A Colorado original: 10th Mountain Division Hut system

If you said to me a few months ago: “You are going to enjoy spending 5 hours at the brink of your anaerobic threshold, gasping for air at 11,000 feet, carrying a 50 pound backpack to a remote hut in the Colorado back country?” I would have called you crazy.

Having just returned from a long weekend involving a 12 mile round trip to Uncle Bud’s Hut, part of the 10th Mountain Division Hut Association, I can say that it was an amazing, once in a lifetime experience.

Once in a lifetime, because, maybe I don’t need to ever do that again.

For example, a few decades ago (1994!) I trained for and completed the Davis Double Century ride; or 200 miles in one day on a bike. I did enjoy the mind-expanding (and thigh-muscle-expanding) experience. The months leading up to the event were both exciting and grueling (riding 20 to 60 miles on days leading up, just to prepare). The actual event was transformative, and an achievement that I’ll always be proud of. Starting out with thousands of other cyclists, decorating the road with the splashy rainbow of cycling jerseys, chatting as we, amoeba-like, engulfed miles of asphalt with human-powered wheels, devouring hundreds of pounds of cyclist snacks every 20 miles, climbing and descending gentle slopes in the company of adventurous souls.

HOWEVER, the last few hours, the last 50 miles, riding in darkness, our newly-purchased bike lights fading, our legs giving out, the bananas and snack bars and chicken soup no longer filling our always-hungry bellies, the road ahead stretching (literally) into invisible infinity, our saddle sores more urgently uncomfortable, our on-the-road cycling companions dropping away and disappearing. And then pulling in to the start/finish line at 200 miles, and, no longer having strength to unclip from my pedals, falling over in both exultation and exhaustion.

After that ride, I did not get back on the bike for a month, and to this day, still have NO interest in joining another 200 mile ride.

In that spirit, I can report that my Uncle Bud’s experience was also transformative. Here’s how it went down. Come along!

  • Go get your stuff. We headed out to Bent Gate, apparently one of the few stores in Denver Metro (Golden actually) that will rent AT ski’s and backcountry gear (All-terrain, for us newbies). $800 for 2 of us for 3 days: avalanche beacon, avalanche 20 foot collapsible probe, shovel, boots, ultra-light skis that somehow behave BOTH like alpine downhill skis with good edges for sliding down and have lockable heels for a stable foot platform, AND are lightweight and can be made into cross-country, pivoting-toe attachment skis. Don’t ask me more. They’re both like telemark skis and also not. ?!?
  • Read the map (OMG 6 miles to Uncle Bud’s, along a fire road and then UP for the last 3 miles). Stress.
  • Plan on making dinner for 17 people on the trip on Sunday night (what to make? will it cook at 11,500 feet? Where is the online cooking guide and adjustment for time/temp for much lower boiling temperature at 11,500? what will taste good at altitude? Are there vegetarians? vegans? allergies? who’s gonna carry all the materials?). Stress.
  • Watch the weather dump an additional foot of snow the week before going. Stress.
  • Carbo-load the night before. Stress.
  • Borrow my daughter’s hike/camp backpack and stuff it with 50 pounds, including sleeping bag and clothing and lunch and dinner supplies and 4 liters of water. Why would I need 4 liters of water for ONE measly hike? 50 pounds is not bad, but that is without skis on the feet. Son and daughter have plenty of advice for “old dad.”
  • Get up at 4:45am, STILL GET CAUGHT in I-70 skier traffic on the way out of town, and instead of taking 2.5 hours to get to Leadville, take 3.5 hours and arrive around 9am. AND, leave behind a winter shell and have to buy a replacement in Leadville. Stress.
  • Get to trailhead as everyone is ready to head up. Buckle up quickly, half-remembering what they guy in the store said about all the boot settings. Wonder how to use the avalanche probe and beacon, trust that 15 of 17 people in your group are Colorado natives and have done this several times a winter for a decade. Start sliding toward the trail.
  • Hey, this is … fun? It is snowing lightly, the sun peaks through occasionally. Even though it is 7 degrees, I’m wearing plenty of layers and a 50 pound backpack. My last-minute winter shell is bright GREEN which goes great with my bright RED ski pants. I’m focusing on pushing with one leg, bending the other knee and pausing to slide for a second before taking a second step. On flat terrain or a slight downhill, this works well for forward motion (I can slide about 1-2 feet for NO ADDITIONAL EFFORT), but side to side balance is a different thing. I nearly topple several times. Just moving toward the trailhead in the parking lot. Stress.
  • Trailhead! OK, this is just a fire-road; the dirt road that trucks in the summer and snowmobiles (and trucks) in the winter go up to service some parts of the forest. The snow is fluffy, nice, not scratchy or icy. There are ruts in the road from recent passage of snowmobiles, but no problem. My feet start to notice that the rental boots are not a perfect fit. Surely this won’t be a problem later…
  • Sloping uphill: Hey! This is hard work! Most of the team has “jogged” out of sight up the hill, whooping it up on the way; they’re in their native element. On the other hand, the bi-coastal transplant to the Mile Hi City is huffing and puffing. Why hasn’t living in Denver for 2 decades translated to growing a second set of lungs? Nice think about the gasping for air as I slide up the trail is it takes my attention of my increasingly painful feet. I also ask my trail-buddy (who has been left behind to guard me against falling to the pack of wolves that pick off slow, enfeebled members at the back of the convoy): “hey is the rest of the trail ahead also this steep?” Reply: “Oh, don’t worry, it gets much steeper ahead.”
  • Lunch! At 3 miles (hey! almost halfway!) we pull over, take off our backpacks, snarf down some snack bars (and my lifesaving colleague pulls out a Banh Mi Vietnamese sandwich and generously donates 1/2 to me) and I have never had such delicious food in all my life. Ambrosia.
  • Then, off the fire road and the REAL trail starts. I become aware of the value of Skins, the unidirectional fibers sticking out of the carpet-like attachment to the bottom of my skis that allow me to slide forward, “catch” the fibers and essentially walk straight up the slope without sliding back, unlike in alpine or even regular cross country skis where a major “herringbone” diagonal walk up the hill is necessary. This is like a stairclimber exercise, but at 11,000 feet with 50 pounds on your back and 30 pounds strapped to your legs. I can feel my heartbeat in my throat going about 170 and my lungs scrabbling for every single O2 molecule. “Hey, isn’t this beautiful, CT?”
    =pant pant= “Huh?
    =pant pant= “Wha?”
    =pant pant= “Where?”
    =pant pant= “Lemme”
    =pant pant= “Catch”
    =pant pant= “My”
    =pant pant= “Breath”
    =pant pant= “Yeh. Nice.”
  • In another 2 miles, my guardian and I catch the 9-year old daughter of friends who is finally starting to get tired. Wow, what an amazing backcountry expert she’ll be growing up! Then some of the teenagers, having reached the hut, dropped their gear, started the fireplace, have come down to help some adults with carrying backpacks the rest of the way. I resolve to carry MY OWN BURDEN the rest of the way.
  • Arriving at the hut is perhaps the sweetest sensation of the past few years. I go in, shuck off everything, swap out clothes, and sleep for a solid 2 hours.
  • We end up making dinners (although cooking is a challenge with water boiling at a lower temp and having to melt all your own snow for drinking water, the food is extra delicious for being so hungry), singing campfire songs accompanied by the ukulele, teaching some kids some ukulele strumming chords, skiing through untracked powder in the coming days and generally having a blast. Moleskin becomes a second skin on my feet.
  • Our slide down is heavenly. There are sections of trail up to a 1/4 mile that qualify as a Maslow’s Peak Experience for me; gliding effortlessly downhill through a glade of trees, the sunlight filtering down, a fine drifting mist of fresh powder, the temperature perfect, my pack and everything balanced just so, knowing that I CLIMBED THIS MYSELF (about 30 minutes of climbing for every minute of gliding down), glimpses of the San Juan mountains encrusted with snow…Wow.
  • Then, back to the car, returning the gear, merging back into I-70 traffic, back to reality. It is something I will never regret having done.

CMIO’s take? I think all Coloradoans should do this. The cameraderie, the triumph of effort over gravity, the cleverness of technology to overcome natural obstacles, the pure transcendent beauty, the sense of achievement and teamwork, and of course, the singing. Have you done a hut trip? Let me know.

Denver Regional Clinical Informatics Summit (and ukulele) – second annual, hosted at UCHealth

Okay, so you’re probably here for the Informatics knowledge, but too bad, we’ll lead with ukulele. Thanks to Dave Beuther for writing us a world-premiere song parody of Grace Vanderwaal’s “I don’t know my name” ultimately winning America’s Got Talent a couple years ago (meaning Grace, not Dave).

I’m really grateful to our Denver Region sister-health-systems. We have quite a few health systems in our region with Clinical Informatics expertise, and we spent the better part of a day getting to know each other, conduct round tables, and discuss our common challenges in designing next-generation, innovative Electronic Health Records to improve the care of patients in Colorado. Thanks to attendees and leaders from: Boulder Community, Steamboat (Yampa Valley), Centura Health, Children’s Hospital Colorado, Denver Health, Kaiser, National Jewish Health, SCL Health, UCHealth and the Denver VA Medical Center.

Amy Hassell explains how components of the Virtual Health Center work to Summit attendees from across Metro Denver

We had about 30 attendees from various health systems touring our Virtual Health Center (VHC), seeing our capabilities for Virtual ICU, Virtual Remote Monitoring, Virtual Urgent Care, Safety View, Telemetry and more.

About 50 attendees participated in our afternoon Clinical Informatics Seminars, a series of Round Table discussions ranging across such topics as Clinical Documentation, Order Sets, EHR burden and optimization, Physician Builders, Virtual Health, Innovation, Clinical Decision Support, Analytics and Data Science. Whew!

What’s a good conference without a Selfie?!

We wrapped up the day with an evening CHIMSS (Colorado chapter Health Information Systems Society) event with a keynote by Dr. Rich Zane on Innovation in Healthcare.

This was followed by a panel discussion on innovation with Brandi Koepp, Pharmacy Coordinator, UCHealth, Paul Schadler, SCL Health, David Beuther, National Jewish Health.

Here are the reviews of the event! https://www.surveymonkey.com/stories/SM-P7KFLZDL/

The evening CHIMSS event in the Bruce Schroeffel Conference Center main auditorium @UCHealth

CMIO’s take? Although we could probably benefit from more frequent information sharing and collaboration, for my taste (as coordinator), once a year is pretty good! It is cool what our sister health systems are doing to improve the care of patients; we are better together!

Video: Dr. Sieja discusses EHR Optimization Sprints

Congratulations to Dr. Sieja and team for publication of UCHealths’ experience regarding EHR Optimization Sprints. You can do it too! Read about our published experience at Mayo Clinic Proceedings.

https://www.mayoclinicproceedings.org/article/S0025-6196(18)30788-2/fulltext#appsec1

There are several online supplements: additional specifics about how we conducted the program (30-60-90 day planning meetings, agendas for the 2 weeks of activity, etc), and the actual pre and post-intervention surveys.

Book review: Turtles All the Way Down

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Five stars.

John Green channels teenage angst like no one, and he parlays them, unaccountably, into riveting novels of pathos and the teen journey. He broke my heart with The Fault in Our Stars, and he did it agai with Turtles. The title of course comes from the story that some old woman was arguing in favor of the Flat Earth theory with a modern scientist who was of course discussing that the Earth is a sphere. The woman then patiently explains, when the scientist asks, that the Flat Earth is, of course, sitting on the back of an enormous turtle. Ah ha! thinks the scientist, who asks, “Well, what is the turtle sitting on, then?” And the immortal response: “Well, it’s turtles ALL THE WAY DOWN.” Duh.

Green parlays that saying into the mental health cycle of the protagonist, whose Obsessive Compulsive Disorder (OCD) pervades the narrative and prevents our heroine from achieving so many great things. Throw in a murder mystery, and you THERE, you’ve lost another full day of your vacation marinating in someone’s fever dreams.

CMIO’s take? I always feel rewarded, when I come out the other side of a novel, feeling like I just lived someone else’s life for a day or so, my adrenal glands all squeezed out, my emotions having been through the wringer, and somehow, my own head a bit clearer for it, and my own problems just a little bit less pressing.

Optimization Sprints: Improving Clinician Satisfaction and Teamwork by Rapidly Reducing Electronic Health Record Burden (published in Mayo Clinic Proceedings Feb 2019)

Sprint team action shot!

Congratulations to Amber Sieja, Katie Markley, Jon Pell, Christine Gonzalez, Brian Redig, Patrick Kneeland, co-authors on our published article in Mayo Clinic Proceedings this week. I’ve spoken of some of the details on this blog, so I’ll let the paper speak for itself. Nice to be recognized! Coming soon: a video by Dr. Sieja explaining some of the highlights of the paper.

https://ac.els-cdn.com/S0025619618307882/1-s2.0-S0025619618307882-main.pdf?_tid=c94d2fe7-8f2b-4e66-9852-277fb952f3eb&acdnat=1551313804_a8d687bb190fdb632cd1ed9f45c8ef41

CMIO’s take? When team members do great work, we all get better.

How Do You Balance Patient Care and Research with Online Patients? Our Proposed Protocol

Flask from nounproject.com

What would you do with the following research requests?

  • The CEO of the health system would like for all patients using the EHR patient portal to be asked to sign a consent form to participate in our system-wide strategic BioBank. In this strategic project, we aim to capture an “extra tube of blood” when a patient is already getting blood drawn for a lab test for clinical care. Then we would apply genetic analysis to large populations of patients to see if we can discover gene-disease linkages that may be useful to patients. May we set up this consent form and present it to patients?
  • A researcher would like to survey ALL patients in the health system to ask them their opinions about marijuana use, both recreational and medical. It would be about 20 questions. The researcher does NOT have an existing relationship with most patients he/she wishes to survey.
  • A physician specialist would like to ask all the patients in his/her own clinic about their symptoms of arthritis, to understand how he/she can improve their own clinic’s care process and maybe publish the improvements when completed.

Such are the challenges of our MHC (My Health Connection) patient portal Clinical Leadership Advisory Group. Our goal is to protect our patients, who have signed up for MHC primarily as a communication tool between patient and clinic/physician, and not allow unsolicited research requests (potentially from hundreds of researchers) or “quality improvement” surveys or projects from “email spamming” their patient portal message inbox. AND YET, we believe that a large fraction of our patients might welcome the chance to participate in a research trial and increase our medical knowledge. How to do this? We struggled and discussed for hours, and came up with the following principles, that we are gradually implementing:

White Paper: Research queries using My Health Connection (MHC)

Executive Summary: How shall we decide on permitting researchers to use MHC for recruiting and contacting patients? Until now, research recruitment has been off-limits. We propose a framework for permissible MHC use for research recruitment and a path forward.

Background:

My Health Connection is the UCHealth rebranded MyChart patient online portal to the EHR. Patients sign up for MHC with the express intent of using it to communicate with their healthcare team directly. We have had repeated complaints from patients when they hear from unexpected sources (Administrators sending messages regarding “flu shots” or other health maintenance, as required by Meaningful Use federal regulations). We have thus been very careful about protecting patient’s presumed interest in using MHC as a purely clinical communication tool.

On the other hand, Researchers at UCHealth have great interest in using MHC for research recruitment. We have not yet (Dec 2018) implemented the Research Module within Epic for recruitment and management of potential and patients currently engaged in research trials.

Our IRB (institutional review board to protect patient rights) has been an excellent partner in restricting use of EHR for research recruitment, balancing patient needs, clinic needs, researcher needs.

To date, the only exception to research use within MHC has been: the UCHealth BioBank for recruitment, processing and notification of patient’s genomic data such as pharmacogenomics and other screenings, approved by Strategic Executive Group (SEG) at UCHealth.

Additionally, the MHC clinical leadership group have previously declined a research request to broadcast a marijuana survey to all 400,000 MHC patients.

MHC clinical leadership HAS allowed broadcasts through MHC for drug or device recalls when there are patient safety concerns.  It has also allowed general health broadcasts as required to meet federal Meaningful Use regulations for patient portal implementation and use (see above).

Assessment/Recommendations for MHC research framework

  1. Large UCHealth strategic initiatives (including research) using MHC are approved by System Executives. IRB approval is also necessary. MHC clinical group also informed.
  2. Research requests by a Principal Investigator (PI) recruiting patients within his/her own clinical practice (where there already exists a treatment relationship between that investigator and/or his/her colleagues and their cohort of patients), should meet ALL the following criteria:
    1. IRB authorizes this project to use MHC for recruitment and communication
    1. Recruited patients have all been seen in the clinic(s) where the principal investigator and co-investigators work, so that there is an EXISTING physician-patient relationship
    1. The Principal Investigator (PI) or authorized study team members, send and receive MHC messages individually. This is not the responsibility of the MHC IT team.
    1. Online MHC recruitment should mirror any paper- or phone-based IRB-approved process
    1. COUNTER-EXAMPLE: System-wide targeted patients across many clinics WILL NOT BE APPROVED AT THIS TIME. An existing physician-patient relationship must already exist between recruited patient and the investigator(s)
    1. There will be ongoing assessment of any complaint received
    1. The MHC team will investigate a method for PI’s to update a patient’s chart in case of DECLINING FURTHER RESEARCH RECRUITMENT.
      1. If patient declines for an individual study it will be up to the PI to track that
      1. If patient declines for ANY research outreach via MHC, we anticipate creating an FYI flag called “NO MHC RESEARCH RECRUITMENT” that we can query later to prevent outreach errors
    1. MHC team will and will not:
      1. WILL: require investigators to ask permission of Clinical Advisory Committee prior to start
      1. WILL: permit 1:1 MHC recruitment messaging from PI to patient when project approved
      1. WILL NOT construct research questionnaires for online transmittal
      1. WILL NOT have patients sign online consents via MHC
      1. WILL NOT help track patients in study via reports or alerts
    1. Approvals thus needed:
      1. IRB
      1. MHC Clinical Advisory Committee
      1. UCHealth Marketing for allowable messages in MHC
      1. UCHealth Patient Literacy Team for 8th grade wording or clearer
    1. Monitoring
      1. PI would present MHC component of research plan to MHC Clinical Advisory
      1. PI would present 6-monthly updates during study to MHC Clinical Advisory
        1. Patient recruitment numerator/denominator
        1. Assurances about only recruiting from permitted clinics/units
        1. Refusal rates and other concerns from patients, clinicians, staff
        1. Anticipated close of research or translation into standard practice
  • NOT PERMITTED: Patient recruitment outside of an investigator’s clinic (eg: show me all diabetes patients; maybe 40,000 patients or please facilitate the outreach to all DM patients). Not allowed at present
  • FUTURE opportunities:  Epic does have a Research Module that we have not yet implemented. It may be possible to integrate research recruitment that follows all IRB necessary protocols to protect patient privacy. UCHealth will partner with UCD School of Medicine leadership to consider implementing this module in the future. As our tools evolve and with patient feedback, we will discuss the tools at MHC clinical group to review and update this guideline.

CMIO’s take: Have YOU implemented a research module within your EHR? Does it solve this problem? Please let me know in the comments!

Book review: Flow (second time review)

Here we are (again)! How can I review this? An incredible landmark of a book, it has sat on my bookshelf for more than a decade, and then on my ‘actively reading coffee table’ for another few years. Despite its mention in almost every important other book I have read, and my repeated abortive attempts to push through, I found this book alternatively revelatory and then densely incomprehensible. I frequently dove in, underlined many passages, got stuck, and put this book down for prolonged periods. 

Finally I convinced my book club friends to tackle this, set a discussion date (Jan 2019), and that was my trick to completing the massive read.

What I’ll take away is the idea of linking happiness NOT to acquisition and idle pleasure, but to difficult challenges that are just outside my comfort zone and skill set, where with maximal concentration, I can succeed. 

Fortunately for me, I have had many times in my life when I have achieved such Flow, and now I have a framework for thinking about it and setting up my day, my home, my work life to achieve this as often as possible for myself and for colleagues. 

Incidentally, I have recently completed the massive tome ‘Alexander Hamilton‘ by Chernow, another incredible read (I was drawn in by, of course the immensely popular musical), and I am led to reflect that Hamilton must, in his voluminous lifetime of groundbreaking writings, must have set up conditions to achieve Flow for quite extensive parts of his life, despite tremendous tragedy, political rancor and his final demise at the business end of a duelist’s pistol. For example, he would read all day, head to bed, then wake up the next morning and just write, with no interruptions, for hours. As a result, his subconscious worked on problems overnight. Often his manuscripts had NO corrections, as he would scribble furiously a final draft, fully formed. This was how he tackled many of the Federalist papers, papers that are studies in minute detail by constitutional scholars to this day. 

My favorite Flow pointers:

  • Attention is how you create your experience and consciousness, and psychic entropy is the opposite: the chaos that detracts from focus and intentional effort. 
  • Flow requires: clear goals and feedback; concentration on the task; a sense of control; loss of self consciousness; transformation of time. 
  • Flow occurs when the top of your skills barely match the presented challenge. Otherwise you get boredom or anxiety. 
  • Source of dissatisfaction at work: lack of variety and challenge; conflicts with other people/boss; too much pressure, too little time. All CAN BE under our control. 
  • Autotelic self: easily translates external threats into enjoyable challenges and maintains inner harmony, transforming potential entropy into creating flow. 

CMIO’s take? I defer to these great words by Chuang Tzu: ‘When I come to a complicated place, I size up the difficulties, tell myself to watch out and be careful, keep my eyes on what I’m doing, work very slowly, and move my knife with the greatest of subtlety, until–flop! the whole thing comes apart like a clod of earth crumbling to the ground. I stand there holding the knife and look all around me, completely satisfied and reluctant to move on, and then I wipe off the knife and put it away.”