CHA2DS2-VASc and HAS-BLED integrated into EHR. Wow. Humility thy name is…

Yes! I am an internist. Yes! I have practiced for many years. Yes! I know about CHA2DS2-VASc and HAS-BLED*. Yes! I vaguely recalled that we installed built-in calculators right into our EHR to reduce the barriers for our docs to use these calculators while seeing patients.

No, until today, I had not actually used them in the service of a patient. I had been able to skate by with awesome colleagues doing these calculations at hospital discharge, or seeing them prior to me, and I would follow the recommendations generated by these discussions.

UNTIL TODAY! So, I typed in dot phrases to invoke CHADS and here come both calculators, fill in some quick data and see above; really awesome automatically generated displays that can be placed in patient charts (and shared with patients!), and now I can have a thoughtful discussion.

I am amazed, and humbled. In a high-functioning physician informatics organization, the CMIO should NEVER be the bottleneck. We should be innovating, improving our EHR, and balancing “good governence” (hey! don’t put all those interruptive alerts in here UNLESS those being alerted agree that this is a valuable use of their time!) with “rapid cycle innovation” (well, if the nurse leaders on that unit REALLY want to have a pop-up alert every 30 minutes, every time a heparin blood test returns, as long as the nurse leadership wants to try it…)

The innovation here is, lowering the barrier for docs to use it IN THEIR WORKFLOW within the EHR. Furthermore, to have it DISCOVERABLE! So many innovations are “hidden” (Oh, you didn’t read our monthly newsletter with 20 items? It was number 12. Oh, our newsletter went to your spam folder? Sorry about that). So, being able to type a search for CHADS or HASBLED into our search field actually teaches the doc how to use the tool. Amazing, being a customer of my own informatics team’s development. Sometimes, stuff just works.

*CHA2DS2-VASc and HAS-BLED are fantastic medical calculators that, based on scads of high quality evidence, that we can now effectively calculate the future stroke risk score of atrial fibrillation patients, AND ALSO that we can calculate the future bleeding risk of anticoagulants (having patients take blood-thinners to prevent stroke in high risk situations). And then we can have a thoughtful data-driven conversation with patients instead of licking our fingers and putting them up to the wind to see which way the wind is blowing that day. You can try it yourself; there are online calculators for CHA2DS2-VASc and HAS-BLED.

CMIO’s take? A big dose of humble pie for the CMIO is part of a good diet. What cool things have YOU discovered in your EHR?

Shouldiscreen.com is a great example of “there are more smart people who don’t work for you than who do.”

https://shouldiscreen.com/

Sometimes our patients push us into our discomfort zone. Thanks to one of my long-time patients, who, as a former smoker, wanted to discuss the risks and benefits of low-dose CT scan Lung Cancer Screening. She had heard of this opportunity at her employer, and wanted to see if I could get her set up for one.

Knowing that we had an entire Lung Cancer Screening clinic set up to discuss this with candidate patients, and to discuss how to think about and address the inevitable “what do I do with THIS tiny nodule in my lung, which is likely benign, but who knows” and “how high IS my risk of cancer exactly, and what is the chance that this will make a difference in my life?”

So, I heavily weighted our discussion: “You could either work with ME and I can figure out some stuff, OR you could go see the EXPERTS who do this all day long and have a thoughtful discussion.”

My patient tells me: “Nah, I want to work with you, and I don’t want another co-pay.”

So there it is. Knowing that we have documentation templates and guides, I dove right in, on the exam-room computer. It does take some humility (see previous post) to discover things in front of your patient (after all, are we NOT supposed to KNOW EVERYTHING?!). But, soon, we discovered there was a nicely structured template, searching “LUNG CANCER SCREEN” in our EHR, that asked the right questions, and then sent me to the above website, which then created a spectacular graph display (for Shared Decision-Making with Patient).

Go see for yourself; the full display is cool

CMIO’s take? Having ‘discoverable’ EHR tools that link to sites of external knowledge, really cool. This is a glimpse into our future, where researchers and knowledge discovery, fully vetted, can be created ANYWHERE and used by ANYONE to improve the care of patients universally. There are more smart people who DON’T work for you, than who DO.

CHIME’s CMIO Leadership Academy in Ojai. Listen and learn.

http://chimecentral.org/mediaposts/cmio-leadership-academy-2019-images

Thanks to George Reynolds and those organizing CHIME’s recent Leadership Academy for existing and upcoming CMIO’s. I enjoyed teaching this year with other co-faculty like Brian Patty, Natalie Pageler, Cindy Kuelbs, George, Howard Landa, Keith Fraidenburg and David Butler.

The topics we covered in our Academy over 2 days included such CMIO best hits such as:

  • The Role of HIT in Today’s Provider Environment
  • Setting Vision and Strategy
  • Making Change Happen
  • Creating Buy-In
  • Demonstrating Business Value
  • Budgets and Business Plans
  • Creating Effective Teams
  • Instilling Customer Service as a Value
  • Organizational Culture
  • Building Networks and Community
  • Achieving Life/Work Balance

Thanks to my awesome and inspiring faculty colleagues; I learned a ton as a N00bie faculty member, and got lots of new books to read, for example Brian Patty’s “What Customers Crave.”

CMIO’s take: See one, do one, teach one is the norm during internship and residency training. Sometimes Teach One ends up being the best learning of all. And, join us next year at CMIO Leadership Academy.

Innovation partnerships at UCHealth (Healthfinch)

Tracy Sawyer, RN

Our UCHealth Care Innovation Center is dedicated to implementing partnerships with companies that improve and simplify our work. Our most recent example is our partnership with Healthfinch to improve prescription renewals, by assessing the data in the electronic health record, presenting it to nurses and pharmacists on a centralized prescription renewal team and demonstrating efficiencies, like cutting per-prescription refill time in half.

As we move into value-based contracts in healthcare, and continually need to remove inefficiencies and lower costs, to stay competitive, partnerships like this will move us in the right direction. See the video of UCHealth’s Tracy Sawyer RN, speaking at the AMDIS conference in Ojai, California, as she describes our journey and our results: http://info.healthfinch.com/implementing-charlie-at-a-centralized-renewal-center-experiences-at-uc-health

CMIO’s take? There are more smart people who DON’T work for you, than who do. Find a way to work with them when you can.

Showing Rx Co-Pay Cost at time of Prescribing, in the EHR (info transparency!)

Sometimes you work hard, and cool things happen. UCHealth is partnering with RxRevu, makers of SwiftRx, an EHR-embedded tool that shows prescribing doctors the co-pay cost of patient medications AT THE TIME OF PRESCRIBING! We believe we’re one of the first in the country to do this successfully.

Yes, at the time of prescribing. NOT the usual “guess-again” game that we’re all tired of. “Hey, I’m gonna prescribe doxycycline from this chronic condition. It’s an older drug so, I’m GUESSING it will be inexpensive at the pharmacy, but WHO KNOWS?!” And then the inevitable phone call “Doc? That prescription has a $241 copay! Isn’t there something else?”

We are all tired of this game.

After quite a bit of hard work and innovative partnering with RxRevu, we are pleased to have launched, about a month ago, the ability for our docs to prescribe medicines within our EHR, and (like magic!) right within their workflow (don’t have to make a phone call, don’t have to launch a web browser and figure out the patient’s insurance specifics, or look up in some massive formulary book), right in our EHR, we see the co-pay! The Real-time benefits check shows up in about 1-2 seconds, just like above.

With that particular patient, we saved him about $200 by switching from tablets to capsules. Silly, but true.

Here’s the news article on SwiftRx at UCHealth.

Here’s the recent webinar I participated in describing this innovation.

CMIO’s take? There are so many ways information transparency will help us and our patients, in healthcare. Have you found success with information transparency? Let me know!

EHR Sprint Optimization Executive Summary – using Stories, Images AND Data to change minds

Many of you know that in my role as CMIO at UCHealth, I’ve stepped in my share of potholes. My Failure Resume is replete with examples (eg: my 16 year journey to implementing Open Notes). Having studied the Open Notes phenomenon back in 2000 and published in 2003, it was a big disappointment when, after presenting to the medical leaders at University of Colorado, I was soundly voted down for implementing this transparency initiative (sharing doctors progress notes with patients online) repeatedly in 2002, 2003, 2004, until I stopped asking. Then, about a decade later, AFTER the Open Notes organization (thanks, Tom Delbanco and others) formed and pushed the agenda in 2011, we gathered steam and I finally succeeded in May 2016 to implement Open Notes system-wide for several million patients). You can call it a failure or an eventual success.

Nevertheless, when we implemented our Sprint Team for EHR optimization, we were at risk of being disbanded and told to return to our usual jobs (I had “stolen” these resources from IT and informatics to “Sprint” one endocrinology clinic of 29 doctors). In defense of our program I wrote this 1 page Executive Summary. We know that readership of white papers drops by half with every additional page. I included images/graphs (internal marketing, make your document attractive and interesting), STORIES (because, what p-value has ever REALLY changed someone’s mind?) and DATA (because, what self-respecting doctor or leader DOESN’T ask for evidence?).

And no, it wasn’t an overnight success, but it was one of the core documents that drove our executive team to finally approve the budget to continue our Sprint efforts. Download the 2-year-summary version below.

https://www.dropbox.com/s/o3qh33l7wdna3xe/2018-08%202y%20Sprint%20Aggregate%20Exec%20Sum.pdf?dl=0

We have now sprinted over 750 clinicians, hundreds of ancillary staff (MA’s, RN’s, front desk clerks), over 70 clinics, with uniformly RAVE reviews. And, even better news, we were recently funded to DOUBLE our Sprint team to 22 people. We are grateful to our leaders for such foresight.

CMIO’s take? Sometimes internal marketing can be as or more important that external marketing. Do you have success stories of how you wrote/composed documents for success? Let me know.

Time management regret? (NYTimes) Work-life (im)balance? Start now.


We can all benefit from reminders. And self-forgiveness. And taking a single step, (or creating the “next action”) as David Allen says in his book “Getting things Done (book summarizing video).” Atomic Habits (book summarizing video) is another book with similar suggestions. There are a growing number of books, articles, videos dedicated to this topic; go ahead and explore. After all, the ancient Chinese saying is: “The journey of 1000 miles begins with a single step.”

We are all burdened with too much work and too little time. If we are not careful, our work overwhelms other parts of our lives and we lose balance. I struggle with this myself. It is helpful, then, to have a quiver of tools to deploy in the moments when your self-awareness kicks in: “whoa, I’m out of balance; I missed my kid’s field hockey game, or that school event, or the dinner with my family.” Or maybe all of the above. 😦

In these moments, as the article suggests, break it down to ONE action.

  • Forgive yourself. Move past it and commit to behaving differently NOW.
    Self-disappointment gets in the way of personal progress.
  • Do ONE thing. Leave today, early enough to go exercise, for example.
  • Find a SMALL thing to change. “Managing time” is a huge monster, but getting THIS particular project started involves finding THAT one phone number. There. That’s progress.
  • Read a book about process (This works for me, instead of doing better, read about doing better, maybe implement ONE idea from it, and rejoice. As you read more and pause and reflect more often, you WILL find more opportunities to change or establish a new habit. It is okay if this takes weeks, months, years, decades. We are all works-in-progress.)
  • Set yourself a task for teaching Work-Life balance. Nothing like see one, do one, teach one, like we did in medical school. Or worse yet, don’t even see one or do one, but figure out how to TEACH one, and that forces you to examine yourself and pay attention. (Speaking of which, come to the CMIO Leadership Academy where I’m going to be teaching … Work Life Balance). Hilarious!

CMIO’s take? Having trouble managing time or really getting started changing yourself? Break it down into a small “next” action. Read the article. Watch a YouTube video. I’m surprised at home many authors now offer their best ideas on video or in short articles. Are Books “so last century”? Maybe so.