article Summary IMPORTANCE Electronic health record (EHR) work has been associated with decreased physician well-being. Understanding the association between EHR usability and physician satisfaction and burnout, and whether team and technology strategies moderate this association, is critical to informing efforts to address EHR-associated physician burnout.

OBJECTIVES To measure family physician satisfaction with their EHR and EHR usability across functions and evaluate the association of EHR usability with satisfaction and burnout, as well as the moderating association of 4 team and technology EHR efficiency strategies.

DESIGN, SETTING, AND PARTICIPANTS This study uses data from a cross-sectional survey conducted from December 12, 2021, to October 17, 2022, of all family physicians seeking American Board of Family Medicine recertification in 2022.

EXPOSURE Physicians perceived EHR usability across 6 domains, as well as adoption of 4 EHR efficiency strategies: scribes, support from other staff, templated text, and voice recognition or transcription.

MAIN OUTCOMES AND MEASURES Physician EHR satisfaction and frequency of experiencing burnout measured with a single survey item (“I feel burned out from my work”), with answers ranging from “never” to “every day.”

RESULTS Of the 2067 physicians (1246 [60.3%] younger than 50 years; 1051 men [50.9%]; and 1729 [86.0%] practicing in an urban area) who responded to the survey, 562 (27.2%) were very satisfied and 775 (37.5%) were somewhat satisfied, while 346 (16.7%) were somewhat dissatisfied and 198 (9.6%) were very dissatisfied with their EHR. Readability of information had the highest usability, with 543 physicians (26.3%) rating it as excellent, while usefulness of alerts had the lowest usability, with 262 physicians (12.7%) rating it as excellent. In multivariable models, good or excellent usability for entering data (β = 0.09 [95% CI, 0.05-0.14]; P < .001), alignment with workflow processes (β = 0.11 [95% CI, 0.06-0.16]; P < .001), ease of finding information (β = 0.14 [95% CI, 0.09-0.19]; P < .001), and usefulness of alerts (β = 0.11 [95% CI, 0.06-0.16]; P < .001) were associated with physicians being very satisfied with their EHR. In addition, being very satisfied with the EHR was associated with reduced frequency of burnout (β = −0.64 [95% CI, −1.06 to −0.22]; P < .001). In moderation analysis, only physicians with highly usable EHRs saw improvements in satisfaction from adopting efficiency strategies.

CONCLUSIONS AND RELEVANCE In this survey study of physician EHR usability and satisfaction, approximately one-fourth of family physicians reported being very satisfied with their EHR, while another onefourth reported being somewhat or very dissatisfied, a concerning finding amplified by the inverse association between EHR satisfaction and burnout. Electronic health record–based alerts had the lowest reported usability, suggesting EHR vendors should focus their efforts on improving alerts. Electronic health record efficiency strategies were broadly adopted, but only physicians with highly usable EHRs realized gains in EHR satisfaction from using these strategies, suggesting that EHR burden-reduction interventions are likely to have heterogenous associations across physicians with different EHRs.

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Perhaps the most dramatic change to primary care over the past decade is the proportion of work mediated by electronic health records (EHRs).1,2 This “desktop medicine” includes patient history review, documentation, quality measure management, and responding to inbox messages—consuming nearly 50% of clinic time3 and frequently extending outside of clinic hours.4 Primary care physicians (PCPs) face the highest EHR burden, as they spend the most time using the EHR, receive the most inbox messages, and spend the most amount of after-hours time using the EHR,5,6 which contributes to burnout, turnover, and lower-quality care.7-10 Reducing EHR burden is a national policy priority as well as a key target for care delivery organizations across the country.11,12 Electronic health record system vendors, health systems, and PCPs have responded with an array of potential solutions. Vendors have focused on improving the usability of their software, including documentation, information presentation, and alerts.13-17 However, these efforts have not been guided by a robust understanding of which specific aspects of EHRs are associated with poor satisfaction for physicians. Evidence also suggests that poor usability is not the sole factor associated with EHR burden—notably, US physicians spend more time working in the EHR and write longer notes compared with their non-US peers using the same software, suggesting that sociotechnical factors, such as workflows, policy, reimbursement, and organizational support, are associated with EHR burden.18,19 To that end, care delivery organizations have deployed a number of EHR efficiency strategies, such as templated text documentation tools and team-based documentation workflows using scribes or other staff members. To date, there is limited generalizable evidence regarding the ability of these efficiency strategies to improve physician satisfaction with their EHR or overcome dissatisfaction with poor usability,20-23 making it difficult to assess what role these strategies should play in efforts to reduce EHR burden. It may December 2025

HOUSE CALL

be that physicians with significant support from teams or who are able to overcome usability challenges feel more satisfied with their EHR. If not, it suggests the need to develop new strategies to reduce EHR burden.

To inform national efforts to reduce EHR burden being pursued by multiple stakeholders, we used a national survey of US family physicians to address 3 research questions. First, to inform vendor efforts, how do PCPs rate satisfaction with their EHR and usability across different EHR functions, and what functions are rated as having the worst usability?

Second, to inform health systems and practicing physicians, what teambased or technology-based efficiency strategies do PCPs use to optimize their EHR work, and how do they rate the effectiveness of those interventions at reducing EHR time? Third, how do those team-based and technology-based efficiency strategies moderate the association between usability and physician well-being outcomes, including EHR satisfaction and burnout? Results from our study have implications for policymakers, vendors, health systems, and physicians interested in addressing EHR burden, physician well-being, and burnout.

SURVEY AND DATA We used data from the American Board of Family Medicine (ABFM) Continuous Certification Questionnaire, a mandatory part of extending certification as a family physician for those who sought recertification in 2022 and reported providing direct patient care. This ensured the survey had a 100% response rate among physicians who were continuing their certification in 2022, and questions could not be skipped. This study was approved by the institutional review board at the University of California, San Francisco with a waiver for informed consent due to the use of secondary data for research. This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline for survey-based research by reporting the sample size and population being sampled, response rate, verbatim text of survey questions, and steps taken for pretesting and validation.

For more than a decade the ABFM has assessed EHR adoption and meaningful use requirements, and in 2022, the survey added questions regarding physician experience with the EHR. These new questions were extensively pretested with family physicians for content validity, including ten 1-hour semistructured interviews with physicians to ensure that questions were relevant and clear. Each physician answers a set of mandatory questions, then is sequentially randomized into 2 sets of different modules. The section on EHR satisfaction used in this study was 1 of 2 modules in the first set and included 50% of the respondents. In the second set of modules, physicians are randomized to 1 of 5 modules with 20% probability, 1 of which included the burnout questions also included in this study. The survey became available December 12, 2021, and closed October 17, 2022.

EHR SATISFACTION We measured overall EHR satisfaction using responses to the question “Overall, how satisfied are you with your current primary, outpatient EHR system?” Responses on a 5-point Likert scale ranged from 1 (very dissatisfied) to 5 (very satisfied.)

EHR FUNCTION USABILITY We measured PCP perceptions of usability across EHR functions using responses to the question “How would you assess the following usability December 2025

dimensions of your current primary EHR system?” across the following 6 functions: entering information, readability of information, amount of information presented on each screen, alignment with the PCP’s workflow or cognitive process, ease of finding relevant information, and usefulness of alerts, all using a 4-point scale with responses options of poor (scored as 1), fair (scored as 2), good (scored as 3), and excellent (scored as 4), as well as not applicable.

We constructed dichotomous measures of usability, classifying each domain as having good usability if the respondent selected good or excellent. We then constructed a usability index for each respondent by assigning each value a score of 1 (for poor) through 4 (for excellent). We scored responses of not applicable as 0, with the logic that respondents chose not to use that function of the EHR (eg, disabling alerts completely). We then took the summation of all 6 domains of functionality to create a composite measure of overall usability, based on a Cronbach α of 0.92 indicating strong internal consistency across the scale. Finally, we created a standardized version of our usability index to a mean of 0 and an SD of 1 to facilitate interpretation in multivariable models.

EHR EFFICIENCY STRATEGIES We measured adoption and effectiveness of 4 common strategies meant to optimize EHR documentation efficiency: scribes, support from other staff (eg, medical assistants or nurses), templated text (eg, SmartPhrases or dot-phrases), and voice recognition or transcription, using responses to the question “Please indicate whether you use any of the following resources to help reduce time that you spend documenting in the EHR” with the response options including “yes, and it leads to reduced time,” “yes, but it does not reduce time,” and “no.” Because strategies may be duplicative, we classified physicians as those using no strategies, 1 strategy, and 2 or more strategies.

BURNOUT We measured burnout using responses to the question “I feel burned out from my work,” with response options never, a few times a year or less, once a month or less, a few times a month, once a week, a few times per week, or every day. This single-item measure has been validated as consistent with the full Maslach Burnout Inventory for PCPs.24 We operationalized this item by scoring respondents from 0 (for never) to 6 (for every day.)

ROBUSTNESS We conducted a variety of tests to ensure that our results were robust to model specification and variable construction. First, we created a model with our usability index as a 25-level factor variable to flexibly estimate the association between EHR satisfaction and overall usability across the distribution of the usability index.

Second, for multivariable models with EHR satisfaction as the dependent variable, we created models specifying our dependent variable as physicians responding either very satisfied or somewhat satisfied, to ensure our results were not due to the subset of very satisfied respondents. We also used this alternative construction in models using burnout as the dependent variable and EHR satisfaction as the independent variable of interest. Third, for all measures DALLAS MEDICAL JOURNAL | 11

HOUSE CALL

Key Points QUESTION

FINDINGS

MEANING

How is the usability of different electronic health record (EHR) functions associated with physicians’ overall satisfaction with their EHR?

This survey study of 2067 family physicians found that there was significant variation in usability across EHR functions, with alerts receiving the lowest score. Greater usability was associated with higher EHR satisfaction, and efficiency strategies were associated with improved satisfaction only for physicians with highly usable EHRs.

This study suggests that overall EHR usability and satisfaction vary greatly and that the benefits of EHR efficiency strategies are likely to be heterogenous across physicians depending on the usability of their EHR.

using a dichotomous dependent variable, we also used logistic regression, and for models using burnout as a dependent variable, we also used an ordinal logistic regression, to ensure our results were robust across different estimators. Fourth, we conducted a robustness test dropping all responses of not applicable to our function usability measures rather than coding them as zero.

STATISTICAL ANALYSIS We used descriptive statistics to assess sample demographics as well as physician overall EHR satisfaction. We then characterized perceptions of usability across our 6 domains and the use of 4 EHR efficiency strategies.

We then created several multivariable linear models using ordinary least-squares regression to evaluate the association between EHR usability, satisfaction, and documentation efficiency tool use.

We chose ordinary least-squares models over logistic regression to facilitate interpretability of the results, as coefficients can be interpreted simply as the marginal association of the independent variable with the outcome.25 First, we evaluated the association between a dichotomous measure of whether a PCP responded that they were very satisfied with their EHR as the dependent variable and each functionality domain of EHR usability defined as a binary variable with respondents who selected good or excellent usability for that function compared with any other response as our independent variables of interest, including controls for EHR vendor, rurality, practice size, organization type, physician gender, value-based payment participation, and efficiency tool use with heteroskedasticity robust SEs. Then, to evaluate the moderating association of strategies to optimize documentation efficiency with EHR satisfaction, we used another multivariable linear regression model with the same dichotomous dependent variable of physicians very satisfied with their EHR, while our independent variable of interest was an interaction term between the standardized usability index and the number of documentation efficiency strategies the physician re12 | DALLAS MEDICAL JOURNAL

sponded that they had adopted and had saved them time (either 0, 1, or ≥2), in addition to the main associations of usability and efficiency strategies. We once again included controls for EHR vendor, rurality, practice size, organization type, physician gender, value-based payment participation, and each individual efficiency tool with heteroskedasticity-robust SEs. Then, to assess how the association between EHR satisfaction and efficiency strategy adoption varies across high-usability and low-usability EHRs, we used postestimation margins to compare associations between high (1 SD above the mean) and low (1 SD below the mean) usability across no, 1, and 2 or more efficiency strategies.

Finally, we evaluated the association between physician burnout and EHR satisfaction with a multivariable linear model with physician burnout frequency, scored as 0 through 6, as our dependent variable and a dichotomous measure of PCPs who reported they were very satisfied with their EHR as our independent variable of interest, again including controls for EHR vendor, rurality, practice size, organization type, physician gender, and value-based payment participation. All analyses were conducted using Stata, version 17.0 (StataCorp LLC), with 2-sided tests indicating statistical significance at P < .05.

SAMPLE CHARACTERISTICS Our analytic sample included 2067 family physicians in 2022; 431 (20.9%) were also administered the module on burnout. Physicians included 1051 men (50.9%) and 1016 women (49.2%), with 1246 (60.3%) younger than 50 years of age; 695 (34.3%) were located in the South, 570 (28.1%) in the West, 467 (23.0%) in the Midwest, and 297 (14.6%) in the Northeast (eTable 1 in Supplement 1). They practiced primarily in urban areas (1729 [86.0%]), at practice types including health systems (744 [36.0%]), independent practices (564 [27.3%]), federally qualified health centers or rural health centers (203 [9.8%]), academic centers (154 [7.5%]), and federal health systems such as the Veterans Health Administration (82 [4.0%]), with 320 (15.5%) responding that they practiced in another setting not listed. Most respondents worked in a practice with 2 to 5 clinicians (675 [32.7%]), followed by 6 to 20 clinicians (649 [31.4%]), more than 20 clinicians (558 [27.0%]), and finally solo pracDecember 2025

HOUSE CALL

tice (185 [9.0%]). A total of 1648 respondents (77.9%) practiced in a primary care clinic only, with 467 (22.1%) in a multispecialty practice.

The most common EHR vendor was Epic (801 [38.8%]), followed by eClinical Works (209 [10.1%]), athenahealth (19 [9.3%]), and Cerner (163 [7.9%]). A total of 1386 respondents (67.1%) participated in some form of value-based care program.

EHR SATISFACTION AND USABILITY Most physicians were somewhat satisfied (775 [37.5%]) or very satisfied (562 [27.2%]) with their EHR, followed by somewhat dissatisfied (346 [16.7%]), very dissatisfied (198 [9.6%]), and neither satisfied nor dissatisfied (165 [8.0%]), with 21 (1.0%) selecting not applicable (Figure 1).

For all domains of usability, the most common response was “good.”

For readability of information, 976 physicians (47.2%) rated good while 543 (26.3%) rated excellent. For ease of entering information, 942 (45.6%) rated good and 429 (20.8%) reported excellent, while for usefulness of alerts, 702 (34.0%) rated good and 262 (12.7%) rated excellent (Figure 2).

EHR DOCUMENTATION EFFICIENCY STRATEGY A total of 229 physicians (11.1%) in our sample reported using scribes and that they reduced EHR time, while 52 (2.5%) reported using scribes but said they did not reduce time in the EHR; 733 physicians (35.5%) reported using other staff for documentation and that this reduced EHR time, while 603 (29.2%) reported using other staff members but said they did not reduce EHR time. A total of 1289 physicians (62.4%) used EHR documentation templates and said they reduced EHR time, while 542 (26.2%) used templates but said they did not reduce EHR time. Finally, 771 physicians (37.3%) used voice recognition or transcription and said they reduced EHR time, while 236 (11.4%) reported using it but without a reduction in EHR time (Figure 3). Scribes were therefore perceived as the most effective at reducing EHR time (229 physicians [81.5%] who reported using scribes found they reduced EHR time), followed by voice recognition or transcription (771 [76.6%]), templated text (1289 [70.4%]), and finally other staff members (733 [54.9%]).

[95% CI, −1.06 to −0.22]; P < .001) (Table). This corresponds to a roughly 18.8% lower burnout score. We found similar results in our robustness test using ordinal logistic regression (eTable 7 in Supplement 1).

MODERATION ANALYSIS In moderation analysis using our standardized usability index, we found that usability alone remained associated with EHR satisfaction, with physicians with highly usable EHRs (1 SD above the mean) 14.7 percentage points (95% CI, 11.0-18.4 percentage points) more likely to be very satisfied with their EHR (P < .001), while physicians using 1 (β = 0.02 [95% CI, –0.03 to 0.07]; P = .37) or 2 or more (β = 0.04 [95% CI, –0.01 to 0.09]; P = .10) efficiency strategies were not significantly more likely to report being very satisfied compared with physicians using no strategies. In our estimated margins comparing physicians with highly usable to lowusability EHRs across the use of 0, 1, or 2 or more efficiency strategies, we found that physicians with highly usable EHRs (1 SD above the mean, equivalent to a score of 21 on our 24-point usability scale) who used no efficiency strategies had a 38.5% chance (95% CI, 31.4%-45.5%) of being very satisfied with their EHR, those who used 1 efficiency strategy had a 47.4% chance (95% CI, 42.2%-52.6%), and those who used 2 or more efficiency strategies had a 51.4% chance (95% CI, 47.6%-55.2%) (Figure 4). However, the trend ran in the opposite direction for low-usability EHRs (1 SD below the mean, equivalent to a score of 11 on our 24-point usability scale)—physicians using no efficiency strategies had a 9.1% probability (95% CI, 5.7%-12.4%) of being very satisfied with their EHR, while those using 1 efficiency strategy (4.7% [95% CI, 10.4%-8.0%]) and 2 or more efficiency strategies (4.2% [95% CI, 0.8%-7.5%]) had a lower probability of being very satisfied with their EHR, showing that only physicians with highly usable EHRs realized gains in EHR satisfaction from efficiency strategies.

ASSOCIATION BETWEEN EHR SATISFACTION, USABILITY, AND BURNOUT In multivariable models, we found that that having good or excellent usability for entering data was associated with a 9–percentage point increase in the probability of a physician being very satisfied with their EHR (β = 0.09 [95% CI, 0.05-0.14]; P < .001). Alignment with workflow or cognitive processes (β = 0.11 [95% CI, 0.06-0.16]; P < .001), ease of finding relevant information (β = 0.14 [95% CI, 0.09-0.19]; P < .001), and usefulness of alerts (β = 0.11 [95% CI, 0.06-0.16]; P < .001) were all significantly associated with increased likelihood of EHR satisfaction, while usability of functions relating to how physicians consume information from the EHR, such as readability of information and amount of information presented on each screen, were not associated with EHR satisfaction (Table). We found similar results in our robustness tests (eTables 2-6 and the eFigure in Supplement 1).

In our multivariable models examining the association between our measure of EHR satisfaction and burnout, we found that being very satisfied with the EHR was associated with reduced burnout compared with physicians with any other level of EHR satisfaction (β = −0.64 December 2025

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HOUSE CALL

REFERENCES 1. Adler-Milstein J, Jha AK. HITECH Act drove large gains in hospital electronic health record adoption.

Health Aff (Millwood). 2017;36(8):1416-1422. doi:10.1377/hlthaff.2016.1651PubMedGoogle ScholarCrossref 2. Apathy NC, Holmgren AJ, Adler-Milstein J. A decade post-HITECH: critical access hospitals have electronic health records but struggle to keep up with other advanced functions. J Am Med Inform Assoc. 2021;28(9):1947-1954. doi:10.1093/jamia/ocab102PubMedGoogle ScholarCrossref 3. Tai-Seale M, Olson CW, Li J, et al. Electronic health record logs indicate that physicians split time evenly between seeing patients and desktop medicine. Health Aff (Millwood). 2017;36(4):655-662. doi:10.1377/hlthaff.2016.0811PubMedGoogle ScholarCrossref 4. Gaffney A, Woolhandler S, Cai C, et al. Medical documentation burden among US office-based physicians in 2019: a national study. JAMA Intern Med. 2022;182(5):564-566. doi:10.1001/jamainternmed.2022.0372 | ArticlePubMedGoogle ScholarCrossref 5. Rotenstein LS, Holmgren AJ, Downing NL, Bates DW. Differences in total and after-hours electronic health record time across ambulatory specialties. JAMA Intern Med. 2021;181(6):863-865. doi:10.1001/ jamainternmed.2021.0256 | ArticlePubMedGoogle ScholarCrossref 6. Overhage JM, McCallie D Jr. Physician time spent using the electronic health record during outpatient encounters: a descriptive study. Ann Intern Med. 2020;172(3):169-174. doi:10.7326/M183684PubMedGoogle ScholarCrossref 7. Adler-Milstein J, Zhao W, Willard-Grace R, Knox M, Grumbach K. Electronic health records and burnout: time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians. J Am Med Inform Assoc.

2020;27(4):531-538. doi:10.1093/jamia/ocz220PubMedGoogle ScholarCrossref 8. Gardner RL, Cooper E, Haskell J, et al. Physician stress and burnout: the impact of health information technology. J Am Med Inform Assoc. 2019;26(2):106-114. doi:10.1093/jamia/ocy145PubMedGoogle ScholarCrossref 9. Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;170(11):784-790. doi:10.7326/M18-1422PubMedGoogle ScholarCrossref 10. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Vol 90. 12th ed.

Elsevier; 2015:1600-1613.

11. Apathy NC, Hare AJ, Fendrich S, Cross DA. Early changes in billing and notes after evaluation and management guideline change. Ann Intern Med. 2022;175(4):499-504. doi:10.7326/M21-4402PubMedCrossref 12. American Medical Informatics Association. AMIA 25x5: reducing documentation burden to 25% of current state in five years. Accessed October 10, 2022. https://amia.org/about-amia/amia-25x5 13. Melnick ER, Dyrbye LN, Sinsky CA, et al. The association between perceived electronic health record usability and professional burnout among US physicians. Mayo Clin Proc. 2020;95(3):476-487. doi:10.1016/j.mayocp.2019.09.024PubMedGoogle ScholarCrossref 14.

Melnick ER, Sinsky CA, Dyrbye LN, et al. Association of perceived electronic health record usability with patient interactions and work-life integration among US physicians. JAMA Netw Open.

2020;3(6):e207374. doi:10.1001/jamanetworkopen.2020.7374 ArticlePubMedGoogle ScholarCrossref 15. Ratwani RM, Benda NC, Hettinger AZ, Fairbanks RJ. Electronic health record vendor adherence to usability certification requirements and testing standards. JAMA. 2015;314(10):1070-1071. doi:10.1001/ jama.2015.8372 | ArticlePubMedGoogle ScholarCrossref 16. Ancker JS, Edwards A, Nosal S, Hauser D, Mauer E, Kaushal R; with the HITEC Investigators. Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system. BMC Med Inform Decis Mak. 2017;17(1):36. doi:10.1186/s12911-017-0430-8PubMedGoogle ScholarCrossref 17. Co Z, Holmgren AJ, Classen DC, et al. The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication–related clinical decision support. J Am Med Inform Assoc.

2020;27(8):1252-1258. doi:10.1093/jamia/ocaa098PubMedCrossref 18. Holmgren AJ, Downing NL, Bates DW, et al. Assessment of Electronic Health Record Use Between US and Non-US Health Systems. JAMA Intern Med. 2021;181(2):251-259. doi:10.1001/jamainternmed.2020.7071 | ArticlePubMedGoogle ScholarCrossref 19. Downing NL, Bates DW, Longhurst CA. Physician burnout in the electronic health record era: are we ignoring the real cause? Ann Intern Med. 2018;169(1):50-51. doi:10.7326/M18-0139PubMedGoogle ScholarCrossref 20. Mishra P, Kiang JC, Grant RW. Association of medical scribes in primary care with physician workflow and patient experience. JAMA Intern Med. 2018;178(11):1467-1472. doi:10.1001/jamainternmed.2018.3956 | ArticlePubMedGoogle ScholarCrossref 21. Apathy NC, Rotenstein L, Bates DW, Holmgren AJ. Documentation dynamics: note composition, burden, and physician efficiency. Health Serv Res. 2023;58(3):674-685. doi:10.1111/14756773.14097PubMedCrossref 22. Rotenstein LS, Apathy N, Holmgren AJ, Bates DW. Physician note composition patterns and time on the EHR across specialty types: a national, cross-sectional study. J Gen Intern Med. 2023;38(5):11191126. doi:10.1007/s11606-022-07834-5PubMedGoogle ScholarCrossref 23. Gidwani R, Nguyen C, Kofoed A, et al. Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial. Ann Fam Med. 2017;15(5):427-433. doi:10.1370/afm.2122PubMedGoogle ScholarCrossref 24. West CP, Dyrbye LN, Satele DV, Sloan JA, Shanafelt TD. Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment. J Gen Intern Med. 2012;27(11):1445-1452. doi:10.1007/s11606-012-2015-7PubMedGoogle ScholarCrossref 25. Norton EC, Dowd BE, Garrido MM, Maciejewski ML. Requiem for odds ratios. Health Serv Res. 2024;59(4):e14337. doi:10.1111/1475-6773.14337PubMedCrossref 26. Bates DW, Singh H. Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety. Health Aff (Millwood). 2018;37(11):1736-1743. doi:10.1377/ hlthaff.2018.0738PubMedGoogle ScholarCrossref 27. Kuperman GJ, Bobb A, Payne TH, et al. Medication-related clinical decision support in computerized provider order entry systems: a review. J Am Med Inform Assoc. 2007;14(1):29-40. doi:10.1197/ jamia.M2170PubMedGoogle ScholarCrossref 28. Khuntia J, Tanniru M, Weiner J. Juggling digitization and technostress: the case of alert fatigues in the patient care system implementation. Health Policy Technol. 2015;4(4):364-377. doi:10.1016/j. hlpt.2015.08.005Google ScholarCrossref 29. Carspecken CW, Sharek PJ, Longhurst C, Pageler NM. A clinical case of electronic health record drug alert fatigue: consequences for patient outcome. Pediatrics. 2013;131(6):e1970-e1973. doi:10.1542/peds.2012-3252PubMedGoogle ScholarCrossref 30. Holmgren AJ, Co Z, Newmark L, Danforth M, Classen D, Bates D. Assessing the safety of electronic health records: a national longitudinal study of medication-related decision support. BMJ Qual Saf. 2020;29(1):52-59. doi:10.1136/bmjqs-2019-009609PubMedCrossref 31. Classen DC, Holmgren AJ, Co Z, et al. National Trends in the Safety Performance of Electronic Health Record Systems From 2009 to 2018. JAMA Netw Open. 2020;3(5):e205547. doi:10.1001/jamanetworkopen.2020.5547 | ArticlePubMedGoogle ScholarCrossref 32. Co Z, Holmgren AJ, Classen DC, et al. The development and piloting of the ambulatory electronic health record evaluation tool: lessons learned. Appl Clin Inform. 2021;12(1):153-163. doi:10.1055/s-00411722917PubMedGoogle ScholarCrossref 33. McCoy AB, Russo EM, Johnson KB, et al. Clinician collaboration to improve clinical decision support: the Clickbusters initiative. J Am Med Inform Assoc. 2022;29(6):1050-1059. doi:10.1093/jamia/ocac027PubMedGoogle ScholarCrossref 34. Health data, technology, and interoperability: certification program updates, algorithm transparency, and information sharing. Federal Register. Published January 9, 2024. Accessed February 25, 2024. https://www.federalregister.gov/documents/2024/01/09/2023-28857/health-data-technologyand-interoperability-certification-program-updates-algorithm-transparency-and 35. Doe S, Coutinho AJ, Weidner A, et al. Prevalence and predictors of burnout among resident family physicians. Fam Med. 2024;56(3):148-155. doi:10.22454/FamMed.2024.875388PubMedGoogle ScholarCrossref

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DISCUSSION In a national survey with a 100% response rate, fewer than 30% of family physicians were very satisfied with their EHR, and more than one-fourth reported dissatisfaction. There was significant variation in usability across domains of the EHR, where most respondents reported that the ease of entering information and readability of information was good or excellent, while usefulness of EHR-based alerts was rated much lower. A small majority of family physicians used EHR templates to improve efficiency, but most do not have access to other efficiency strategies—fewer than 15% used scribes, which was rated as the most effective strategy to reduce documentation time. Although greater usability of most EHR functions, especially alignment with the physicians’ workflow or cognitive processes, usefulness of alerts, and ease of finding relevant information, were associated with greater EHR satisfaction, the use of EHR efficiency strategies improved satisfaction only for physicians with highly usable EHRs. Finally, we found physicians who responded that they were very satisfied with their EHR also reported significantly lower burnout.

We found that only one-fourth of family physicians were very satisfied with their EHR, while another one-fourth reported being somewhat dissatisfied or very dissatisfied, numbers consistent with other national surveys of physician EHR satisfaction.4 This finding is notable given the study’s 100% survey response rate, compared with much lower response rates to voluntary surveys, suggesting that physician dissatisfaction with the EHR is not due to response bias. Our results specifically suggest starting with addressing alerts, as they received the lowest usability scores. Although alerts have been shown to have important benefits (particularly reducing medication errors),26,27 research suggests that they are often poorly configured, have high dismissal rates, and have been associated with “alert fatigue” that harms physician well-being and patient outcomes.16,17,28,29 The focus of most alert-based research has been in the inpatient setting, where studies often find poor performance and a high level of “nuisance” alerts.30,31 Office-based physician alerts are relatively understudied and less sophisticated in comparison.32 A growDecember 2025

HOUSE CALL

ing literature suggests that alerts can be improved through collaborative efforts between clinicians and informaticists,33 and recent policy action has added requirements for EHR vendors to support a feedback loop for decision support alert functionality.34 Although documentation makes up the plurality of time spent in the EHR and is the focus of several burdenreduction initiatives,5,12 fewer than 7% of physicians reported that the ease of entering information was poor, suggesting that it may not be usability challenges that are associated with documentation burden.

Many family physicians used at least 1 EHR documentation efficiency strategy, with the most common being documentation templates, which are low cost and may be included in default EHR builds. Templates, despite being broadly adopted, were far from the most effective strategies, adding evidence to research suggesting that while some use of templated text reduces documentation time, overreliance may increase EHR burden as physicians document to the template, rather than each patient’s specific needs.21,22 Although scribes were reported as the most effective documentation efficiency strategy among physicians who reported using them, documentation by other staff members was the least effective.

It may be that while offloading documentation to staff reduces EHR burden, effective implementation requires a dedicated role and accompanying workflow adaptations, rather than relying on other staff on an ad hoc basis.

Despite many physicians using at least 1 effective efficiency strategy, our moderation analysis found that while usability was associated with overall EHR satisfaction, the benefits of these efficiency strategies were realized only by physicians with highly usable EHRs. Understanding this association is critical to informing future efforts to address EHR burden.

It may simply be that at low levels, usability dominates physician perception of their EHR so strongly that effective team-based or technologybased efficiency strategies are not able to overcome poor software usability. If this is the case, resources to improve documentation efficiency are unlikely to help physicians with low-usability EHRs. Given that the usability of entering information is frequently rated higher than functions such as finding information or alerts, it is likely that documentation-focused efficiency strategies such as scribes or templated text are unable to address the salient pain points of low-usability EHRs. Instead, technology tools that may be on the horizon, such as artificial intelligence that summarizes bloated notes or improved data standards to ensure patient information is available in a standardized format, may be necessary to improve EHR satisfaction for these physicians. Conversely, for physicians with highly usable EHRs, strategies to reduce documentation time are associated with EHR satisfaction, suggesting that investments in these team and technology interventions are worthwhile. Our results therefore suggest that the effects of popular EHR burden-reduction interventions are likely to be heterogenous across users with different levels of EHR usability. Physicians, EHR vendors, and health system leaders should design burden-reduction efforts with these results in mind. The association between high EHR satisfaction and burnout highlights the potential for renewed policymaker and vendor attention to EHR optimization to contribute to broader efforts to address persistent and increasing rates of physician burnout in primary care.35

does not assess granular details, such as the intensity of documentation efficiency strategies. For example, there is likely variation across physicians using staff for documentation (ie, the staff member performing the task and the degree of training they receive) that we do not observe. To address this concern, our measure of efficiency strategy use included only physicians who reported that those efficiency strategies reduced EHR documentation time, but there is likely variation in implementation of each strategy. Future research should explore what specific team, technology, and contextual factors facilitate successful implementation of each EHR documentation efficiency strategy. Our study assesses only the association between EHR satisfaction and burnout, but many other factors, including work environment and feeling valued, are known to be associated with burnout, and we were unable to fully capture the spectrum of possible antecedents to burnout. Finally, the survey-based nature of our study relied on family physicians’ self-reported data that we were unable to independently verify.

However, our high-level results are similar to other survey-based estimates of PCP EHR use.4 CONCLUSIONS This unique national survey with a 100% response rate found that only one-fourth of physicians were very satisfied with their EHR, while a substantial minority were dissatisfied, and usability was correlated with overall EHR satisfaction. Although most physicians reported using some type of efficiency strategy, such as scribes, templated text, or voice recognition to reduce EHR documentation time, gains in EHR satisfaction were realized only by physicians with high-usability EHRs, suggesting that addressing physician EHR burden requires a targeted approach to address the EHR needs of the specific physician. DMJ

LIMITATIONS Our study has some limitations, including that results from our cross-sectional descriptive analysis precludes causal inference. Second, our survey December 2025

DALLAS MEDICAL JOURNAL | 15

HEALTH ALLIES

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The Rights and Responsibilities of Providing Care to Uninsured and Immigrant Patients

by Brandon Kulwicki, Attorney with Hall, Render, Killian, Heath & Lyman, P.C

T

exas continues to lead the nation in the percentage of uninsured residents, with particularly high rates among immigrant families and children. This reality places many health care providers in the position of navigating complex legal and ethical questions related to access, eligibility, and the rights of individuals without insurance or legal immigration status. Understanding what the law requires and permits is critical for any practitioner treating vulnerable populations across the state.

First and foremost, under federal law, hospitals with emergency departments are obligated to provide care to all individuals, regardless of insurance or immigration status. The Emergency Medical Treatment and Labor Act mandates that anyone who presents to

December 2025

an emergency room must receive a medical screening examination and stabilizing treatment, if necessary. This duty applies equally to undocumented immigrants and uninsured children.1 Outside of emergency settings, private physicians and clinics are not legally required to accept all patients.

However, Federally Qualified Health Centers and community clinics often operate under funding with mission-driven goals to serve all individuals, including those without insurance or legal documentation.2 In terms of access to public benefits, undocumented adults are generally ineligible for programs like Medicaid.

However, Emergency Medicaid is available for undocumented patients who meet income requirements and need urgent treatment. Importantly, lawfully present immigrant children may qualify for Medicaid or Children’s Health Insurance Program (“CHIP”) depending on their specific im-

DALLAS MEDICAL JOURNAL | 17

LEGAL CORNER

Physician Practice Guidance Physician Practice Guidance is sponsoring a Zoom talk on the topic, “Key Strategies for Improving Practice Revenue.”

This talk will focus on common errors made by the revenue cycle team, ways to improve the team’s performance and best practices to ensure increased collection of practice revenue. The talk will include checklists for improving the performance of the front desk, biller and coder. The talk provides practical advice on an essential topic for all practices.

Sabrina Skeldon is inviting you to a scheduled Zoom meeting: Time and Date: January 7, 2026 at 7:00 PM, CST https://us02web.zoom.us/j/85237046532?pwd=T31akZxJTYsLj6zOrapVmJKF3t34a8.1

Meeting ID: 852 3704 6532 Passcode: 600043 Physician Practice Guidance focuses on helping small practices develop stronger revenue cycle processes. Its business website is www.physicianpracticeguidance.net.

migration status and length of residency. Additionally, U.S.-born children of undocumented parents, who are U.S. citizens, are fully eligible for Medicaid and CHIP if they meet the financial criteria, even if their parents are undocumented.3 A major barrier to care often lies in the administrative complexity of enrolling in public health programs. Families may be required to submit documentation such as income verification, residency status, or proof of identity, which can be difficult to navigate. Many children have lost coverage during Texas’s post-pandemic Medicaid “unwinding” not due to ineligibility, but because of procedural lapses like missed deadlines or incomplete paperwork. Medical providers can support patients by referring them to trained health benefit navigators to help with enrollment.

Immigrant families may also hesitate to apply for benefits out of fear it could affect their immigration status under the “public charge” rule.

However, the Biden administration clarified in 2022 that use of Medicaid and CHIP does not count against public charge determinations for most immigrants.4 Furthermore, patients are protected by HIPAA, which prevents disclosure of sensitive information, including immigration status, without consent.5 Health care providers in Texas must balance regulatory compliance with a commitment to equitable care. By staying informed, assisting with enrollment, and avoiding unnecessary inquiries into immigration status, clinicians can play a pivotal role in protecting access to care for uninsured and immigrant populations, especially children, across our communities. Just as importantly, patients and families must be empowered to understand their legal rights. Fear, misinformation, or confusion should never be a barrier to necessary health care. Knowing what protections exist under the law whether it be the right to emergency treatment, confidentiality, or eligibility for children’s health programs, families should have the confidence to seek timely care and protect their health with security. DMJ This article is educational in nature and is not intended as legal advice. Always consult your legal counsel with specific legal matters. If you have any questions or would like additional information about this topic, please contact Brandon Kulwicki at (214) 615-2025 or your primary Hall Render contact.

Brandon Kulwicki is an attorney with Hall, Render, Killian, Heath & Lyman, P.C., a national law firm focused exclusively on matters specific to the health care industry. Please visit the Hall Render Blog at blogs.hallrender.com for more information on topics related to health care law.

REFERENCES 1. Emergency Medical Treatment & Labor Act (EMTALA), CMS (last modified Dec. 6, 2024), https://www.cms. gov/medicare/regulations-guidance/legislation/emergency-medical-treatment-labor-act.

2. Federally Qualified Health Centers (FQHC), CMS, https://www.cms.gov/medicare/payment/prospective-payment-systems/federally-qualified-health-centers-fqhc-center (last visited Apr. 29, 2025).

3. Akash Pillai et al., How States Verify Citizenship and Immigration Status in Medicaid, KFF (Apr. 16, 2025), https://www.kff.org/medicaid/issue-brief/how-states-verify-citizenship-and-immigration-statusin-medicaid/#:~:text=Some%20immigrants%20with%20qualified%20status,present%20immigrants%20and%20undocumented%20immigrants.

4. Public Charge Resources, U.S. CITIZENSHIP AND IMMIGRATION SERVICES, https://www.uscis.gov/greencard (last visited May 1, 2025).

5. Health Care and U.S. Immigration Enforcement: What Providers Need to Know, NATIONAL IMMIGRATION LAW CENTER (2025), chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.nilc.org/ wp-content/uploads/2025/03/Health-Care-and-U.S.-Immigration-Enforcement_What-ProvidersNeed-to-Know_Guide_PHR-and-NILC-2025.pdf.

18 | DALLAS MEDICAL JOURNAL

December 2025

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ADVOCACY

The Year in Review: Reproductive Rights, Gender-Affirming Care, and the Fight for Child Health Care Access

by Brandon Kulwicki, Attorney with Hall, Render, Killian, Heath & Lyman, P.C

O

ver the past year, Texas has seen significant developments in health law and policy that has directly impacted medical professionals, patients, and families. Three major issues have dominated headlines and courtrooms: reproductive health access, gender-affirming care for minors, and health care coverage for children. These developments have not only tested the limits of legislative authority and medical ethics, but also exposed gaps in care and equity across the state’s health care system. This year-in-review aims to highlight the key legal changes, judicial rulings, and public health consequences stemming from these controversial and consequential policies.

REPRODUCTIVE HEALTH AND ABORTION ACCESS In 2022, Texas passed a comprehensive abortion law prohibiting abortions in nearly all circumstances.1 This law prohibited

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any person from performing, inducing, or attempting an abortion regardless of cases regarding rape or incest. The only exception is for situations in which the life or health of the patient is at risk. Under this exception, three factors must be met: (1) a licensed physician must perform the abortion; (2) the patient must have a “life-threatening condition” and be at risk of death or substantial impairment of a major bodily function; and (3) the physician must try to save the life of the fetus.2 Physicians who provide abortions outside of this exception could be charged with a felony, have their licensed revoked, and subjected to civil penalties of at least $100,000.3 Physicians and their attorneys’ interpretation of this law led to negative effects as the strict language led to some providers failing to provide women with necessary care. Since the passage of the law, the rate of hospitalization due to sepsis developed as a result of second trimester miscarriages has increased by more than 50% as a result of delay in receiving the proper medical treatment because their conditions were December 2025

ADVOCACY

not initially determined as “life-threatening.”4 Physicians urged lawmakers to change the abortion law as they were unable to properly provide the needed care due to the stringent nature of the statute.5 To combat this issue, the Texas Senate unanimously voted to amend the ban to omit language of the exception rule requiring “a life-threatening condition” and instead stating that the condition must be a medical emergency.6 Furthermore, Texas enacted the Life of the Mother Act, clarifying that an abortion may be performed when, in a physician’s reasonable medical judgment, the pregnancy poses a life-threatening condition or serious risk of substantial impairment to a major bodily function of the pregnant patient.7 These revisions allow more discretion for physicians to act and provide care to women in need.

GENDER-AFFIRMING CARE AND LEGAL CHALLENGES In 2023, the Texas Senate passed Senate Bill 14 (“the Bill”), prohibiting health care professionals from providing gender-affirming medical care to minors, including treatments such as puberty blockers and hormone therapies.8 The law was challenged by parents, doctors, and LBGTQ+ advocates who argued that the Bill violated a parent or guardian’s constitutional right to make medical decisions for their children.9 However, in June 2024, the Texas Supreme Court upheld the Bill in an 8-1 ruling, recognizing parental rights, but emphasizing the state’s authority to regulate medical practice. This past June, the Supreme Court of the United States held that a Tennessee law prohibiting certain gender-affirming treatments for minors does not violate the United States Constitution. Consequently, the Texas bill is further reinforced and going forward, states’ interests in regulating gender-affirming care for minors need only satisfy a “rational basis” standard of review10 which is considered the lowest level of scrutiny in constitutional law. Under the rational basis standard the law is presumed to be valid unless the party challenging it can prove it is arbitrary and lacks any conceivable rational justification.

Medical professionals who violate this bill are at risk of losing their medical license. In late 2024, Texas Attorney General, Ken Paxton, filed lawsuits against three physicians for allegedly prescribing prohibited gender transition treatments to dozens of minors violating the Bill.

The lawsuits claim that the physicians concealed the treatments by using false diagnoses and billing codes, which state officials view as experimental and harmful.11 As a result, two12 of the physicians13 entered into agreements to stop practicing medicine on patients, while the third physician was placed under a court injunction prohibiting them from providing such treatments to minors.14 HEALTH CARE ACCESS AND EQUITY In 2023, nearly one million children in Texas went without health insurance at some point during the year. Texas currently has the highest uninsured rate for children in the nation at nearly 12%.15 Despite many being eligible for public programs like Medicaid and the Children’s Health Insurance Program, bureaucratic barriers, long wait times, and a confusing application processes have caused significant coverage gaps.16 The effects of backlogs and procedural disenrollments, rather than actual ineligibility, led to over 1.3 million children losing coverage during the Medicaid “unwinding” after COVID-19 protections ended.17 Efforts to streamline enrollment have stalled in the Texas Legislature, and the state has not adopted broader Medicaid expansion, which reDecember 2025

search shows could increase child enrollment.18 As a result, many uninsured children go without routine care or delay treatment until emergencies arise.19 Pediatricians and health advocates stress that insurance leads to better outcomes, yet families often avoid care due to cost concerns, even for basic issues. Community health centers help fill the gap, but access to specialized care remains limited for uninsured kids.

CONCLUSION As the year has come to an end, Texas has remained at the forefront of the national conversation on health care regulation and patient rights. The effects of the state’s restrictive abortion laws, ban on gender-affirming care for minors, and persistent issues with children’s insurance coverage have created widespread challenges for both providers and patients. These legal developments have underscored the complexity of balancing government oversight with medical autonomy and individual rights. Moving forward, Texas lawmakers, courts, and the medical community must work collaboratively to address the real-world impacts of these policies, ensuring that care remains both legally compliant and ethically grounded for the people of Dallas and across the state. DMJ This article is educational in nature and is not intended as legal advice. Always consult your legal counsel with specific legal matters. If you have any questions or would like additional information about this topic, please contact Brandon Kulwicki at (214) 615-2025 or your primary Hall Render contact.

Brandon Kulwicki is an attorney with Hall, Render, Killian, Heath & Lyman, P.C., a national law firm focused exclusively on matters specific to the health care industry. Please visit the Hall Render Blog at blogs.hallrender.com for more information on topics related to health care law.

REFERENCES 1. Tex. Health & Safety Code § 170A. 2. Tex. Health & Safety Code § 170A. 3. Tex. Health & Safety Code § 170A. 4. Andrea Suozzo et al., Rates of Pregnancy-Related Sepsis and Deaths Grow in Texas After Abortion Ban, THE TEXAS TRIBUNE (Feb. 20, 2025), https://www.texastribune.org/2025/02/20/texasabortion-ban-impact-death-hospitalization/#:~:text=Pregnancy%20became%20far%20 more%20dangerous,the%20second%20trimester%2C%20ProPublica%20found.

5. Pooja Salhotra, Texas OB-GYNs Urge Lawmakers to Change Abortion Laws After Reports on Pregnant Women’s Deaths, THE TEXAS TRIBUNE (Nov. 3, 2024), https://www.texastribune. org/2024/11/03/texas-ob-gyn-letter-abortion-laws/ 6. Nadia Lathan, Texas Lawmaker Introduces Bill to Clarify Medical Exceptions in State’s Abortion Ban, AP (Mar. 14, 2025), https://apnews.com/article/texas-abortion-medical-exceptionslegislation-aab7ae983006d5872e1adba8d60f8368.

7. S.B. 31. The Life of the Mother Act. https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:2facc9f73ec4-4305-b8d0-8343277c6859.

8. S.B. 14, 88th Leg., (TX. 2023).

9. William Melhado and Asad Jung, Texas Supreme Court Upholds Ban on Transition-Related Care for Minors, THE TEXAS TRIBUNE (June 28, 2024), https://www.texastribune.org/2024/06/28/ texas-supreme-court-gender-affirming-care/.

10. United States v. Skrmetti (Jun. 18, 2025), https://acrobat.adobe.com/id/ urn:aaid:sc:VA6C2:d8da1dc9-0e85-4792-b404-83b54eac0264.

11. Attorney General Ken Paxton Stops Texas Doctors Who Illegally Gave Children “Gender Transition” Drugs from Practicing Medicine, OFFICE OF ATTORNEY GENERAL OF TEXAS (Feb. 4, 2025), https://www.texasattorneygeneral.gov/news/releases/attorney-general-ken-paxton-stopstexas-doctors-who-illegally-gave-children-gender-transition-drugs.

12. The State of Texas v. May C. Lau, chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/ https://www.texasattorneygeneral.gov/sites/default/files/images/press/Lau%20Rule%20 11%20Agreement.pdf 13. The State of Texas v. Cooper, chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https:// www.texasattorneygeneral.gov/sites/default/files/images/press/Cooper%20Rule%2011%20 Agreement.pdf 14. State of Texas v. Granados, chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https:// www.texasattorneygeneral.gov/sites/default/files/images/press/Granados%20Agreed%20 TI%20Order.pdf 15. Kim Krisberg, Texas Has the Highest Rate of Uninsured Children, and It’s Getting Worse, PUBLIC HEALTH WATCH (Feb. 26, 2025), https://www.texastribune.org/2025/02/26/texas-childrenchip-medicaid-uninsured/.

16. Id. 17. Id. 18. Id. 19. Id.

DALLAS MEDICAL JOURNAL | 21

ADVANCEMENT

Case study: Failure to properly manage patient’s central venous catheter

by Laura Hale Brockway, ELS, Vice President, Marketing, Texas Medical Liability Trust (TMLT)

A

63-year-old woman was hospitalized for treatment of renal and urological issues. Two years earlier, she had been diagnosed with renal cell carcinoma. The patient’s history included diabetes, obesity, and breast and colon cancer. The patient lived in a small, rural community.

The patient had seen multiple physicians during her hospitalization, including her long-time physician, Family Physician A. She was discharged to a local rehab center with diagnoses of radiation cystitis, acute renal failure, right renal mass, urinary tract infection, E. coli infection, pneumonia, and splenomegaly. She was to receive IV antibiotics at the rehab center.

PHYSICIAN ACTION During a visit on day 32 of her rehab stay, Family Physician A documented that the patient had signs of infection in the central venous catheter (CVC). His handwritten note said “septic-unlikely pt apprs well.” A typed assessment stated: “1. Groin area fungal infection 2. Right port-a-cath with hyperemic irritation part of the chest rash or infection secondary to patient already having a lot of skin reaction will treat with only [fluconazole]. 3. Skin reaction. 4. Septic? (Consider this diagnosis in need to transfer to [city], discussed with [son] to help with getting patient to a urologist, patient medical problems could be addressed and patient could get surgery done since it keeps getting postponed, [son] prefers [hospital name] but agrees and other hospital would be ok, not septic.”

Family Physician A’s plan was to treat the patient with diphenhydramine, cetirizine, and fluconazole. “Refer to surgery for removal of

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December 2025

ADVANCEMENT

port-a-cath. Will look for another urologist. Discussed with [son] about accepting another urologist for the renal cancer . . . to hospitalize patient in [city] so that the surgery can occur as soon as possible, if still a candidate.”

Two days passed and rehab center staff advised Family Physician A that the patient had a fever. He told staff to take the patient to a local ED if the fever did not respond to acetaminophen. Following a phone call from the patient’s son reporting that the patient had a hard, painful area on her lower right abdomen, Family Physician A instructed rehab center staff to take the patient to a local ED. The patient was admitted to the hospital that day with “acute septic shock likely secondary to urinary tract infection for Gram negatives; hypotension; acute kidney injury superimposed on chronic kidney disease stage 4 or 5; allergic reaction, Stevens Johnson like type; and renal mass, which is likely cancer.”

The next day, the patient was transferred to an urban medical center.

Her prognosis was poor, and she died two days after the transfer.

ALLEGATIONS A lawsuit was filed against Family Physician A. The allegations were failure to discontinue the CVC when it was no longer needed and failure to order cultures and antibiotics if he suspected a CVC infection.

LEGAL IMPLICATIONS Although physicians who reviewed this case for the defense stated that Family Physician A met the standard of care, there was concern that he did not order cultures or start antibiotics though he noted a possible infection. Reviewers also stated that the order to remove the CVC should have been designated as “STAT.” Regarding causation, one physician reviewer stated that the patient likely had an acute skin condition such as Stevens-Johnson Syndrome or toxic epidermal necrolysis at the CVC site. Further, if the CVC site was infected and that infection became so severe that it caused the patient’s death, the site would likely have displayed gross evidence of infection (swelling, redness, warmth, tenderness, etc.). According to this physician, the sepsis, septic shock, and multi-system organ failure that caused the patient’s death were “entirely independent” of the CVC. Documentation was a weakness in this case. He testified that though he did not think there was a CVC infection, he documented that there was so the patient could be transferred to an urban hospital and undergo surgery for the renal mass. He stated he was trying to help the family.

Yet it was later discovered that the notes about the expedited transfer to an urban hospital were added to the medical record six days after the patient’s death.

DISPOSITION This case was settled on behalf of Family Physician A. RISK MANAGEMENT CONSIDERATIONS Physicians who practice in rural areas face unique circumstances that can increase liability risks.

December 2025

• Limited access to specialists often means primary care physicians manage complex conditions that would typically involve specialty consultation in urban areas.

• Greater distances to specialized care centers can delay transfers when urgent issues arise.

• Fewer resources for diagnostic testing can lead to delayed diagnoses.

• Staffing shortages may cause less frequent patient monitoring.

For physicians practicing in rural communities, developing strong referral networks and clear transfer protocols is essential. Telemedicine can be a valuable tool to bridge some of these gaps, allowing for remote consultation while keeping patients in their communities when appropriate.

Proactive risk assessment — identifying which patients might need more urgent intervention or transfer — can help mitigate these care challenges.

Documentation becomes even more critical when treating patients in these settings, as care coordination between physicians and facilities requires clear communication. However, inaccurate documentation was a factor in this case. Family Physician A’s notes were inconsistent with his testimony, and he admitted that he documented an infection that he believed did not exist to facilitate a transfer. Furthermore, the notes regarding the expedited transfer were added to the medical record days after the patient’s death.

To maintain the accuracy and integrity of medical records, document patient assessments factually and contemporaneously.

Avoid falsifying or exaggerating conditions to achieve secondary goals like transfers. Accurate medical information must be available to all members of the care team and lessens the chance that the facts of the case can be contested.

Avoid making late additions to the medical record after an unexpected outcome. An addendum or late entry in a medical record may be allowed if done in a timely manner and clearly identified. Include the date and time of the addendum, the date and time of the actual encounter, reason for the late entry, the added information, and signature of the author. After-the-fact entries may be viewed as record alterations and may ultimately compromise the defense. DMJ This closed claim study is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of the physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. This study has been modified to protect the privacy of the physicians and the patient.

Re-printed with permission from Texas Medical Liability Trust (TMLT).

DALLAS MEDICAL JOURNAL | 23

ADVANCEMENT

DCMS CAREER CENTER FIND & POST JOBS TODAY

FOR OUR MEMBERS: Featured jobs Resume review Recruiting products Insights & Coaching

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HEALTH ALLIES

Mental Wellness Boost: Free, Confidential Online Counseling Now Available for Texas Physicians and Families

T COMMON ISSUES ADDRESSED: Anxiety Burnout Depression Grief Guilt Addictions Overwhelm Sleep disturbance Low motivation Isolation Marital strain Lack of interest Irritability

December 2025

he Texas Medical Association and TMA Insurance Trust have partnered with Anticipate Joy, a groundbreaking mental health and wellness company, to give Texas physicians and their families access to free, confidential, HIPAA-compliant online counseling.

Designed to make getting support easier and more obtainable, this program helps remove common barriers—so care fits naturally into your life. Every session with your licensed counselor is private, judgment-free, and completely on your terms.

WHO IS ELIGIBLE TO USE ANTICIPATE JOY? This program is available to all physicians practicing in Texas and their immediate family members.

HOW MUCH DOES IT COST? There is no cost to you. This program is fully funded through the Texas Medical Association and a generous grant provided by TMA Insurance Trust. You may have as many sessions as needed, for as long as you need them.

WILL THE TEXAS MEDICAL BOARD KNOW I’M USING THIS PROGRAM? No. Using this counseling program will not impact your medical license. The Texas Medical Association (TMA), TMA Insurance Trust, and the Texas Medical Board (TMB) are entirely separate organizations. They do not share information, nor will they have access to anything related to your counseling sessions.

HOW IS MY PRIVACY PROTECTED? Your privacy isn’t just respected—it’s kept fully confidential. What you share with your therapist stays between you and them. No one will know you’re using the program unless you choose to tell them. TMA will never have access to your personal information or counseling records. It is never shared with your employer, family, patients, peers, or any licensing authority.

WHY IS TMA OFFERING THIS RESOURCE? TMA recognizes the intense emotional weight physicians carry—both professionally and personally. This initiative is one way TMA and TMA Insurance Trust are working together to help ease that burden by offering access to real care, without judgment or red tape.

When you’re ready, you’ll find support waiting.

HOW DO I BEGIN? Accessing support shouldn’t feel like another burden. Anticipate Joy uncomplicates the process with simple, straightforward steps: • Enroll easily online by completing a brief intake form on the Anticipate Joy platform.

• Review available licensed therapists using filters and request one that best suits your needs.

• Choose how your sessions take place—by video, audio, or text—and a time that works for you and your therapist.

You show up for your patients without question. This is an opportunity to do the same for yourself. DMJ Visit www.tmait.org/anticipate-joy to learn more.

DALLAS MEDICAL JOURNAL | 25

SHILOH OFFICE PARK MEDICAL CONDOS

OWN OR LEASE YOUR OWN CONDO

George Bush Corridor at Renner Road and Shiloh Located directly across from Methodist Richardson Medical Center

Contact: Suzy Murff 972.898.7047

MEMBERSHIP

2025 TMA Vaccines Defend What Matters grant recipients

W

e are pleased to share that UTSW TMA Medical Student Section and Union Gospel Mission Dallas received Vaccines Defend What Matters local impact grants this year.

A brief description of the funded events are below and you can find the full list of this year’s grant recipients on TMA’s Local Impact Grants page.

If you’re unfamiliar with this program, Vaccines Defend What Matters (VDWM) is TMA’s community-driven public health education and advocacy effort to overcome vaccine hesitancy and increase vaccination rates in Texas. County medical societies, TMA Alliance chapters, medical student chapters, and TMA member-physician practices and clinics are eligible to apply for grants of up to $3,500 to fund vaccination activities, educational resources, and community outreach events.

We hope you’ll join us celebrating this year’s community health driven events in your county and look forward to the 2026 opportunities. If you have any questions or would like to hear more about this program, please don’t hesitate to reach out. DMJ

Brother Bill’s Helping Hand Student-Run Free Clinic will provide free immunizations and Spanish-language vaccine education to the uninsured LatinX community. Offering flu, Tdap, Hepatitis B, COVID, and shingles vaccines, the clinic operates bi-weekly and during community nights to increase access and combat misinformation.

Union Gospel Mission Dallas will host a free Pediatric Health Fair serving homeless children and families in Dallas. The event will offer immunizations, screenings, and health education, aiming to improve vaccine access and equip families with tools for long-term wellness and preventive care.

More info: https://www.texmed.org/LocalImpactGrants/

December 2025

DALLAS MEDICAL JOURNAL | 27

MEMBERSHIP

2025 In Memoriam Mark Michael Altenau, MD April 21, 2025 DCMS member for 46 years

Willis Irving Cottel, MD March 3, 2025 DCMS member for 48 years

Sam T. Hamra, MD October 1, 2025 DCMS member for 42 years

Gabor Bela Racz, MD June 21, 2025 DCMS member for 44 years

John H. Baker, MD August 17, 2025 DCMS member for 39 years

Rody Powell Cox, MD September 28, 2025 DCMS member for 37 years

Edwin E. Harrison, Jr., MD June 28, 2025 DCMS member for 65 years

Sharon Coplen Reimold, MD November 13, 2024 DCMS member for 17 years

Denis L. Beaudoing, MD October 26, 2025 DCMS member for 47 years

Jewel Simpson Daughety, MD December 31, 2024 DCMS member for 70 years

Alfredo H. Jimenez, MD December 30, 2024 DCMS member for 24 years

Bennie Bench Scott, MD August 6, 2025 DCMS member for 49 years

Wendell A. Jones, MD September 1, 2025 DCMS member for 65 years

John Edward Touhey, MD June 14, 2025 DCMS member for 8 years

Robert L. Kirby, MD October 12, 2025 DCMS member for 42 years

Albert Vaiser, MD February 1, 2025 DCMS member for 59 years

Peter M. Loeb, MD February 28, 2025 DCMS member for 48 years

McDonald Hugo Walker, MD July 25, 2025 DCMS member for 6 years

Russell Lionel Martin, Jr., MD March 22, 2025 DCMS member for 60 years

Randall Gene Wilson, MD December 28, 2024 DCMS member for 5 years

Alan Newton Miller, II, MD December 17, 2024 DCMS member for 68 years

Aubrey Gordon Worsham, MD July 31, 2025 DCMS member for 68 years

Bobby Gene Black, MD September 1, 2025 DCMS member for 56 years David Leeper Bond, MD June 17, 2025 DCMS member for 63 years George Edward Bone, MD May 16, 2025 DCMS member for 47 years David Michael Bookout, MD May 21, 2025 DCMS member for 59 years W. Lee Bourland, Jr., MD January 31, 2025 DCMS member for 42 years Richard S. Bryant, MD April 8, 2025 DCMS member for 27 years Luis Orlando Castillo, MD November 29, 2024 DCMS member for 34 years

28 | DALLAS MEDICAL JOURNAL

Irvin Atwood Ebaugh, Jr., MD August 26, 2025 DCMS member for 63 years Phillip James Eichhorn, MD February 2, 2025 DCMS member for 44 years Gene E. Ewing, MD March 8, 2025 DCMS member for 41 years Dennis J. Factor, MD March 28, 2025 DCMS member for 62 years Fred M. Foster, MD January 17, 2025 DCMS member for 70 years Gordon D. Frank, MD December 15, 2024 DCMS member for 66 years James Bernhardt Goodman, MD January 26, 2025 DCMS member for 50 years

H. Leslie Moore, II, MD September 3, 2025 DCMS member for 54 years Neil R. Morrow, MD February 2, 2025 DCMS member for 60 years

December 2025

PHYSICIAN LEADERSHIP CERTIFICATE PROGRAM 10% COURSE DISCOUNT FOR DCMS MEMBERS

“This program offers a challenging curriculum of leadership training and self reflection. The speakers from the different sectors of healthcare were engaging and provided real examples of how our healthcare system weaves together, for better or worse. I feel more prepared as an effective leader of the teams I influence today and the teams of my future.”

Gates Colbert, MD, FASN

The healthcare landscape is evolving rapidly, and physician leaders who can navigate valuebased care, manage team dynamics, and drive quality outcomes are more essential than ever. The Dallas County Medical Society and UT Dallas Alliance for Physician Leadership are proud to offer a comprehensive Physician Leadership Certificate Program designed specifically for practicing physicians ready to expand their impact. This six-month, cohortbased program addresses the leadership competencies that matter most in modern healthcare, including: Physician wellness and resilience strategies Essential leadership and communication skills Value-based contracting and managed care navigation Quality performance improvement Emerging IT and informatics tools Revenue cycle and financial management Population health and social determinants of care We understand the demands on your time. Our program combines focused, in-person learning with a flexible format that adapts to emerging industry trends and your cohort's priorities—providing maximum value without overwhelming your clinical commitments. .

MORE INFORMATION

JOIN THE COHORT NOW CLASSES BEGIN JANUARY 16, 2026

Ruby Blum, VP Policy & Legislative Affairs ruby@dallas-cms.org (214) 413-1424 VISIT OUR WEBSITE

dallas-cms.org/leadershipprogram

SOCIETY

30 | DALLAS MEDICAL JOURNAL

December 2025

SOCIETY

DCMS Family Day at the Arboretum This year’s DCMS Family Day at the Dallas Arboretum was a spectacular blend of professional community and seasonal magic! Held on October 26, the event brought together physicians and their families for a relaxed afternoon amidst the breathtaking fall display. Between the towering pumpkin houses of the Pumpkin Village and the vibrant fall blooms, the children enjoyed STEM activities in the Rory Meyers Children’s Adventure Garden while parents enjoyed a much-needed chance to reconnect with colleagues over refreshments. The cool autumn breeze and the stunning backdrop of White Rock Lake made it a perfect reminder of why this annual tradition is such a cherished highlight for our members.

December 2025

DALLAS MEDICAL JOURNAL | 31

RESEARCH

A Road Map for Reducing Deep Tissue Pressure Injuries

by Matthew Quinton Pompeo, MD, CWSP, Lisley Viana Pt, MS, and Audrey Kim, MD

P

ressure injuries in general, and deep tissue injuries in particular, continue to plague our health system and represent one “never” event that is not improving.1 Deep tissue pressure injuries (DTPIs) were recognized as a subset of decubitus pressure injury and along with “Unstageable” were added to the National Pressure Injury Advisory (NPIAP) staging system in 2007. In addition to causing morbidity and mortality, these injuries are very costly to our health system, and are frequently the basis for increasingly costly litigation.2 To reduce DTPIs, we need to understand the factors that are contributing to their formation, and then address each factor to the extent possible. In this report we will briefly recap the physiology of DTPIs, present a typical case, and look at the numerous factors that contribute to deep tissue injuries, from the bedside realities to the regulatory and economic factors. As we define the issues, possible practice and policy solutions will be presented. Lastly, we will examine our current accountability system, which is our legal system, and see if there may be a better way to fairly compensate for these injuries, and reduce them. The consideration of this topic is based on the writers’ combined experience of over 60 years in directly caring for these patients, and review of over 200 legal cases for pressure injury.

32 | DALLAS MEDICAL JOURNAL

Litigation concerning pressure ulcers has increased since the 2000’s as medical advances have raised patients’ expectations to prevent such injuries.2,3 Additionally, a retrospective analysis in 2019 revealed that the plaintiffs have been successful in 75% of the nursing home cases between 1987 and 2019.4 Over time, the lawsuit awards have increased, from as little as $300,000 in the 2000’s to as much as over $3 million in the most recent years.4 The recommended measures to reduce and/or exclude liability include strict adherence to guidelines, risk assessment, family involvement, and successful collaboration between physicians and government institutions. However, the most crucial measure remains to be clinical documentation, demonstrating prevention policies and activities.2 Deep Tissue Injury Physiology: The physiology of deep tissue pressure injuries has been described extensively. Put simply, the pressure of a decubitus can be greatest at the muscle/bone interface, and muscle can be more susceptible to pressure than skin, so the tissue death occurs in the deep tissue.5 There has also been work showing that reperfusion injury is a part of the damage.5 Modeling of these injuries has shown that more prominent bone areas with less intervening cushioning of fat and muscle, and single blood vessel supply, make the heels particularly vulnerable.6 December 2025

RESEARCH

Our roadmap to reducing DTPIs will mainly require ensuring less pressure to vulnerable areas, which means more re-positioning and more effective use of pressure-reducing surfaces for trunk wounds and heel elevation devices for heel ulcers.

Deep Tissue Injuries can resolve completely, or they can go on to become unstageable and later stage 4 ulcers, and this wide variation confounds easily predicting what may happen at the case level.

Deep Tissue Pressure Injuries present as purple or maroon discoloration in light skinned individuals or dark or bruised appearance in dark skinned patients. They are particularly sinister because the damage occurs deep to the skin, and the injury is often not obvious to the untrained eye. In fact, they are frequently erroneously not recognized as a pressure injury at all, or called stage 1 (or if slightly open, stage 2 injuries) When they finally become an open wound, it can seem like it happened very quickly. They are like a hidden bomb with a 7–10-day fuse for the initial color change to turn into skin break or eschar for most patients.7 Very often the legal cases involve the transfer of a patient with such a “hidden bomb” to an unsuspecting recipient facility.

WHY HAVE WE FAILED TO REDUCE PRESSURE INJURIES? 1. Our medical improvements allow older and more frail patients to live longer: As our medical system has provided more effective treatments for many diseases, but especially for cardiovascular disease, infections, and cancer, we have kept patients alive longer, which can be taxing to the largest organ in the body, the skin. To some degree we are “victims of our own success.” And while “heart failure” carries no stigmata against a facility, “skin failure” is less easily explained.

In addition, patients are often heavier than they used to be, and that affects the staff resources needed to (safely) turn them.

2. Our documentation and current legal system require that nurses spend considerable time documenting instead of caring for patients.

Our electronic medical record (EMR) systems offer many advantages over paper charting such as remote access and legibility, but seem to require even more tending than the patients.

3. Inflation in general, but especially increased labor costs, put pressure on facilities financially. Reimbursements have not risen enough to offset these increased costs. This causes patient to staff ratios to be stretched.

Along these lines we are also seeing less use of wound nurses. In skilled nursing facilities, some locations are using physician groups that round typically weekly and do measurements to replace (they believe) the role of their wound nurses. This guarantees less expertise and focus on wound treatment and prevention the other 6 days of the week.

If wound nurses are not eliminated completely, their amount of coverage, such as on weekends, is steadily being decreased in some facilities as well.

4. Foley catheters are avoided as much as possible: Urinary diversion to protect the skin via foley catheters is less often used, due to the risk of urinary tract infections. We have replacements that are generally not as reliable in keeping the skin dry, and we know wet skin is more susceptible to injury.

5. True Low air loss beds are less or not available in some facilities: December 2025

Due to financial constraints, many hospitals now purchase their beds and try to reduce or eliminate specialty bed rental. Renting of highly effective low air loss beds in the past presented the advantages of more reliable placement, often more effective surfaces, and better sanitation between patients.

6. Patient transfers in and between facilities often interrupt pressure relief. For patients who actually have a DTPI or are at high risk of developing one, even a short lapse in pressure relief can produce or worsen a deep tissue injury. Lapses can occur at any time, but two instances deserve special mention. The first is when a patient leaves the intensive care unit (ICU). It is common that ICU beds are specialty beds, often with low air loss and/or alternating air. When patients leave the ICU, the bed typically stays, and they transition to whatever the bed is on the general ward. For ICU patients at high risk, provision of the appropriate surface should be proactively planned and done seamlessly, but this often does not occur. An even more dangerous move for patients is when they go to a rehabilitation or skilled nursing facility (SNF), especially if it is late Friday or on a weekend. SNFs often do not have the staffing levels or expertise to consistently recognize a patient with a DTPI or high-risk patient, and their supply chain may be less expeditious as well. In the time (often days) it takes to recognize the risk and get an appropriate surface, a DTPI can be sustained.

7. Emphasis on shortening patient length of stay creates tremendous pressure on staff to discharge patients! Transitions out of acute care are being affected by our Diagnosis Related Group (DRG) funding policies. Put bluntly, hospitals are forced to get patients out as soon as possible, especially with the labor costs and inflation they are facing with no corresponding reimbursement equalization. Patients with a DTPI often require debridement and if they are sent to a facility that cannot provide that type care, they will predictably need to be sent back when the wound requires debridement and/or the patient becomes septic.

8. Specialty bed use at home is also restricted: For patients who are at home, Medicare policy coverage of specialty beds has become increasingly restrictive, currently now only covering low air loss surfaces for multiple stage 2 or stage 3 and 4 ulcers that are of sufficient size.8 High risk or DTPI is not even recognized as a factor. It is ironic that the current Medicare policy for home patients would not suffice as the standard of care for a patient in a facility.

WHAT ABOUT RE-POSITIONING? Our stated standard of care is that patients be turned every 2 hours. However, there is no objective data available that suggests any health care environment consistently achieves this goal. In fact, when objective evidence was used, published studies show that turning is typically not done anywhere near every two hours, and often is not done in a way to be effective. Studies examining adherence to turn protocols have estimated it to be between 10% and 64%, and often the turns are not done in a way to effectively offload the wound area. 9,10 In another study at a Long Term DALLAS MEDICAL JOURNAL | 33

RESEARCH

acute care hospital, using a pressure map that recorded turning, it was found that turning occurred an average of every 4 hours.11 Another, more recent study using a wearable patient sensor on ICU patients showed that overall compliance with turning was only 54% and less than half the turns were greater than the 20 degrees established as the minimum effective turn.12 Empirically, we also find when we ask our visiting families if they observe while they are at the bedside if their loved ones are turned every two hours, the answer is invariably “no.”

Any one of these systemic challenges could possibly be overcome, but taken in toto, our system needs numerous factors improved to reduce the incidence of pressure injuries.

If we want to get on the road to reducing Deep Tissue Pressure Injuries, we need to address as many of these factors as possible. It will require ingenuity, effort and the will to get it done.

The majority of facilities are not turning every two hours, and there are basically two ways we can change that: 1. Hire more staff (it seems unlikely unless funding changes).

2. Get more turning out of existing staff: Regarding nursing leadership, Juli Heitman, RN wrote in Three Ways Leadership can get nurses back at the bedside:13 “Leaders must look at the litany of responsibilities shouldered by nurses and make efforts to curb the administrative tasks so there can be a return to the clinical duties at hand.

Hospital leadership needs to sort through the multiple extra responsibilities placed on staff and ask themselves what can be reduced for the short term. This could be a reduction in committee meeting work or simplifying education requirements to conserve nurses’ physical, intellectual, and emotional energy.

We need nurses back at the bedside because it’s the essence of the role: nurses thrive from being a part of a patient’s journey by being “present,” updating family members, and engaging the healthcare team to work seamlessly to get them back to their state of wellness. According to a recent study published in the Journal of Advanced Nursing, less than one-third of a nurse’s time was spent with patients.

Nurses shouldn’t be bogged down by tedious paperwork or endless charting; they should have every opportunity to care for their patients. With this in mind, the question now centers on how we can empower our nurses and ease their collective burden. In an increasingly digital world, I would argue that embracing technology must be a major consideration for our nurse colleagues.”

As we try to define and accentuate the essential role of nurses and improve their productivity, there may be no way better way to do it than to have leaders who actually work shifts just like their employees do regularly, so that they can appreciate the true barriers we need to fix.

In order of what we perceive as the most critical on down, here are some ideas: 1. Improve Turning compliance and quality. a. Automated recording of turning. Either a sensor on the patient or a pressure map-based system can automatically record turning and inform contemporaneously the effectiveness of the care delivered. More time can be spent providing care and less time charting. Numerous studies have shown that such systems improve turning compliance and effectiveness and can actually reduce health care costs.12,14,15, One study showed that use of such a system reduced their hospital 34 | DALLAS MEDICAL JOURNAL

Deep Tissue Injury Case Study This patient suffered diverticulitis and required a colectomy and was very resistant to being turned post operatively due to his abdominal pain (photos used with permission of patient).

Figure 1a: 12/30/23.

This initial photo shows a very classic purple DTPI and this is what we saw on the day it was reported.

Figure 1b: 01/04/24.

5 days later is the first minor break in the skin and to a novice might be staged as a stage 2.

Figure 1c: 01/09/24.

10 days after initial presentation the tissue has turned into eschar and it would be called “unstageable.”

Figure 1d: 01/12/24.

13 days after discovery this is how it looked after being debrided in the Operating room.

There is still poor quality tissue in the base and at this point the wound is getting contact ultrasound treatments at the bedside several days a week.

Figure 1e: 02/29/24.

Now about 2 months later, seen in the wound clinic, the wound is much improved.

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acquired pressure injury rate by 85%.15 Our current “compliance” looks at what we CHARTED about turning which may or may not be related to actual turning. Perhaps soon we can just video all bedside care and let AI do the charting of it. Certainly privacy issues would arise, but patients could be given the choice. We could even consider a payment system that looks at actual bedside care so that hospitals are incentivized to make bedside care a priority. Companies that insure facilities could also give financial incentives for them to use systems which document and promote turning. b. Consider different turning schedules based on patient risk. If many patients don’t need to be turned every two hours, we can concentrate our resources on those that may need it even more often. Numerous studies have delineated risk factors that predict DTI, such as low blood pressure, anemia, hypotension, diabetes, vascular disease, etc.16,17 c. Develop wards/hospitals with verified turning excellence.

Once we have a unit or a hospital with verified turning that is proven over an extended time frame, see how they do it and what that will cost to replicate on a system-wide basis. We may find that for what we are currently able to pay in terms of staffing levels or hourly wages, it is not possible to establish or duplicate turning excellence. If we find the cost to actually provide the care is beyond current reimbursement, we can either pull resources from other areas, or establish what the “reimbursed” standard of care actually is.

Our current posturing is to declare one standard but fund another, and that is a recipe to create lawsuits.

2. Obtain an effective pressure reduction surface- and document that the patient is actually on it. One of the most common difficulties we find in defending pressure ulcer cases is in identifying documentation of the specialty bed. We know from experience that identifying an order does not necessarily mean the surface was delivered. Any bed is a trade-off of features. For instance, the best low air surfaces for reducing interface pressure typically immerse and envelope patients more, and that can make it more difficult to get in and out of and hamper physical therapy.

If the patient’s need for therapy (or patient refusal of a low air loss bed) affects the bed utilized, document as such.

Concerning low air loss surfaces, the 2019 National Pressure Injury Advisory Panel (NPIAP) position statement makes the following observation: Recently published US standards suggest that immersion and envelopment should be used to characterize pressure redistribution and provide test methods for these parameters.

Regarding individualization of bed selection the NPIAP position statement says: “Choosing a support surface for an individual should take into account their specific needs.

7.1: Select a support surface that meets the individual’s need for pressure redistribution based on the following factors: • Level of immobility and inactivity • Need to influence microclimate control and shear reduction • Size and weight of the individual • Number, severity and location of existing pressure injuries • Risk for developing new pressure injuries. (Good Practice Statement)” Concerning larger patients, the NPIAP standards say: Evidence Discussion: “Standard beds are 32 to 36 inches (81 to 91 cm) in width. Individuals who fill the width of the bed may be restricted December 2025

in their ability to turn side-to-side or into positions that offload the sacral area. Selection of support surfaces should also consider the individual’s body dimensions, ensuring there is adequate space for repositioning.”

Summary of bed selection: the most important aspect is to individualize specialty bed selection for each patient. It is therefore not possible to purchase one or two bed models that will be optimal for all patients.

What about patients who are non-compliant with turning or medically too unstable to be turned? In defending care givers, we see this situation often. The key in these cases is to document the situation, ideally, repeatedly. For medically unstable patients, unless there is a physician order not to turn, turning should be attempted and the results documented (such as desaturation). Being unstable once does not negate trying to turn for days; as their condition improves gentle turning trials should be attempted when clinically possible to do so with documentation of each result.

Patients also have a right to refuse treatment, but we must document we made them aware of the potential risk, and if there is any question about their ability to understand, try to educate the family if there is one.

ACTIONS TO TAKE WHEN A DTPI IS IDENTIFIED: • Notify family, physician(s) and document accordingly.

• Photos are the best documentation.

• Discuss with staff the turning plan and document any barriers and what is being done to address them.

• Offer to have family see the area, and document their awareness.

This is important for several reasons: 1. Failing to notify family is a common accusation in litigation about DTIs. 2. Often part of the problem is offloading, and the family can help to advocate for offloading to encourage the patient and staff to do so.

3. Once the family becomes part of the treatment team, they will understand the challenges and have a more common stake with the health care team.

4. Educating about the possible outcomes of a DTPI can take out the surprise element which is sometimes the nidus for considering a lawsuit.

In other words, it is often not just a poor outcome, but the “surprise” of a poor outcome that instigates legal cases. Families ideally should understand that even with excellent care, once a DTPI is established, the central area will often go on to eschar and will likely need sharp debridement.

CONCERNING OFFLOADING FOR TRUNK AREAS It is not uncommon for patients to turn themselves back onto their back after being turned. Often wedges are necessary to keep patients off their backs. Consider an air fluidized surface if necessary (for instance if effective turning is just not getting done or if they have been on a low air loss surface but seem to still be getting too much pressure.) One small study suggested use of a air fluidized bed could reduce progression of the injury and be cost effective.18 We have DALLAS MEDICAL JOURNAL | 35

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observed that patients with low blood pressure (especially diastolic in the 50s) are a group that are particularly vulnerable to DTPIs and may need the lower interface pressure an air fluidized system can provide.

REFERENCES 1. Agency for Healthcare Research and Quality. Declines in hospital-acquired conditions. 2020. https://www. ahrq.gov/data/infographics/hac-rates_2019.html. Last accessed January 1, 2025.

2. Gibelli F, Bailo P, Sirignano A, Ricci G. Pressure ulcers from the medico-legal perspective: a case report and literature review. Healthcare 2022;10(8):1426. doi:10.3390/healthcare10081426.

3. Fife CE, Yankowsky KW, Ayello EA, et al. Legal issues in the care of pressure ulcer patients: key concepts for healthcare providers–a consensus paper from the International Expert Wound Care Advisory Panel©.

Adv Skin Wound Care 2010;23(11):493-507. doi:10.1097/01.ASW.0000390494.20964.a5.

4. Jehle CC, Hartnett D, Snapp WK, et al. Assessment of malpractice claims associated with pressure ulcers.

Plast Reconstr Surg Global Open 2019;7:90.

5. Smart H. Deep tissue injury: what is it really? Adv Skin Wound Care 2013;26(2):56-8. doi:10.1097/01.

ASW.0000426712.72787.f3.

6. Salcido R, Lee A, Ahn A. Heel Pressure ulcers: purple heel and deep tissue injury. Adv Skin Wound Care 2011;24(8):374-80.

7. Black JM, Berke CT. Deep tissue pressure injuries: identification, treatment, and outcomes among critical care patients. Crit Care Nurs Clin North Am 2020;32(4):563-72. doi:10.1016/j.cnc.2020.08.006.

8. Centers for Medicare and Medicaid Services. Pressure reducing support surfaces - group 2. n.d. https:// www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33642&ver=26&keyword=low%20 air%20loss&keywordType=starts&areaId=all&docType=NCA,CAL,NCD,MEDCAC,TA,MCD,6,3,5,1,F,P&contr actOption=all&sortBy=relevance&bc=1. Last accessed Jan 1, 2025, 9. Schutt SC, Tarver C, Pezzani M. Pilot study: Assessing the effect of continual position monitoring technology on compliance with patient turning protocols. Nursing Open 2018;5:21–8.

10. Winkelman C, Ling-Chun C. Manual turning in patients receiving mechanical ventilation. Critical Care Nurse 2010;30(4):36–44. doi:10.4037/ccn2010106.

11. Pompeo MQ. Pressure map technology for pressure ulcer patients: can we handle the truth? Wounds 2013;25(2):34-40.

12. Pickham D, Pihulic M, Valdez A, Mayer B, Duhon P, Larson B. Pressure injury prevention practices in the intensive care unit: real-world data captured by a wearable patient sensor. Wounds 2018;30(8):229-34.

13. Heitman J. Three ways leadership can get nurses back at the bedside. 2021. https://www.medpagetoday.com/opinion/kevinmd/94807. Last accessed Jan 1, 2025.

14. Nherera L, Larson B, Cooley A, Reinhard P. An economic analysis of a wearable patient sensor for preventing hospital-acquired pressure injuries among the acutely ill patients. Int J Health Econ Manag 2021;21(4):457-71. doi:10.1007/s10754-021-09304-7.

15. Walters B, Jamison K, Zafer D, Sanders T. Transforming pressure ulcer prevention in the icu with patient wearable technology and nursing leadership. Lecture presented at: Texas Organization of Nurse Executives. February 2016; Austin, TX. 16. Preston A, Rao A, Strauss R, Stamm R, Zalman D. Deep tissue pressure injury: a clinical review. American Journal of Nursing 2017;117(5):50-7. doi:10.1097/01.NAJ.0000516273.66604.c7.

17. Rao AD, Preston AM, Strauss R, Stamm R, Zalman DC. Risk factors associated with pressure ulcer formation in critically ill cardiac surgery patients: a systematic review. J Wound Ostomy Continence Nurs 2016;43(3):242-7. doi:10.1097/WON.0000000000000233.

18. Allen L, McGarrah B, Barrett D, Stenson B, Turpin PG, Vangilder C. Air-fluidized therapy in patients with suspected deep tissue injury: a case series. J Wound Ostomy Continence Nurs 2012;39(5):555-61. doi:10.1097/WON.0b013e318264c2ec.

19. Driver VR, Yao M, Miller CJ. Noncontact low-frequency ultrasound therapy in the treatment of chronic wounds: a meta-analysis. Wound Repair Regen 2011;19(4):475-80. doi:10.1111/j.1524-475X.2011.00701.x.

20. Tricco AC, Antony J, Vafaei A, et al. Seeking effective interventions to treat complex wounds: an overview of systematic reviews. BMC Med 2015;13:89. doi:10.1186/s12916-015-0288-5.

21. Voigt J, Wendelken M, Driver V, Alvarez OM. Low-frequency ultrasound (20-40 kHz) as an adjunctive therapy for chronic wound healing: a systematic review of the literature and meta-analysis of eight randomized controlled trials. Int J Low Extrem Wounds 2011;10(4):190-9. doi:10.1177/1534734611424648.

22. Viana L, Pompeo M. Healing rate of chronic and subacute lower extremity ulcers treated with contact ultrasound followed by noncontact ultrasound therapy: the VIP ultrasound protocol. Wounds 2017;29(8):231-9.

23. Honaker JS, Forston MR, Davis EA, Weisner MM, Morgan JA, Sacca E. The effect of adjunctive noncontact low frequency ultrasound on deep tissue pressure injury. Wound Repair Regen 2016;24(6):1081-8. doi:10.1111/wrr.12479.

24. Honaker JS, Forston MR, Davis EA, Wiesner MM, Morgan JA. Effects of non contact low-frequency ultrasound on healing of suspected deep tissue injury: a retrospective analysis. Int Wound J 2013;10(1):65-72. doi:10.1111/j.1742-481X.2012.00944.x.

25. Honaker J, Forston M. Adjunctive use of noncontact low-frequency ultrasound for treatment of suspected deep tissue injury: a case series. J Wound Ostomy Continence Nurs 2011;38(4):394-403. doi:10.1097/WON.0b013e31821e87eb.

26. Wagner-Cox P, Duhame HM, Jamison CR, Jackson RR, Fehr ST. Use of noncontact low-frequency ultrasound in deep tissue pressure injury: a retrospective analysis. J Wound Ostomy Continence Nurs 2017;44(4):336-42. doi:10.1097/WON.0000000000000342.

27. Dyson M. Non-thermal cellular effects of ultrasound. Br J Cancer Suppl 1982;5:165-71.

28. Dyson M. Therapeutic applications of ultrasound. In: Nyborg WL, Ziskin MC, eds. Biological effects of ultrasound (clinics in diagnostic ultrasound). New York, NY: Churchill Livingstone; 1985:121–33.

29. Harvey W, Dyson M, Pond JB, Grahame R. The stimulation of protein synthesis in human fibroblasts by therapeutic ultrasound. Rheumatol Rehabil 1975 Nov;14(4):237. doi:10.1093/rheumatology/14.4.237.

30. Webster DF, Pond JB, Dyson M, Harvey W. The role of cavitation in the in vitro stimulation of protein synthesis in human fibroblasts by ultrasound. Ultrasound Med Biol 1978;4(4):343-51. doi:10.1016/03015629(78)90023-6.

31. Fyfe MC, Chahl LA. Mast cell degranulation: a possible mechanism of action of therapeutic ultrasound.

Ultrasound Med Biol 1982;8(Suppl 1):62–5.

32. Young SR, Dyson M. Macrophage responsiveness to therapeutic ultrasound. Ultrasound Med Biol 1990;16(8):809-16. doi:10.1016/0301-5629(90)90045-e.

33. Unger PG. Low-frequency, noncontact, nonthermal ultrasound therapy: a review of the literature.

Ostomy Wound Manage 2008;54(1):57–60.

34. Escandon J, Vivas AC, Perez R, Kirsner R, Davis S. A prospective pilot study of ultrasound therapy effectiveness in refractory venous leg ulcers. Int Wound J 2012;9(5):570–8.

35. Yao M, Hasturk H, Kantarci A, et al. A pilot study evaluating non-contact low-frequency ultrasound and underlying molecular mechanism on diabetic foot ulcers. Int Wound J 2012;11(6):586–93.

36. Kavros SJ, Schenck EC. Use of noncontact low-frequency ultrasound in the treatment of chronic foot and leg ulcerations: a 51-patient analysis. J Am Podiatr Med Assoc 2007;97(2):95–101.

37. Serena T, Lee SK, Lam K, Attar P, Meneses P, Ennis W. The impact of noncontact, nonthermal, lowfrequency ultrasound on bacterial counts in experimental and chronic wounds. Ostomy Wound Manage 2009;55(1):22–30.

38. Seth AK, Nguyen KT, Geringer MR, et al. Noncontact, lowfrequency ultrasound as an effective therapy against Pseudomonas aeruginosa-infected biofilm wounds. Wound Repair Regen 2013;21(2):266–74.

39. Liedl DA, Kavros SJ. The effect of MIST ultra-sound transport technology on cutaneous microcirculatory blood flow. Lecture presented at: Symposium on Advanced Wound Care; April 30–May 3, 2001; Las Vegas, NV. 40. Thawer HA, Houghton PE. Effects of ultrasound delivered through a mist of saline to wounds in mice with diabetes mellitus. J Wound Care 2004;13(5):171–6.

41. Lai J, Pittelkow MR. Physiological effects of ultrasound mist on fibroblasts. Int J Dermatol 2007;46(6):587– 93.

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DIRECT WOUND TREATMENTS A. Consider Non-contact ultrasound treatments. (MIST) MIST™ Therapy (Sanuwave, Eden Prairie), also referred to as Noncontact Low Frequency Ultrasound (NLFU) has been shown to have a positive impact in the treatment of various types of chronic wounds.19,20,21,22. Some studies suggest that the benefits of NLFU can also extend to the treatment of DTIs.23,24,25,26 The mechanism by which NLFU works is particularly unique because it offers a way to actively treat an injury that is still below a layer of closed skin.

Ultrasound is a modality employed in wound care to accelerate healing processes. Unlike the ultrasound equipment used in diagnostic imaging or the treatment of soft tissue injuries in sports medicine and traditional physical therapy, the devices used in wound care operate at significantly lower frequencies. Specifically, wound care ultrasounds function within the kilohertz (kHz) range, as opposed to the megahertz (MHz) range utilized in diagnostic and therapeutic applications.

The wound-healing benefits of low-frequency ultrasound are primarily due to its nonthermal effects, specifically cavitation and acoustic streaming. Research shows that acoustic streaming modifies cell membrane permeability and second messenger activity27,28, which leads to increased protein synthesis29,30 mast cell degranulation,30 and the production of growth factors.31 The MIST™ system operates at a low intensity of 0.2–0.6 W/cm² and a frequency of 40 kHz. Unlike high-frequency ultrasound, the longer wavelength produced by the MIST™ equipment enables deeper tissue penetration. This capability is crucial for treating wounds of virtually any etiology, and particularly interesting for the treatment of DTIs. In this case, the primary objective of NLFU is to stimulate the damaged area caused by DTI at both cellular and molecular levels.

With MIST™, ultrasound is delivered perpendicularly to the wound bed without direct tissue contact, utilizing a saline mist as the coupling medium. When the ultrasonic energy impacts the wound cells, it induces biophysical effects such as the stimulation of cellular activity. These mechanical forces promote cell division, protein synthesis, activation of inflammatory cells, and fibroblast activation through the production of chemical mediators.32 Additionally, NLFU contributes to the reduction of inflammation,33,34 bacterial count,35,36 and biofilm disruption.37 It facilitates vasodilation,38 angiogenesis,39,40 growth factor production,40 and collagen deposition.35,39,41 Studies have demonstrated the benefits of NLFU in promoting the healing of DTIs and suspected DTIs.23,24,25,26 The timing of treatment initiation may be a crucial factor. Starting NLFU treatment within five days of DTI onset, alongside standard care, may enhance outcomes compared to standard care alone.26 Furthermore, a retrospective study involving 44 subjects supports the potential benefits of NLFU for both hospital-acquired and pre-existing DTIs, suggesting that NLFU could be equally beneficial for both types of DTIs.26 In a 60-subject prospective study,23 Honaker et all showed that, at discharge, the treatment group exhibited a significantly greater decrease of 8.8 cm² (t = 2.41, p = 0.014, r² = 0.10) compared to the control group.

At discharge, the final pressure ulcer stages in the control group were December 2025

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predominantly unstageable pressure ulcers (57%) and deep tissue pressure injuries (27%). In contrast, the treatment group exhibited less severe final pressure ulcer stages at discharge, with stage 2 pressure injuries (50%) and deep tissue pressure injuries (23%) being the most common.

The evidence underscores the importance of integrating a timely initiation of NLFU into standard care protocols to enhance the healing of DTIs and reduce their severity over time. These findings highlight the limitations of standard care alone in promoting optimal improvement for DTIs and point to the need for adjunctive therapies like NLFU to achieve better clinical outcomes.

B. Dressings and Medications Topical treatments will change as the DTI changes. Balsam of peru ointment while skin is intact can be considered, with or without a border foam, although the evidence for it is weak.

Border foams have been shown to help reduce pressure to the area, but we think they should be changed ideally daily so the area is monitored more closely.

The advantage of ordering at least a daily treatment is that there will be records of attention to the area in the MAR this way.

If stool incontinence is a major factor, barrier cream might be considered but it does obscure somewhat. When there is desquamation starting we like Silvadene because of its activity against gram negative organisms. . Once there is eschar, we like honey or Silvadene. Silvadene is especially cost effective when there is a relatively large area involved.

Debridement: When the area is demarcated, debridement at Bedside or in OR may be appropriate. If there is not yet separation it will likely be more bloody and painful, but if the patient is not showing signs of infection and the wound can be given time to have more separation, it is typically less painful.

Some of these patients may be quite terminal as well, and hospice will be appropriate in lieu of surgical treatments.

SPECIAL CONSIDERATIONS FOR HEEL OR FOOT DTIS Beware of Ted Hose! We have seen multiple legal cases where an advanced heel ulcer is found under a ted hose. The ted hose do not cause them, but they hide them. Ted hose should be removed at least daily if not at each shift to assess heels. Cutting the heel portion out can make it easier to do a heel skin evaluation.

Float the Heels. Specialty beds alone do not offload the heel well because the area is too small. Use pillows and/or heel offloading devices.

One study showed patients using foam or similar offloading devices did not have their heels suspended off the bed as well as pillows, and developed pressure ulcers more rapidly than those using pillows.7 However, one disadvantage of pillows is that they can become ineffective from patient movement. Whatever method is chosen, frequent evaluation by the medical staff, and documentation, is helpful.

Define vascular status. If there is significant peripheral arterial disease (PAD), heel perfusion will be reduced and that will make pressure injury more likely. Good pulse exams are relevant for these patients.

If there is an ulcer and pulses are not palpable, further vascular evaluation should be considered in appropriate candidates, and debridement should be deferred until the vascular situation is defined, and optimized if possible. The posterior tibial artery is particularly important because it often supplies the heel angiosome. Even with a palpable dorsalis pedis pulse, revascularization of the posterior tibial artery may be worthwhile December 2025

for a heel injury. Heel eschar should not necessarily be debrided if it is stable (dry and no signs of infection) because the fibrofatty tissue of the heel area does not have as good of perfusion as other areas of the body even when PAD is not present. It is important to explain to the patient and family that dry eschar can be watched, but over time it may turn wet or get infected and require debridement. If there is PAD present it is best to explain that we want to balance the risks of infection or dead tissue vs. the risk of creating a larger deeper wound that will be hard to heal. If the patient has severe PAD that cannot be corrected, a higher level of amputation may even be the appropriate procedure Severe leg contractures can cause torque and increase pressure injuries to feet, ankles and heels. We have seen a good number of legal cases involving very contracted legs. In some cases they are impossible to offload, and there is not good evidence that even extensive physical therapy can prevent or reverse lower extremity contractures. Revascularization usually cannot be done in severe cases either. In fact, it has been our experience that sometimes above knee amputation is the only definitive treatment to offer.

Our Current accountability system for pressure injury is our legal system. It is not working. We can do better. Our current system could be greatly improved by: 1. Giving resolution sooner. Our experience is that most cases do not resolve for 2 to 4 years. Most recipients would be much better served to have that happen more quickly.

2. Mandate that 15% of the settlement or award goes into a fund that gives resources to facilities for pressure sore reduction and enforces accountability. Even when the plaintiff is successful, it seems there is no incentive for facilities to change behavior. One could argue that losing a case could cause insurance rates to go up which actually gives them fewer resources in the future to take care of patients.

We could solve these two problems with a Pressure Ulcer Specialty Arbitration Board. We could move cases through much more quickly, get plaintiffs their rewards sooner, and I would like to see some of the settlement go into resources and enforcement to help facilities reduce pressure ulcers.

CONCLUSION Deep Tissue Pressure Injuries are a particularly sinister subset of pressure injury. They occur in our most fragile patients and require constant vigilance to prevent. Once they form, the outcome can be wide ranging. We can definitely reduce their occurrence, but our current health care system has many features that could be improved to increase the bedside care that would be the central factor in reducing these injuries. We need to bring accountability to the bedside, rather than have it enforced years later in our legal system. If we could set up a special branch of our legal system to speed up the process and fund initiatives to support education and prevention of these injuries, we might finally be able to reduce the damage deep tissue injuries are causing. DMJ

DALLAS MEDICAL JOURNAL | 37

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The firm’s growth through multiple economic cycles reflects its purpose-driven approach to client service. Wick Phillips maintains long-standing relationships with organizations ranging from Fortune 500 companies to emerging enterprises and professional practices.

Grounded in trust, responsiveness, and a clear understanding of client objectives, the firm’s model emphasizes flexible, solutions-oriented counsel designed to help clients achieve their goals—an approach captured in its commitment to practice Law with Purpose®.

Z360 IS AN ENTERPRISE-GRADE ARTIFICIAL INTELLIGENCE PLATFORM designed for small and medium-sized service organizations, including outpatient and ancillary healthcare practices facing high inquiry volumes and persistent staffing constraints. Developed to address operational inefficiencies common in resource-limited settings, the platform centralizes customer engagement, sales follow-up, and task automation within a secure, unified architecture. Integrating with more than 100 business systems, Z360 operates as a continuously available front-desk assistant, automated follow-up engine, and intelligent CRM, with the explicit objective of eliminating missed inquiries, shortening response times, and reducing administrative workload.

40 | DALLAS MEDICAL JOURNAL

Early implementations demonstrate substantial operational benefit, with reported 40 percent gains in employee productivity, 30–50 percent improvements in lead conversion driven by automated followup, and removal of 15–20 hours per week of routine administrative tasks. The platform offers real-time analytics, enterprise-level security, rapid deployment within two weeks, and fully managed support, positioning it as a cost-efficient alternative to fragmented digital tools.

For smaller healthcare and service organizations seeking to modernize communication workflows and strengthen financial performance, Z360 provides an integrated AI infrastructure designed for measurable, nearterm return on investment.

Ready to transform your business with AI? Contact: Ansar Ullah Anas, Founder Richardson, TX z360.biz Z360 is built by Zikra Infotech LLC, bringing 8+ years of small business expertise to AI innovation.

December 2025

In This Season of Reflection,

We Wish You Health and Peace in the New Year.

Insurance For Good reflects our ongoing commitment to physician well-being throughout the year, using surplus funds to provide Texas physicians and their families with meaningful resources beyond insurance coverage.

Anticipate Joy is one of the many benefits we’re honored to offer.

Through free, completely confidential, HIPAA-compliant online counseling, Anticipate Joy helps lighten life’s demands and makes mental health care simple to access. Every session with a licensed counselor is private, compassionate, and on your terms — whether by video, phone, or text, making it easier to find balance in everyday life.

We’d be glad to share more about the Anticipate Joy benefit and support your insurance needs. Our advisors are available at 1-800-880-8181, Monday through Friday, 8:00 AM to 5:00 PM CST, or learn more at tmait.org.

SCAN TO LEARN MORE

AT S V M I C , W E ’ R E

PREPARED PROTECTED TO KEEP YOU AND YOUR PRACTICE

We help doctors stay focused on delivering exceptional patient care by protecting their practices from malpractice claims. Our in-house attorneys collaborate closely with local defense experts to provide the preparation and support you need, whenever you need it.

Get a quote at svmic.com/texas

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