Fatal crashes, the Macintosh, and the Shallows

https://www.wired.com/story/how-dumb-design-wwii-plane-led-macintosh

Thanks to WIRED for this article on the design of planes, specifically the B-17 bomber in World War II and how fatal crashes led to better design and human/machine and human/computer interfaces, leading to the Macintosh.

Although thought provoking, I dislike and disagree with some of the discussions in this article:

  • Carnival Cruise’s idea that a “personal genome” should learn your preferences as you wander the ship, and show and encourage you to see more of the same. Where is serendipity, discovery, and being exposed to contrasting ideas?
  • Furthermore, what about The Shallows: what the internet is doing to our brains? Like what I’m doing to you here, reading my blog post, probably sent here from a link from your Twitter or Linkedin or Facebook streams. We are skimmers, not readers anymore. Can we even hold a complex thread of ideas in our head on one topic?
  • I’m reminded of the medical term “clang association” where patients with psychosis hear something which reminds them of an unrelated conversation. Distractable, are we.
  • Also, the pre-flight checklist, I think, comes from the B-17 bomber, the plane that was claimed to be “too complicated for humans to fly”.

CMIO’s take? See how I illustrated clang associations for you? AFAIK I don’t have psychosis or schizophrenia, but then maybe — SQUIRREL!

Metabolomics, University of Colorado, and the Tour de France

from university of colorado website

https://news.cuanschutz.edu/news-stories/metabolomics-the-science-behind-a-tour-de-france-winner

NEWS FLASH

I so enjoy working at a University with such a broad spectrum of interests. The latest is the move to more precision medicine. We began with genomics: the existence of mutations or gene variants in patients or persons, then moved on to proteomics, the expression from genes into proteins (remember transcription from high school or college or medical school science?), and now metabolomics, which is not just protein expression, but the interaction of these proteins, and WHEN they exist in a patient’s or person’s body.

Complicated?!

Turns out, the more we learn about the body, the more there is to understand. Not only do we have genes and variants of genes (remember sickle cell disease, for example?), we also have messenger RNA, the strand that copies off a specific gene, which can be turned on or off. Turns out mRNA can also interfere with OTHER mRNA, increasing or decreasing the effectiveness of those molecule strings. Also, mRNA is translated into proteins depending on the environment, and THEN, those proteins interact with each other. This happens, and possibly slightly differently, in every cell. How are we even alive?

A glimmer

So, now, we can measure proteins in this metabolome with increasing precision, and start to glance at the dance behind the curtain. Some exercise physiologists have spotted some patterns in the metabolome in regards to elite athletes, and this has led to some breakthroughs in performance, to-wit, the most recent Tour de France champion. Read on.

CMIO’s take? The metabolome rocks.

What clinical informatics is NOT. Also Nerd Glasses and Propeller Hats.

My offspring. An out-take from Go-Go, their K-pop dance routine. See hyperlink below.

I’m reading a book called Mindfulness in Plain English: another book my daughter left laying around the house with her annotations in it. I love the underlining and ‘YES!’ marks and also the ‘is it though? You shouldn’t wait to be perfect…’ comments. Just a few short years ago, she was in the playpen, and now I love to see her mind at work.

Anyhow, mindfulness meditation is something that I aspire to: I have had months where I meditate daily, and there are times when I forget and lose the habit. I have found it calming and centering and have found clarity through the practice.

You can refer to my blog series ‘CT Meditates, a comedy’ from 2017.

What I love about this current book is the chapter on what Meditation is Not. I love it. It helps define the thing by talking about what it is NOT. For example an annotated list:

WHAT MEDITATION IS NOT

  • Misconception 1: meditation is just relaxation
  • Misconception 2: meditation means going into a trance
  • Misconception 3: meditation is mysterious and cannot be understood
  • Misconception 4: meditation is for saints. Not regular people.
  • Misconception 5: meditation is running away from reality

I love this idea. Writing about the negative space helps clarify what something IS. So, here goes.

There are lots of misconceptions about what Clinical Informatics is.

It can be defined as the science and practice of managing information by capturing, storing, analyzing, retrieving, and using data to improve the care of patients and populations.

Sure, whatever. Perhaps it is more meaningful to talk about misconceptions.

WHAT CLINICAL INFORMATICS IS NOT

  • Misconception: informatics people are the secret Star Chamber of the Electronic Health Record. They wear propeller hats or nerd glasses. <– Yes, these are my nerd kids wearing propeller hats and nerd glasses. And yes, I am proud of them.
  • Misconception: informatics helps you set up your computer. (That’s Information Technology)
  • Misconception: informatics has to do with servers, network cables, wifi problems. (still, IT)
  • Misconception: informatics is a way to force people to do things they don’t want to do. (no, no, no)
  • Misconception: informatics is only about designing things, we leave training to others. (ok, partly right, but we all fail if we don’t train adequately)
  • Misconception: informatics is for people who prefer computers and don’t like talking with humans. (no. please do not send us “the doctor who is our resident computer nerd.”)
  • Misconception: informatics is quick and easy, just put a hard stop there, and DONE! (no. we do not “force those other doctors to do this thing because it makes it more convenient for me and my project” UNLESS it is also good for patient care and clinical leaders all agree)
  • Misconception: informatics has no need of customer/user (patient or clinician) feedback. (just no)
  • Misconception: informatics is a special and arcane field that only computer geeks will understand. (sigh. we fail if this happens)
  • Misconception: informatics is a field of medicine where most people tell you, NO we can’t do that.
  • Misconception: informatics always takes months to achieve the goal or complete a project. (when we do Sprints, we can amaze our docs)
  • Misconception: informatics is unnecessary: an EHR project only needs a subject matter expert and a computer analyst (sorry, without an informaticist to translate, such a project is likely to fail)

Informatics is NOT “Hard stop, and Done!” Instead it is building relationships, understanding the pressures and desires of patients, providers, staff, and understanding the ultimate goal of health care.

Indeed, it is perhaps, one of the major advances of modern healthcare. I would argue, the field of “clinical informatics” should eventually become standard curriculum for ALL physicians.

CMIO’s take: Health care is about using our best science, our best work-flow, our best teamwork. We use this information to heal individual patients and improve the health of our communities. We need great, up-to-date information to do that. Only by capturing, storing, analyzing data, creating new knowledge, and delivering that seamlessly to the provider at the bedside (or directly to the patient) can we grow, improve and evolve as a learning health system.

UCHealth launches OurNotes: how patients co-author clinic progress notes

As of November 2, 70 primary care practices went live with Our Notes. Read more about OurNotes here. Dr. Tom Delbanco and Jan Walker, researchers at Beth Israel Deaconess initiated and ran the study.

In brief, it is a way for patients, just ahead of an upcoming appointment to tell their provider what has happened to them since their last visit: changes in medication, new or changing symptoms, life changes. And then to ask up to 3 questions they’d like to discuss with their provider at the visit.

These notes were then automatically inserted into the providers’ progress notes. They could then be cited in their entirety, with no action needed by the provider while composing the rest of their progress note. Or, the provider could edit for clarity before signing the note. In this way, both patient and provider contribute the data from that visit, improving communication and collaboration.

We were so successful from our pilot test, conducted in coordination with Beth Israel Deaconess Medical Center (BIDMC), in our one primary care clinic, we have now launched it for ALL primary care clinics throughout UCHealth.

Our early findings showed that over 90% of providers (physicians and APP’s: advance practice providers) responding to surveys viewed OurNotes positively and wanted to continue, as did over 90% of patients who participated.

Not all patients who have a patient-portal account respond to the OurNotes questionnaire ahead of their visit. Those who do not, have a regular visit, just like before. About 15-20% of patients who have an appointment respond send an OurNote, and providers are using the notes regularly.

Others are catching the OurNotes trend as well, including Sanford health, UCLA, and the original OurNotes health system research partners: BIDMC, University of Washington and Dartmouth-Hitchock. Thank you to all the trailblazers out there for transforming patient-centered care.

CMIO’s take? More like this please! IT is a win-win-win: better engagement for patients, shared documentation for providers, more readable, narrative notes in our EHR’s.

EHR v Covid-19. Trends in testing, telehealth, hospitalizations

Welcome back to Where does the data lead?!

Here we are eight plus months into the pandemic and our testing volume and our positivity rates have been up and down. Testing volumes have varied because of limitations on receiving re-agents for our labs to process the specimens. It does appear that our test positivity rate, on the red line above, is increasing this month. This is also concordant with our Colorado state level data.

During this time, UCHealth has continued to grow as a system. We have opened a few new facilities in the past year, so the clinic volume, the patient population we serve, as well as the test volume has increased. So, lots going on here, and probably no one factor explains the pattern.

Visit Volumes at UCHealth

Our in-person visit volume for 2020 showed that precipitous drop in mid March (light red) and then nadir at mid April, with gradual recovery to 90% volume by July. At the same time (light green), our telehealth volume exploded at the same time, from a baseline of 20 visits a day, reaching a peak of about 4000 visits a day by mid April. As we figured out how to see patients safely in clinic, our in-person visits gradually returned and our telehealth volume declined, and we are now steady-state at about 1000 telehealth video-visits per day. Magenta is the scheduled telephone visits, a new visit type that Medicare began reimbursing. Blue is the regular telephone volume, essentially unchanged. The dark red is a gradual but consistent increase in patient portal messages, both gratifying that our patients have found a way to connect with their provider, and also worrisome in that this near-doubling of volume does impact the unreimbursed workload of providers in our system.

Cliffhanger

We are now back to our “cliffhanger” TV series. What will happen tomorrow? UCHealth has restarted our Incident Command Center given the increase in hospitalizations. Like many hospitals around the country, we are seeing a bump in inpatients with COVID-19. We had a peak of about 120 in April, then gradually fallen to a nadir of 17 inpatients in late summer, and are back up to mid 50’s this week, and rising.

CMIO’s take? Hang on to your hats.

My Interview on INFO BLOCKING With 33 Charts

Thanks to Dr. Bryan Vartabedian for a fun wide-ranging conversation about INFO BLOCKING and our information transparency efforts at UCHealth over the past 2 decades. A trip down memory lane, and the potholes I’ve stepped in, and the battle scars from pushing the edge of what providers are ready for…

In case you are willing to come reminisce with me for 50 minutes…

My Failure Resumé: A TALK

You know you’ve wanted to see it, hear it, and revel in the schadenfreude: CT Lin’s famous FAILURE RESUMÉ: a talk.

http://colorado.himsschapter.org/event/virtual-professional-development

CT has failed at so many things, it isn’t funny. Or maybe it is.

Date: Thursday, November 12, 2020. Noon, Mountain Time.

Thank you to the Colorado Chapter of HIMSS (Health Information Management Systems Society) for sponsoring and presenting My Failure Resume. Sign up (free) here.

Those of you who follow The Undiscovered Country know that this is by far my most popular blog post, in 3 years of weekly posts on health care, informatics, leadership, change management, and the general chaos of our lives.

I hope you can make it! Here are some random pictures to whet your appetite.

But what does it all mean? Come find out! Hope to see you there.

When Can I See Results in My Patient Portal?

We are all scrambling to put together simple documents to explain to patients and providers about INFO BLOCKING / SHARING coming in a week. Here’s our latest document. Link to full PDF here. Feel free to adapt this for your organization. We are also hoping our very smart Epic colleagues in Wisconsin can add a patient-preference setting into MyChart to accommodate the variety of patients out there, regarding seeing their own test results.

Remember, the rest of our INFO SHARING education documents are on my last blog post HERE.

CMIO’s take? Are you developing education tools that are simple 1-page explanations of complex topics? Let me know.

What is a MMOLC, and how is it solving Info Blocking?

The national discussion on Info Blocking / Sharing is resulting in rapid improvement. MMOLC helps a great deal!

What is a MMOLC? Read to the end.

Being part of the Epic userweb community of health systems and also the SmartServ list serve of Epic-using academic health systems is a privilege. There are lots of smart people doing and sharing important work regarding Information Blocking / Information Sharing. See previous blog posts.

Some things are becoming clearer: how to write brief, useful Executive Summaries on 1 page. How to improve the clarity of explanations. What positions to take regarding the INFO BLOCKING federal rule, given the lack of clear definitions in the 1200 page rule (!)

In our grid above, we have added a few new categories (Progress notes: Sensitive/Legal, and Progress notes: Behavioral Health).

I’m attaching the current versions of our working documents that we are broadcasting and discussing at our leadership meetings throughout UCHealth:

Updated INFO SHARING documents

  1. INFO BLOCKING executive summary with Release Grid
  2. How To Write an Open Note (with more and updated examples)
  3. This great editorial in the Annals of Int. Med by Dr. Heather Gantzer (thank you)
  4. This great online explanation by Dr. Brian Vartebedian
  5. An upcoming Office Hours with Steve O’Neill re: Open Notes in Mental Health

Feel free to use these documents to move the conversation at your organization forward. Although this is massive culture change for our providers and clinical staff, this is welcomed by our patients. And it is the right thing to do.

CMIO’s take?

I am grateful to all the brilliant colleagues in our online community. Hmm. Like an MMORPG (Massively Multiplayer Online Roleplaying Game) that my kids play (Minecraft, Rocket League), we have a MMOLC (Massively Multiclinician Online Learning Community). That is our superpower. Thank you.