February 2017 – The Undiscovered Country

Wall Street Journal: How to get patients to take more control of their medical decisions (news)

he-aa316_active_p_20170223120405 — Courtesy of Wall Street Journal original article

At UCHealth, based in Aurora, Colo., as soon as a doctor finishes signing a note, it is available to patients in their electronic record, according to CT Lin, chief medical information officer. Doctors are encouraged to use language such as “you and I have agreed that you will take these actions,” Dr. Lin says. Bella Wong, 39, who had a double lung transplant four years ago at UCHealth’s University of Colorado Hospital, says online access to her own records and doctors’ notes has helped her become a more engaged patient than when she was first diagnosed with lung disease eight years ago and left decisions mostly to doctors. Though she once viewed the word of doctors as “gospel,” she says of her relationship with them now, “I want to know everything that is available to me and understand all my options—you are not just telling me what to do, we are making a decision together.”

https://www.wsj.com/articles/how-to-get-patients-to-take-more-control-of-their-medical-decisions-1488164941

Thanks to the Journal and Laura Landro for a great writeup. Proud of our team, our patients and our organization for sharing this journey.

Review: Dark Matter

Dark Matter by Blake Crouch

My rating: 5 of 5 stars

Some books slink onto the bookshelf and lay there for months or years. Some books keep popping up insistently until you say “FINE” and buy it, just to shut up the voice in your head. This is one of the latter. I saw this on my Audible.com feed, highly recommended among my friends on Goodreads, and finally(!) as a first-ever flyer for “Book Club” near the restrooms in my building in Academic Office One at work. A Sci-fi book for nerdy academic physicians and their staff?

Once I picked up this book, I couldn’t put it down. Sure, the Spielberg-like, idyllic family life for the protagonist, check. The “gotta go out for just a minute” (don’t do it!), check. The inevitable “event” that upends the world for the protagonist, check. Sure, I’ve read (and maybe some of you, following me on this blog?) about the Hero’s Journey at the root of so many stories, and maybe, with my new eyes, I was anticipating some of the next steps.

But.

Sometimes an author pulls you along, and then starts unwinding some big ideas. Okay, maybe the title “Dark Matter” should have been a giveaway. Maybe the first chapters, as the protagonist’s grogginess wears off, seemed to telegraph the author’s hidden intentions.

But then, as my favorite sci-fi books do, the author shifts it into a higher gear and starts spinning a terrific yarn: a tale of hard choices, yearning, “what-if’s”, superpositions, love, Schroedinger’s cat(?), and nape-of-the-neck Spidey-sense tinglers. Any book that includes the phrase: “that person will decohere the quantum state” is okay in my book. Especially if it makes total sense when you get to that point in the narrative.

CMIO’s take? There are times in our lives that we wished we did something differently, and wonder if things would have turned out differently, at work, at home, whether we would be happier, wouldn’t we have fewer regrets, if only…

I suggest: live your life in the present. This present. This one, where you have to read this amazing, thoughtful, science-fiction-isn’t-even-as-weird-as-real-science book, ‘cuz I’m not gonna spoil it for you.

BONUS ROUND: Book club at work was hilarious and fun. Met with staffers at the academic center, all of whom had interesting backgrounds, found very different points of the book to be fascinating, and we had a great exchange. Why don’t we have more book clubs at work? We should.

View all my reviews

Pager inversus? Beeper Obliterans?

(images: http://throwbackvb.blogspot.com/2009/04/pager-code.html and http://www.zeppy.io/discover/us/used-pager-system)

There was a time when the last major industries using a pager were: drug runners and physicians. But then, drug runners switched to disposable, cash-purchased “burner” phones. Apparently, Breaking Bad and The Wire taught us about this. Having seen neither show (yet: saving up to “power-disk” them some day), I’m still faithfully carrying my pager around.

Why are physicians the last ones? I’d have to agree with other articles that reliability (signal penetrates buildings where cell signal might not), flexibility (don’t have to give out personal cell number, and don’t ‘have to’ respond to a page), low maintenance (change the AA battery once a month, so what if hospital power goes out), and low cost ($10 per month or less) are the main drivers. That, and massive inertia.

I’ve been in healthcare since 1985, and in that time, I remember wearing audio pagers (bee-doo-bee-doo! *static* Doctor, please call *static* 347 *static* Come QUICK! *static*). Sigh. What was the full phone number? Who? Where?

I’ve seen some services try to transition to texting (Please come tell Mr. Jones in 307 that he is HIV positive). Sigh. What was that thing about privacy? Did you really just tell AT&T about Mr. Jones?

I’ve seen other physicians miss critical messages because texting did not work in certain internal locations in hospitals. Gives a new meaning to “dead zones.”

With a growing number of hospitals installing internal cell-signal repeaters, it is possible that pagers are finally on their way out. I will miss them, when they’re gone. They did inspire an entire range of emotions over my career.
PRIDE: Hey! You mean medical students get to wear one?!
FEAR: Oh, man, this thing never stops. Can I just eat/pee/poop without being disturbed?
JOY: Finally, I have graduated residency and I am TURNING THIS DAMN THING OFF!
RESIGNATION: Oh, I have to wear one as an attending physician?
HOPE: Maybe, just maybe we can get rid of it and use our anticipated secure texting system

Finally, I recall my favorite research article, published in JAMA in 1992: BEEPER OBLITERANS. It references the older style “audio” pagers with a small “test” button on the top surface that was easy to accidentally “set off.” I won’t ruin it; you have to read it:
http://www.neonatology.org/pearls/beeper.html

Epic Sprint! Or, how we learned to love the EHR (part 1)

Ok, so maybe that’s a little overstated, but it got your attention. And maybe Dr. Strangelove seems too apt a reference for our times.

In the past few months, our fantastic Epic informatics physicians partnered with our EHR analysts and developed a new way to improve the circumstances of our physicians using the Epic EHR. We all know about the national plight of physicians and the epidemic of ‘burnout.’ Much of this burnout is attributed to the documentation burden of interacting with an EHR.

Of course, having lived through the past 22 years of the birth and growth of informatics, this situation is a stake through my heart. I know, for a FACT, that the future of healthcare REQUIRES a high functioning Electronic Health Record, and a team of forward thinking informaticists looking to tie together this often-mindless, multi-headed beast of a health care system with a nimble, responsive, intelligent, adaptive, predictive nervous system. At its best, an EHR can remind, prod, nudge, assist and sometimes advise and improve, the care of individual patients, and even entire populations and communities.

So, it is heartbreaking to hear stories of doctors retiring, “burning out,” losing the joy of practice, and looking forward to retirement, citing the EHR as a reason.

In the past years since launching Epic in 2011, we have tried many ways to improve the lot of our docs. We tried:

**A lecture series in the early AM, at noon, in the evening (mostly flops).
**We tried anonymous email tips (‘The Surgeon’s Friend’). Ok, it was funny and maybe some folks read it, but no.
**We tried emailing a ‘tip of the week.’ And various forms of EHR newsletters. We still send out monthly newsletters with 4-6 tips in social-media-like teasers with hyperlinks (getting about a 25-30% readership rate, not bad, but…)
**We tried adding a topical “Haiku” poem (the Epic Haiku, get it?), and hoping that at least my colleagues might read 17 syllables about Health IT. As a result, I received email critiques on my syllable count and not adhering to the “true spirit” of Haiku.
**We tried restricting our IT ‘optimization’ and tech improvements efforts to those items that would benefit most of our 3000 physicians (thus, being very generic improvements, not specialty-specific and, like milque-toast, accepted blandly). For example, making general improvements to the sorting of the Problem List (partnering with a company called IMO on their Intelligent Problem List), adjusting Chart Review to be easier to navigate, for all doctors, etc.

**We tried an ‘EHR Genius Bar’ stolen whole-cloth from Apple, where we waltzed into clinic with a steel rolling table “borrowed” from the OR, and parked ourselves in a conspicuous corner of the clinic. (Thanks to Trish Milton-Hoffman for sneaky execution of this project “under the radar.”) We brought a couple of IT analysts, a trainer and a physician informaticist, to administer the Genius Quiz (top 10 ways to be more efficient in the EHR). Those answering more than 7 of 10 right got an I’M A GENIUS sticker, with (pick one) a picture of Einstein or Homer Simpson with a tiny brain. And, if you were NOT YET A GENIUS, we would teach you tips until you WERE a GENIUS. At least the stickers went over well.

Actually, this effort over VERY well, with physicians feeling “heard and appreciated” for their struggles. The team spent a week in clinic, observing use of the EHR (amazing what one can spot in about 30 minutes of silent observation). Then, there would be 1:1 training sessions specific to the individual physician’s “pain points” and specific struggles, and the analysts would occasionally “fix” some templates or smart-phrases, or set up some preference lists and short cuts. Eventually, the physicians who wore their GENIUS stickers on their hospital badges piqued the interest of other docs who were ignoring us, leading to a snowball effect of interested docs dropping by the GENIUS BAR.

Unfortunately, dedicating even a small team of analysts, trainers and docs to this effort was costly (the opportunity cost of other projects they were taken away from), and requesting the formal budget to fund such a team, or teams on a more permanent basis, was very, very difficult, as it never had a “return on investment” that would show up in dollars. And, such a team could “only” help one clinic at a time for a week. With our health system encompassing 50 clinics back in 2011, and 350+ now, our work would never be done. After living on for several months, and helping out about a dozen clinics, even this effort closed its doors.

Stay tuned for future Episodes of … The Epic Sprint.