Is the EHR Inbasket a Hyperobject? And what are you going to do about it?

Inbasket Hyperobject: hard to grasp, even harder to cut down in size.

https://www.wired.com/story/timothy-morton-hyperobjects-all-the-way-down/

This is a mind-blowing read. What is a hyper-object? It is a somewhat disturbing concept of something bigger than an object, something that transcends our understanding as a human. The concept’s inventor, Morton, defines it as: “phenomena too vast or fundamentally weird for humans to wrap their minds around.”

Okay. What?

Consider examples like “all the plastic in the world” or “climate change” or “a black hole” or “massive oil spills.”

Science fiction author Jeff VanderMeer has said “hyperobject” neatly describes the bizarre alien phenomenon he wrote about in Annihilation, his surreal novel turned 2018 movie.

Annihilation: Southern Reach Trilogy, Book 1 | Books, Novels, Audio books
from Jeff Vandermeer

OK, now that’s disturbing, as I read the book and felt chills during a summer evening. That guy can write. This is as close to a jump-scare that I’ve ever had, reading a book. Even had to put it down for awhile to calm down.  =shiver=

Now, I’m thinking: the Epic electronic health record’s INBASKET is a hyperobject.

EHR Inbasket as Hyperobject?

Now, we’re talking. Something that is weird, difficult for humans to grasp, and alas, vast. To the uninitiated, the Epic EHR inbasket is a message center where much of our internal communication takes place: incoming phone calls from patients can be sent to inbasket for nurses, docs, assistants to help manage the request; incoming patient portal messages come here; prescription renewals from pharmacies, from patients; consultation reports from specialists, hospital discharge summaries; notifications that “you did not finish writing this note for this patient visit”; test results from blood tests, radiology studies, biopsy reports; nurse-doctor communications; provider-provider communications. Lots of things.

And, for our busy clinicians, some inbaskets have dozens, hundreds, and sometimes THOUSANDS of unread messages that can be weeks, months, YEARS old. Yikes.

Hyperobject.

Solving the Rubik’s (hyper)cube?

First, improve teamwork, huddles

Ok, but that is a future post. Aside from the idea that we need to improve our internal teamwork and fundamentally redesign how we use our internal tools, there are some simple changes we can start with.

Time to cut our hyperobject down to size. We know that incoming inbasket messages from patients has tripled (see previous post). We know that our healthcare professionals are suffering from burnout (see previous post). We (I) have been guilty of delivering automated messages to our docs that we originally thought were helpful. Maybe it is time for a re-think.

Our plan to re-size our Hyperobject:

  • Pick a date (in December 2021), a one time PURGE of all messages 6 months or older in our Inbaskets. This is 7 million messages. Seriously. Rationale: If the provider hasn’t handled this by now, either the patient has called or messaged again (a more recent message), already come for a visit, or perhaps even left the practice to go elsewhere; there is NO VALUE in keeping these.
  • In December, begin a 90-day expiration clock on all new incoming messages. If you haven’t addressed a concern or responded or read a message by 3 months, it will disappear. Yes, there are theoretical risks of deleting reminders to complete a task or respond to a patient. But, here we are in mid November; is it still relevant that a patient called for advice in August, before school started? Also it is theoretically possible that a provider will stop someday and spend a weekend reading and replying to thousands of messages, but this is not likely at all. We are aware of some inbaskets with messages that number in the thousands. Yes, we are not proud of it. Our current setting where we NEVER delete old messages, I consider a personal failure of bad EHR design and configuration on my part. Behold: the man who ruined healthcare. :(. But, we’ll fix it now.
  • We are discontinuing the delivery of automatic CC (carbon-copy) messages from consulting specialists back to the referring provider and PCP (primary care provider). In 2011, CT Lin and his merry band thought we were doing everyone a favor by CRUSHING the BLACK HOLE (a DIFFERENT HYPEROBJECT!) of the University docs who never remembered to send a consultation letter back to the referring doc. “Hey, we sent you a patient for this clinical question, and WE NEVER HEARD BACK FROM YOU.” We created a technical solution to AUTOMATICALLY send a specialist’s clinic note back to the referring doc AND the primary care doc (if different). In the beginning, this was a great idea! However, this rule now sends several HUNDRED THOUSAND messages a year to our 6000 internal and innumerable community providers. I am personally burying my colleagues. Asking one of my full time internal medicine colleagues, he tells me “I receive about 100 to 150 auto-CC notes per week. Every couple of weeks I take a Saturday and read through 200-300 messages of which about 5 are useful to me. But I can’t NOT read them, what if I miss something?” What an excellent, OCD (obsessive compulsive) physician. But also the way to burn out on patient care. You work 40-60 hours a week and then spend evenings and weekends “catching up” on the blizzard of messages and tasks in the EHR. We need to do Today’s work Today. By the way, specialists can always manually send an important note back to the referring doc or PCP “hey, calling your attention to this” with a single click. And, our specialists ALREADY do this, so I often receive the automated note AND a manually sent note for specific concerns.

Thus, I feel pretty good about stopping the automation. How often do you read that sentence from a CMIO?

Clearly insane CMIO

To be clear, we have “internal” providers who use our Epic EHR and can look up the consultant specialist’s notes the next time they see the patient. These are the folks who will benefit. ON THE OTHER HAND, we have “external” providers in our communities who do NOT have access to our Epic EHR, they use a different EHR or perhaps are still using paper: We plan to continue to eFax or otherwise deliver these notes UNCHANGED. Thus, still addressing the community need for information and stopping the internal clogging of our own pipes.

Whew! That was a lot more long-winded than I intended, but this is a big deal, a big movement, that has already generated a lot of heat, a lot of concern about “why are you moving my cheese?” So far, in our internal provider discussions, we are hearing 90% support and 10% anxiety from our colleagues. We plan on moving forward and creating innovative solutions for those who do not see this as an improvement.

CMIO’s take? Hang on everybody. This Inbasket Hyperobject is getting resized. We have lots more plans for reducing the burden of inbasket messaging, this is just phase 1 of 4 major phases to come. Stay tuned!

Thanksgiving #2 During Pandemic: giving thanks

Dear Reader. This is an email I sent to my Large PIG (physician Informatics Group) this week. I wish you all a restful holiday. CT

Dear Provider Informatics Group members: My General Medicine Division Chair sent this today, and it makes me reflect about Thanksgiving. I wanted to pass this along to you. It has been 20 months of chaos, emergency changes and emotionally draining life at work and outside work.

“The arc of the moral universe is long, but it bends toward justice.”

Martin Luther King

It is a reminder that in our day-to-day, all we see are boulders and rockslides in our path. In the long run we are bending the path to reduce burnout, improve connection and improve care. Our work affects 6000 providers, 15,000 nurses, and a couple million patients. 

I am thankful to be on this journey with you. I hope you can take some time this week with family and loved ones. CT

—–

From: Earnest, Mark
Subject: Giving thanks 

Dear GIM Colleagues,

Ms. Sutton, my third grade teacher, taught me to start letters that way – with the word “dear.”  

Since leaving her classroom, I’ve not really given the word much thought.  Aside from placing it at the start of letters, or employing it generically as a term of endearment for my wife, I haven’t used it much.  I use it even less now since “hi” or just a stand-alone first name have become de rigueur for email greetings.  Using it less, I think, is a mistake.   According to Google, “dear” means “regarded with deep affection; cherished by someone.”

Today, I want to use the word with intention. 

So, let me start again.

Dear GIM Colleagues,

We are approaching the one day in our calendar each year that we set aside for thanks.  I’ll confess that after 20 months of the pandemic and all the associated fire-drills, chaos, and public acrimony, I’m much more facile at bringing to mind the things I’m not thankful for.  That may be the most compelling reason to devote my attention this week to its intended purpose – focusing on the things in my life that I cherish and regard with deep affection. 

I’ll not bother you with my gratitude list in its entirety other than to say how much I look forward to a house that is again filled with its full complement of family.  I do want to reflect for a moment on work.

As a young man, choosing a career path, I was clear about one thing.  I didn’t want a job.  I wanted a purpose.  I was fortunate to find that calling in medicine and ultimately in GIM.  I chose well.  I have always loved caring for patients.  Along the way, I’ve found other, related opportunities for growth and points of purpose: teaching, mentoring, helping others find and actualize their purpose…  In all honesty, work for me has been a great source of joy and satisfaction.  A wonderful side effect to finding my purpose, has been the privilege of working alongside other purpose-driven people.  If I could start from scratch and hand-pick a group of people to take this journey with, I could do no better than you – my dear GIM colleagues.  It is a profound privilege to be part of such a caring, committed, selfless group of people. 

Now – after twenty long months and in the midst of a surge – is almost certainly not the easiest time for any of us to hold our work dear.  It has been hard.  Nevertheless, it is possible to be tired, even exhausted, and thankful at the same time (ask any marathoner at the finish line).   Unfortunately, we are not yet at the finish line.  We have a challenging winter ahead of us.  That in and of itself should be reason to pause and reflect. 

I hope this week that each of you can find a moment to consider our common purpose(s) and find the space to be thankful for it.  Doing so need not deny the challenges we’ve faced or the sacrifices made.  Each day, in ways big and small, you have all made our world a little better.   Because of your work, each day there is a little less suffering, a little more hope and a little more knowledge and understanding.  Surely that is worthy of thanks. 

I am not aware of much more we can do to turn the tide of the pandemic.   Somewhere ahead of us is a finish line.  We will face more challenges before we cross it.  We cannot control all of those difficulties, but in the months ahead, we will be focusing on the ones we can change.  We will be looking closely at the circumstances and structures that impede our purpose and make our work, particularly our clinical work, more difficult and less joyful.   We will be looking for meaningful, actionable ways of rethinking and restructuring our work to make it more joyful and sustainable.

In the meantime, I hope you all can find the space to feel thankful for what you’ve done through this great time of trouble.  I am thankful for each of you my dear colleagues, and hope that this week you will enjoy rest and gratitude among those you hold most dear. 

With gratitude and thanks,

Mark

Mark Earnest from History Colorado dot org website

Mark Earnest, MD, PhD, FACP|Professor (Pronouns: he, him, his)
Division Head –  General Internal Medicine
Meiklejohn Endowed Chair of Medicine

Making clinicians worthy of medical AI, Lessons from Tesla… (statnews)

Novel idea: ensure docs KNOW how to operate AI (!) (image: ETHAN MILLER/GETTY IMAGES, via Statnews)

Here is a different take on AI in healthcare: train and only allow clinicians who understand the limitations of AI, to use AI. Make savvy clinicians better. Don’t give it to all clinicians.

This is a throwback to our experience with Dragon Speech recognition over the past decade: DON’T give Dragon speech to a clinician struggling with computer use; instead, give Dragon to a clinician who is computer-savvy and understands the limitations of Dragon.

But, (in the early years) give the non-computer savvy clinician an “opt out” to dictate their notes by dictaphone or telephone, and gradually bring them along.

Having given several non-computer savvy docs access to Dragon in those early years, our hair stood on end when we ended up reading their notes later: they were clearly NOT proof-reading their work and assuming the Dragon engine was perfect at transcription.

Back to the future.

CMIO’s take? Be careful out there, everyone, both on the road with Tesla, and in healthcare with AI.

An AI-human bill of rights?

https://www.wired.com/story/opinion-bill-of-rights-artificial-intelligence/

Read the Wired.com article. In brief, it outlines the emerging risks of relying on AI (artificial intelligence) tools that can unintentionally create bias and other consequences.

This is a nascent class of technology that, at its root, is often a black box: what is inside, is opaque to us, the users, and often to us as the designers.

I feel this critique personally. Having participated in the design of several AI tools in healthcare, I worry that, although we do our best, we don’t know what we don’t know.

CMIO’s take? I have no “best practice” lessons to impart here, on bias and the unknown. Do you? Please share. This is a big mountain we are about to climb, and we need to help each other.

The pandemic, patient messages and phone calls: Octopus or Starfish?

Here we are 19+ months into the pandemic. Time to look at our (unvalidated) trends within our 12 hospital, 1000 clinic health system in Colorado.

Top (blue) line indicates outpatient visit volume monthly from Sept 2019 through Sept 2021. Over 2 years, we saw that dramatic dip in volume in March. That was followed by a gradual recovery and a 10% sustained increase in volume since then. We have added some clinics to our system in the meantime.

Magenta line indicates online messages. We started at 58,000 monthly messages in September 2019, and have sustained 180,000 messages in the most recent 3 months of 2021, a 3 fold increase in patient messaging. OK to ignore that weird peak in Mar 2021, related to a one time system broadcast. This is a real concern for provider workload.

Orange: Surprisingly, we also see an increase in telephone messages (triage-type phone calls): from 23,000 to 35,000, a 1.5 x increase. This means that online messages have NOT replaced phone calls since the onset of the pandemic. This could be related to the growth in percentage of our patients who now have a portal account (growth from 70% to 85% of our patients enrolled in a portal account, over 1.6 million accounts), as well as existing portal-using patients sending more requests and messages, wanting to avoid in-person visits.

Red: Additionally, Scheduled Phone Calls (non-existent prior to pandemic) are now at 5000 monthly messages, and

Green: video (virtual) visits went from nearly zero, up to a peak of 70,000 a month, then stabilizing at 23,000 monthly.

It is an interesting, evolving picture. We have not formally changed staffing or workflow to accommodate this change in message and visit volume, and it has resulted in a massive increase in inbasket messages for providers and staff, with concerns of an unmanageable burden and real risks of burnout for providers and clinical staff.

We believe that, at its root, patients want care, are more anxious about their health during a pandemic, want to avoid in-person visits, have learned about our online tools, and are unclear as to the best way to interact with us.

We could: improve our “front door” experience “Here is how best to contact and work with us”. We could improve our triaging of incoming messages to find the right location/time/place (online message, eVisit by messaging, online chat, scheduled phone call, virtual visit, urgent care, emergency department, other innovative approach).

We could ensure our teams know the best practice for: handling patient questions, prescription renewals, referral requests, outreach programs, remote monitoring, when to suggest video or phone visits, huddling in-person to replace unending back-and-forth messaging.

OCTOPUS

As a result, we are kicking off a major Inbasket redesign initiative. Although our inbasket settings were carefully considered and modified over the years since 2011 (our original Epic go live) with careful feedback from our physicians and informaticists, we still have opportunities:

Inbasket TECHNICAL changes:

  • Eliminating “messages > 12 months old”
  • Reducing the “FYI” and not-actionable messages
  • Auto-deleting some categories of messages after some period of time
  • Creating smartphrase responses to improve thoughtful responses to team mates and to patients
  • Streamlining the ‘response buttons’

Inbasket WORKFLOW changes:

  • Creating best-practice teamwork for “top of license” work
  • Considering innovation tools to “auto-reply” to common questions
  • Moving complex conversations away from portal messages to scheduled phone calls, virtual visits, in-person visits, urgent care as appropriate
  • Considering billing for complex portal messages with patient consent

Just like with Physician Burnout and Wellness in general, there is plenty of work for everyone in Inbasket improvement: there are at least 8 arms to this octopus. Even if we can just “hack off” some of the arms (hmm, perhaps not the best metaphor for healthcare), we can certainly reshape the octopus into something more manageable (a starfish?).

STARFISH

CMIO’s take? Is your inbasket an octopus or starfish, or some other marine animal entirely? It is time for a wholesale re-imagining of our messaging and communications with patients and with each other. What are you and your teams doing in this area? Let me know.

This video about storytelling will change your life

I have followed Andy Goodman’s work (he teaches storytelling to nonprofit organizations), and have learned so much about how to be effective at my own work.

It is nearly an hour long, and who has an hour? You do, if you know what is good for you.

But, I know you’re busy, so, if nothing else, watch at 10:30 minutes for 7 minutes. It will be the best 7 minutes.

Then, since you’ll be hooked by then, watch the whole thing. You won’t regret it.

No one ever made a decision because of a number. They need a story.

Daniel Kahneman, in Thinking, Fast and Slow

CMIO’s take? Storytelling by masters like this change lives. He did mine.

Canyonlands, the Zen of Sand, and my most embarrassing moment

Canyonlands Utah in the 1990’s was a beautiful getaway for me and my then-fiancée. Having heard of this wonderful mountain-bike mecca, we had come, bikes-on-top of my subcompact, met up with our tour group, a diverse crew of men and women of various ages.

100 miles

It would be 100 miles in 4 days across rugged terrain on mountain bikes with a group of 12, a couple of guides and a required-escort (at that time) park ranger. Check it out for yourself, it is a quintessential southwest wonderland.

https://www.nps.gov/cany/planyourvisit/whiterimroad.htm

We begin with a 1000 foot descent into the canyon along a jeep trail. We had brought our old unsuspended bikes with hand brakes. Although the ride was hard on our bodies, we were pleasantly surprised that our equipment was up to the task.

wildflowers from nps.gov
from nps.gov

Our ride was a blast: wildflowers, spectacular vistas, and good company, with mostly flat single track.

Great Canyonlands photography at traveldigg.com

Our guides drive a 4×4 SAG wagon with our gear and food and set up not only our first lunch, but all our meals for the coming days. We have gallons of water that we don’t have to carry! Our camelback hydration backpacks are fantastic for on-the-bike refreshment. This is the life.

Glamping (glamour camping)

At about 25 miles into the trip, at the end of the first day, we get to camp: our guides have driven ahead, set up our site. Dinner is ready and all we have to do is pitch a tent, grab a plate and a folding chair, sit and eat. So awesome. And after dinner, a campfire (apparently forbidden in recent years in the park) and then the Milky Way. Canyonlands, and other national parks, are famous for the lack of light pollution and the spectacular view of the night sky.

photo by the author on an iPhone (!), but in Gunnison National Forest, not Canyonlands

At the end of our third day of riding, as we set up camp, our guide tells us: the Green River is about 4 miles away for anyone wanting an extra excursion. Only I take up the challenge, others choose to rest at our campsite. At the time, I was training to ride my first (and only) double century later that summer (200 miles in a day: the Davis Double, but that is a story for another day), and I was anxious to get in some additional miles.

The Zen of Sand

Solo, I head out. We had learned from our guides about long patches of deep sand on the trail, and the “zen” trick of sitting back, focusing on being “smooth and circular” on the pedals, having a fingertip light touch on the handlebars, and gazing far down the track to improve balance. If done just right, one could “float” over deep sand on the trail. Turns out, this guy agrees with me (youtube).

I actually had a few moments of success doing the sand-float in the shadow of the Airport Tower formation, entirely alone with the crags and formations of the Southwest landscape. Other times, I did the meditative sand-bike-walk.

Sun God

Arriving at the river, I stash my bike in the shrubbery. I see a flat rock jutting out into the river and I determine that I’m going to skinny dip, be clean for the first time in days, and sun myself dry on the rock. Should be great.

To my parched, sand-and-sunscreen-caked, sun-blasted body, splashing in water is heaven. I soak in the cool, rub off the grime, submerge my head and hair and luxuriate.

Then I climb out into the rock, buck naked and unafraid. It has been days since I’ve seen more than our merry biker band, and they’re all kicking back at camp. I shall air-dry, sensually alive and glorious.

Author sitting on a rock outcropping. But not naked. And not the same rock.

I am a glorious human form.

I am one with nature.

I am a Sun God.

Tinnitus?

In the back of my head, I begin to hear a buzzing. What is that? Do I have tinnitus? Odd.

It gets louder. Hmm. A washing machine? Absurd.

Yet louder. An airplane? I look overhead. No contrails. Nothing. Clear blue to the horizon.

Unmistakably the sound of machinery. Rrrr-rrrr-mmm-mmm.

cdn.getyourguide.com

… and around the bend of the river, a 20-seater tour boat, 20 feet away, a gawk-fest of tourists, with a couple kids pointing out the naked man with a bike-shorts-tan splayed out on a rock in the river.

I believe all parties were mortified.

What was there to do, but wave? And then =plop= back into the river.

author, hidden

I am a bottom-dwelling salamander.
I am a shrinking violet.
I am an overexposed slide.

Predictive Algorithms Save Lives Sepsis @uchealth: A 5-slide talk

This data dilettante (see previous posts: dilettante #1, dilettante #2) has enjoyed armchair theorizing with all of you, my best (online) friends. Today we explore how our super-smart team scrambled our way to improving sepsis care with a predictive algorithm we built.

The old saying goes: the success of any major project in a large organization follows the 80:20 rule. 20% of the work is getting the technology right, and 80% is the socio-political skill of the people doing the work.

We all underappreciate this fact.

It turns out that we spent months building a sepsis alert predictive tool, based on various deterioration metrics, and a deep analysis of years of our EHR data across multiple hospitals. We designed it to alert providers and nurses up to 12 hours BEFORE clinicians would spot deterioration.

We patted ourselves on the back, deployed the predictive score in a flowsheet row, and in the patient lists and monitoring boards, with color coding and filters, and stepped back to revel in our glory.

Right?

Nope.

Turns out that our doctors and nurses were ALREADY FULLY BUSY (even before the pandemic) taking are of critically ill patients. Adding YET ANOTHER alert, even with fancy colors, did NOT result in a major behavior shift to ordering IV fluids, blood cultures, or life-saving antibiotics any quicker.

Hmph.

See the fancy patient-wearable tech on the left (Visi from Sotera, in this case), and one of our hardworking nurses, with ALL of our current technology hanging off her jacket and stethoscope. She should be the visual encyclopedia entry for “alert fatigue.” 😦

(right: one of our overburdened hardworking nurses, image used with authorization)

Back to the drawing board

As result of our failure, we huddled to think about transforming the way we provided care. It was time to disrupt ourselves. We decided to implement a Virtual Health Center, mimicking what we had seen in a couple places around the country: we deployed 2 critical care physicians and about a half-dozen critical care nurses on rotation, off-site at an innovative, award-winning Virtual Health Center.

This second time around, we created a cockpit of EHR data and predictive alerts to the VHC clinicians, who were dedicated to watching for deterioration across ALL our hospitals, and responding quickly. This does several things:

  • Takes the load off busy front line clinicians
  • Creates a calm environment for focused, rapid response
  • Dramatically improves the signal-to-noise ratio coming from predictive alerts

This way, the VHC nurses view all the alerts, investigate the chart, and contact the bedside nurse when the suspicion is high for sepsis, and start the sepsis bundle immediately.

Soon, by tweaking the ways our teams worked together, we were able to reduce the burden on bedside nurses and physicians and simplify handoffs.

See chart above: Before the VHC, bedside nurses were responsible for detecting sepsis (infrequent, subtle signals during a busy shift with lots of loud alarms for other things), with many ‘grey box’ tasks, as well as ‘magenta box’ delays.

After implementing the VHC, the VHC nurses took over the majority of ‘green box’ tasks, reducing the bedside ‘grey box’ work and completely eliminating ‘magenta box’ delays.

As a result, we have dropped our “time to fluids” by over an hour, and “time to antibiotics” by 20 minutes, which we estimate has saved 77 more lives from sepsis each year.

CMIO’s take? Predictive analytics, data science, machine learning, call it what you like. This is a paradigm shift in thinking that requires disrupting “business as usual” and is hard, but rewarding work. I can’t wait to see what we all can achieve with these new tools.

Chimerealism

Mashing ideas together

Greg's Webvault

this is where Greg puts stuff he wants to keep

Discover WordPress

A daily selection of the best content published on WordPress, collected for you by humans who love to read.

Daring Fireball

CT Lin's CMIO Blog

ALiEM

CT Lin's CMIO Blog

HIStalk

CT Lin's CMIO Blog

the other fork in the road

navigating life via acute corners, wrong turns and dead ends