Project CORE, e-Consults and my 1997 view “email should be part of an electronic record”

In 25 years, communication technologies have gone through several generations of change. Look back and see what I saw in 1997.

From Dall-E. Doctors at a computer, treating patients, optimistic

 

 

Throwing out old files from my office recently, I came across this blast from the past. In effect: “we should include an e-mail or electronic message function in the Electronic Health Record” or at least, “could you allow us to use our email program on the same computer as our electronic medical record? Then we could possibly cut and paste important questions and conversations between providers and cut down on full consults and referrals and improve coordination of care”

In 1997. At least 3 EHR implementations ago.

I hate to say “I told you so, but … I told you so.”

Here we are in 2020, and we have since studied patients having online portals and using online communication with providers and found these tools to be practical for providers and nurses and patients, and also shown to improve adherence to treatment and high satisfaction.

We have implemented Project CORE, a method for docs to request electronic consults from specialists on their patients; straightforward questions that come up regularly can be quickly and easily answered by colleagues WITHOUT having the patient physically go see the specialist. It is a win-win-win (speed of response for referring doc, no extra effort for patient, easy question/answer by specialist and decompressing packed schedules to make availability for more complex patients). Almost all our specialties now offer this to our primary care colleagues.

We have implemented Secure Chat within our EHR, an ability not only to send email-like messages (have had that since we implemented in 2011), but to send near-real-time text-like messages, securely within the mobile app (Haiku) associated with our EHR (Epic). Here’s an article from Providence Health System in Portland describing the features. Such interruptive alerting can be intrusive, but also when used well, can power highly-functioning teams.

Some observations: 

  • Email in 1997, at the time of this document, was a “new thing”. In fact, connecting computers to a “network” directly into the wall-jack was a new thing. I had purchased several generations of modems for home, where I could connect by phone line to the “Internet”. Of course, we WOULD NOT put patient charts on the computer, right? That’s just a ridiculous idea. 
  • Mobile phones in 1997 were increasingly common, but the number pads were a TERRIBLE way to type an SMS message. It would not be until the Blackberry in 1999 showed us that a ‘chicklet keyboard’ was a faster way to type what later became instant messages. 
  • And now, both of these communications technologies are embedded in EHR’s.  

This reminds me of something someone said to me when she was 5:

“That was back in the days of the dinosaurs, when you were alive, but I wasn’t.”

–baby daughter Lin, age 5

CMIO’s take? 1997 to 2023: electronic messaging in EHR’s? I told you so. I was just 25 years too early.

Epic man, singing about immediate release of results, covers Anticipatory Guidance.

Immediate release of test results, discussed with a radiologist audience: a pro and con debate. What could go wrong? And, of course, the ukulele.

Thanks to Dr. Jennifer Kemp who designed and invited me to present a panel called: “Information Blocking Pro and Con: A  Debate.”

I am at RSNA today. My first. Did you know the Radiological Society of North America is the largest medical conference in the world? I did not know this until yesterday. 40,000 attendees, over 4000 speakers. That works out to about 80 speakers PER HOUR. Geez.

I was one.

Disappointingly, not all 40,000 attendees came to see our panel presentation. 🙁

Nevertheless, of the 80 attendees, we had an excellent discussion in the context of releasing complex radiology images to patients, including MRI CT PET etc. and the resulting problems if/when patients find out about cancer or other devastating result by viewing their results online.

There are exceptions to the federal rule:

  • If the patient prefers not to see the results
  • If releasing the results may result in Physical Harm to the patient or other person (note that anxiety or psychological harm does NOT qualify)
  • Systematic embargo or delay of release of result is forbidden based on this federal rule.
  • The proposed penalty for violating this rule is $1 million. However, we are aware of only about 400 registered complaints of information blocking, 3/4 of which are organization to organization blocking, and only about 100 of patients registering because of not receiving notes or results. And we are not aware of any successful complaints resulting in actual penalties, as yet.

Question from the UK

We had a question from a colleague from the United Kingdom, as they are just now about to formulate a similar law. ‘Would it be reasonable given US experience to establish a national standard for embargo: let’s say all providers uniformly delay a high risk result for 3 days?’

Our reply: probably not. Airline passengers are now aware of every moment of their luggage transport, and every moment of their arriving Uber driver. Why would radiology reports be any different? The consumerism movement is unidirectionally toward more transparency. Maybe 5 years ago, if the UK was considering a standard, that would have been standard of care in the US, but no longer. 

Furthermore, research that we (reference) did

indicate that among 8000 patients who had already received test results from a patient portal, 96% indicated they wished to continue to receive results immediately. Even among those receiving abnormal results, 95% still wished to receive results immediately.

It is also true, however, that 8% of patients receiving immediately released results did worry more. However, we believe this worry is based on getting “bad news” more than it is about getting “bad news immediately.” These are the patients we need to focus on, and more details we need to study. 

Our suggested plan: that ordering physicians use anticipatory guidance: ordering physicians will eventually need to explain the result to the patient. Why not spend one more minute at the time of ordering to dramatically reduce the anxiety of the patient when they view the result later at home?

3 easy steps:

1. We are ordering a test. You may see the result before me. Best case, this is normal and I will contact you this way…

2. Worst case it could be … there is X% chance of this. If that is the case this is how I would reach you…

3. You have a choice: look immediately or wait to hear from me. What Q do you have?

In our experience this works very well and doesn’t take much time at all.

And for radiologists, publishing a contact number for patients to call if they have questions is very reassuring to patients and, guess what: they rarely use that number: in a busy multi-radiologist practice over the course of years reading hundreds of thousands of studies, their office has received 1-3 phone calls A YEAR from patients. And most of the time it is about factual errors in the report, and rarely is it to ask about the medical impact of the findings. It is quite minimal work.

CMIO’s take? The time for immediate release is here. There are great solutions to the anticipated problems. It also happens to be the law in the US.

If you’re still not convinced, or even if you are, here is a song for you, fresh from Chicago’s RSNA 2023:

Epic Man 2023: Information Blocking. (YouTube)

Predicting Sepsis and Virtual Health Center at UCHealth: News. Colorado Sun

Saving lives at UCHealth: a combination of predictive analytics (AI) and a dedicated team: the Virtual Health Center nurses. Come see how the sausage is made (kinda cool)

 

Can AI improve health care? Doctors at UCHealth are trying to find out.

Thanks to John Ingold and the Colorado Sun for highlighting our ongoing work to defeat sepsis at UCHealth using predictive algorithms and the Virtual Health Center (VHC). I appreciate my colleague Amy Hassell for the outstanding team she leads in this work.

Together we have reduced mortality, by the equivalent of 800+ lives saved per year from sepsis and other in-hospital deteriorations.

We have moved our internal process. We began in 2018 by showing everything to the bedside team. No change in outcomes.

Then we put the Virtual Health Team as a back-up service to the primary team. Slight improvement (200 more lives saved per year over baseline).

Now, we have the Virtual Health Team as primary service, both detecting deterioration and taking direct action, with the patient’s primary bedside team in the background. This dramatically improves speed and consistency of response to a complicated disease requiring a coordinated approach: now 800+ more lives saved per year from in-hospital deterioration.

We are happy with our internal improvements and are always hungry for more opportunities. Thanks to Amy and the amazing VHC.

Why this piece of AI art can’t be copyrighted (Wired.com)

The next evolution is here: court battles about what constitutes original artwork, where products of machines or non-humans are not copyrightable, even though the human painter generated 624 prompts and numerous photoshop adjustments to the combined artwork…

https://www.wired.com/story/ai-art-copyright-matthew-allen/

Podcast with me, CT Lin and John Lynn: CIO Podcast

Now, without further ado, we’re excited to share with you the next episode of the CIO Podcast by Healthcare IT Today.

CIO Podcast – Episode 63: Patient Messaging with CT Lin, MD
Interview w John Lynn

For the 63rd episode of the CIO podcast hosted by Healthcare IT Today, we are joined by CT Lin, MD, CMIO at UCHealth-Colorado to talk about patient messaging. To kick off the episode we dive into his work in sharing patient results and the efforts to keep it private. Next, we talk about how the sudden increase in patient messaging has led to some practices charging for the service to get Lin’s experience and thoughts on the topic. Then we take a look into Lin’s past projects to get his insights on what project he felt was the most successful and what made it successful. Looking forward, we also discuss what projects Lin wants to work on but hasn’t had the time. We then talk about AI and where we think it’s heading. Finally, Lin shares the best career advice he’s been given and how playing the ukulele has impacted his career.  Plus, he finishes off the episode with a health IT ukulele song.

Here’s a look at the questions and topics we discuss in this episode:

  • You were ahead of the curve with sharing results with patients. Where are you at today with Information Blocking and sharing data with patients?
  • Patient messages are overwhelming doctor’s Epic inboxes. Many are starting to charge for these messages. What’s been your experience with this and how is UCHealth approaching it?
  • What’s the project you’ve worked on that’s brought you the most personal satisfaction and feeling of success and what made it successful?
  • What’s a project you want to work on, but just haven’t had time to yet?
  • Where is all this AI headed?
  • What’s the best piece of career advice you’ve been given?
  • Where did you learn to play the Ukulele and how’s that impacted your professional career?

The most important question about long COVID (Harvard news)

It is not a single disease. We still don’t have a grasp of the underlying mechanism. We see several collections of symptoms: loss of smell and taste, severe fatigue, myocarditis (heart inflammation), lung disease / shortness of breath, mimicry of Chronic fatigue syndrome. I am glad there is significant work in this area, as it is possible that up to 1 million people are out of the workforce in America as a result of this illness. 

https://hms.harvard.edu/news/most-important-question-about-long-covid

Image from Harvard News.

 

I’m speaking at CHIME Fall Forum: the pre-course on informatics AND the main forum

Come for the Informatics discussion, stay for the ukulele. Or don’t. Topics: Big Data / AI in practical use; Blowing up the Classroom for EHR Training; Inbasket Hyperobject: what is that, exactly? And can we deconstruct it?

Here is the registration link:

https://www.chimeinnovation.org/nov23-clinical-informatics-innovation-summit

Hope to see you there! Looking forward to our discussions.

 

Incremental Healthcare (Dr Nick Van Terheyden) Audio Podcast with CT Lin

An audio podcast of EHR trends including AI chatbots, shiny new objects, and boring old governance.

Thanks to Dr. Nick for hosting me on his podcast the Incrementalist.

We covered a bunch of topics in our time together:

  • AI, big data
  • CMIO work
  • Digital Health
  • Disruptive tech
  • EHR trends

Healing Harmonies – Dr Nick (incrementalhealthcare.com)

And maybe, a ukulele song. Transcript available for those who aren’t patient enough to listen (but then, song lyrics and melodies don’t translate well with an auto-transcriber).

CT

New Research: Information transparency with immediate release: Oncology clinician and patient perceptions

Highlights: Clinicians and patients have varying insights on the role of immediately released reports (pathology/radiology) in oncology. We must support the expansion of patient-centered strategies and tools for patient understanding and empowerment. These include patient portal tools (glossaries, summaries, and additional information) embedded into released results.

from thenounproject.com

https://www.sciencedirect.com/science/article/pii/S0002961023005214

More research work on immediate release of test results to patients. There is divergent opinion between patients and oncologists, and our conclusion is that this is a new world, and it is time to adjust our clinical care, perhaps with anticipatory guidance. See our other article “I don’t think it should take you three days to tell me my baby is dead.”

The time is ripe for our change in practice.

How to build resilience against loneliness in aging (Harvard news)

Harvard researchers have some insights into older adults and some recommendations and concrete actions to take to combat loneliness as we age.

https://hms.harvard.edu/news/how-older-adults-can-build-resilience-against-loneliness

 

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