You Cannot Mandate Your Way to Change and Adoption with Dr. Ethan Booker
Dr. Ethan Booker is the Chief Medical Officer for Telehealth at MedStar Health, founding director of the MedStar Telehealth Fellowship, and a senior attending physician in emergency medicine at MedStar Washington Hospital Center. He has been building connected care programs since 2015, which in telehealth years makes him one of the original builders in this space. His work sits at the intersection of workforce sustainability, technology adoption, and what it actually takes to make a program that people want to use.
Solving a Problem People Actually Wanted
The MedStar connected care program did not start with a technology decision. It started with primary care physicians describing what was killing them: medication management in the portal. Two to ten hours of pajama time after the clinical day was done, spent looking through charts, checking labs, and deciding whether it was safe to renew a prescription. Work that generated no RVUs, eroded professional identity, and had nothing to do with why anyone went to medical school.
The program MedStar built applied surgical practice logic to primary care. In surgical practices, APPs are given a circumscribed role that frees the surgeon to do the work only they can do. Add a PA to an orthopedic practice and the orthopedist generates higher productivity in the operating room. Primary care had never been structured that way. MedStar structured it deliberately, with nurse practitioners taking on same-day and next-day acute appointments, medication renewals, and portal message volume, freeing primary care physicians for higher complexity and new patient appointments. The model was financially sustainable because the nurse practitioners billed for their visits. The pajama time disappeared.
The listening process was not a formal intake system. It was being embedded in the organization, having relationships at both the frontline and leadership level, and paying attention to what people were actually saying. That is not a complicated process. It is consistently not done.
Adoption Variability and the Doctor Who Felt Like Doing It
When Ethan described adoption variability across the program, his observation cut straight to something most health systems spend enormous energy avoiding saying out loud. The variability had nothing to do with payer mix. Nothing to do with patient age or panel demographics. It came down to whether the doctor felt like doing it.
Physicians who wanted to manage every medication renewal themselves were permitted to do so. Physicians who wanted to see all of their own acute care patients were not required to hand any off. The program was not mandated. Physicians who were at the limit of their productivity and their after-hours time leaned in early, saw the benefit within weeks, and became fast followers who made it visible to everyone else that this was worth doing.
Most implementation strategies are designed to convince skeptics. This one was designed to deliver real value to the people who were ready and let the social proof do the rest. The physicians who stayed out were not failures of the program. They were people whose circumstances did not create the same burning platform, and forcing the model on them would have undermined the trust that made the whole thing work.
Ambient AI and the Productivity Story That Did Not Arrive
MedStar has generated somewhere in the neighborhood of a million notes using ambient AI, predominantly in urgent care, specialty services, and some primary care. The adoption pattern mirrors the connected care program almost exactly. Some clinicians love it, some barely use it, and the specialty does not predict which. A kidney stone specialist who had already optimized his clinic notes to near-perfect efficiency saw no reason to change. A GI doctor who discovered he could look his patient in the face and actually have a conversation said do not ever take it away.
Most clinicians have not seen the dramatic time savings ambient AI was supposed to deliver. What keeps coming up instead is the quality of the patient encounter when the physician is not simultaneously trying to document it. That is a different and harder value to measure, but it is what is actually driving sustained adoption among the people who love it. If your deployment strategy is built around time savings and efficiency metrics, you may be measuring the wrong thing and missing the real argument for adoption entirely.
Epic and the Integration Brittleness Problem
MedStar is transitioning from Oracle Cerner to Epic, and Ethan’s framing of that decision is one of the more honest assessments of the consolidation trade-off available from someone inside a large health system. Most of the places where telehealth implementations break are integrations. Registration integrations, billing integrations, data feeds that require matching one system to another. That brittleness is the most consistent failure point across eleven years of building.
The Epic consolidation trades some capability for a data environment that is clean, reliable, and unlikely to break. For most tools that trade makes sense. A seamless, reliable, integrated experience that works consistently is worth more in practice than a superior experience that breaks unpredictably.
The calculus changes for patient safety tools. A sepsis deterioration detection tool that is genuinely superior to what Epic can offer is worth the integration complexity because the stakes are categorically different. Epic’s responsibility, Ethan argued, is to make sure that best-of-breed patient safety tools can plug in cleanly rather than forcing health systems to choose between integration reliability and the best possible clinical outcome.
Retention, Identity, and What Well-Being Actually Means
As MedStar rolled out the connected care program sequentially across its primary care footprint over eighteen to twenty-four months, associate survey scores for intention to stay in the organization improved in rough synchrony with the rollout. No significant changes to compensation packages during that period. When they talked to physicians the answer was consistent: you listened to what was killing us and you did something about it. That is the kind of organization I want to stay in.
Clinicians want to feel they are doing the work they were trained to do. They want to be productive. Work that feels erosive of professional identity erodes well-being faster than almost anything else. Work that robs them of productivity erodes it too. Pats on the back do not fix either of those things. The technology programs that improve retention are the ones that remove the specific friction that was making the work feel wrong and signal to the workforce that someone was listening.
Principles for Healthcare Leaders
Start with the problem people actually want solved. The specific burning platform the people doing the work are describing, not the problem that makes the technology look impressive.
Adoption variability is not a failure. Physicians who do not lean in may simply not have the same burning platform. Mandating a model on people who do not need it undermines the trust that makes voluntary adoption work.
Design for the early adopters and let the social proof do the work. Make the value visible to the people who are ready. Fast followers come when they can see the benefit in someone who looks like them.
For ambient AI, measure the quality of the patient encounter. The productivity story is not landing the way anyone expected. Build your adoption strategy around what is actually driving sustained use.
Integration brittleness is the most consistent failure point. Know where the reliability trade-off breaks down and it breaks down when the stakes are patient safety.
Clinician well-being is about identity and productivity. Remove the work that feels erosive of professional identity. Make physicians productive in the ways that matter to them.
Listening and responding is itself a well-being intervention. The programs that improved retention at MedStar were operationally effective and they signaled to the workforce that the organization had heard them. That signal matters as much as the program itself.
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Related Resources
Episode 12:Building Digital Health Adoption from the Inside out
Episode 11 Why Most Digital Health Programs Never Cross the Threshold
Episode 10: The Gap Between Good Tech and Actually Using It with Stéphane Tholander
Article: 95% of Adoption Fails
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Dr. Aditi Joshi is the CEO of Ardexia and host of the Ardexia podcast. She's an emergency physician who has built multiple digital health programs across three continents and specializes in turning failed digital health implementations into measurable clinical and financial success.