Thanks to the medical informatics division at UC San Diego Health for hosting me at their informatics seminar series. I gave a talk about our efforts on improving physician well-being and reducing burnout (see previous blog posts on Sprints and Practice Transformation).
Sometimes, I travel with my ukulele. Sometimes, I sing at the end of my presentations. Sometimes, I climb out of my meditative, introvert bubble and see what happens.
Thanks to the one guy in the seminar who clapped for me. Kidding. UCSD has a great crew of informaticists doing great work. Christopher Longhurst (CIO) and his team are implementing a team with the purpose of getting physicians “Home for dinner” among the many other good things they’re doing.
Thanks to my University of Colorado School of Medicine colleague Steve Ross MD who challenged me to think about how we improve the clinician experience in EHR’s.
Yes, we are all worried about Physician Burnout, and about the EHR Burden, and bemoan how difficult it is to assemble all the important pieces of data about a patient into a coherent whole, so that the physician can GROK the patient (instantly understand; thank you to Robert Heinlein’ Stranger in a Strange Land) and thus treat him/her effectively and humanely.
Let us not forget where we came from. Although paper was more familiar, and tactile, and you could SEE HOW HEAVY a patient’s past medical history was by how many volumes the clerk would deliver from the warehouse and slam down on your desk, it was NEVER a joy to approach the chart and begin to consume it, page by page.
AND YET we are still far away from the ideal state where a physician can walk up to an EHR, bring up the patient, and on ONE SCREEN have a pre-digested, specialty-specific, visit-specific, patient-centered, view of the patient. We have all dreamed of the ideal “chart-biopsy” tool that would allow us to see all the many pieces of a patient’s past history, gathered into one place. I have yet to see such a tool.
In my view, such an ideal GROK-board should pursue the following:
Be HUMANE and emphasize the patient’s goals, preferences, and identity
Thanks to Gregory Makoul for his fantastic work in patient-physician communication. We need to improve the visibility of patients as humans in the EHR so that physicians can more quickly connect as person to person; this results in improved patient outcomes and less physician burnout.
Increase SIGNAL to noise ratio of the information presented
Prioritize MOST IMPORTANT next actions
Make the RIGHT thing easy
Make it QUICK to grok and then act
CMIO’s take? I don’t pretend to have a monopoly on this vision. I challenge all of us to make something better than the GROK-board I threw together the other evening.
More news about our EHR 2.0 Sprint efforts; we’re getting some attention from around the country and it is gratifying on several levels: 1) that organizations are taking Physician Burnout seriously and 2) that our efforts at concretely moving the needle on EHR burden and Physician Burnout are getting some attention nationally.
Certainly our internal clinics are benefitting from these efforts.
CMIO’s take? More is not always better, unless (work and burden) is better.
This is of course the distillation of the frustrated physician at the computer in the corner (you may recognize the physician-actor), with dissatisfaction cascading to the patient. Why does it have to be this way? How did we get here? Well, we are often victims of ‘translational’ thinking, with insufficient ‘transformational’ thinking. What I mean is: just because the doctor carried the paper chart into the room and scribbled on it, doesn’t mean that putting a computer in the room is sufficient. Would we: ask an airline pilot to review the passenger manifest and take tickets? Would we ask the courtroom judge to take detailed notes in the courtroom?
Here, let’s just pile on, with a kids view of their doctor typing away in the corner. What a gut punch. Is this what children (and adults!) think of seeing the doctor now?
So here is an incremental improvement. Think about bringing the patient down from the exam table (so many stories of doctors calling questions over their shoulder at unseen patients on the exam table!) think about having them sit next to you and talk about what you’re doing on the computer and whether that looks right. Use it as a method of reflective listening.
Take it a step further with MA’s doing advanced rooming role and also scribing for the physician. This implies a doubling or quadrupling of the MA staff, but can dramatically reduce physician burnout, improve quality metrics and improve throughput resulting in cost neutral staffing in a fee-for-service model, and dramatic improvements in quality in the near-future Value-Based Care model.
How about this? Use speech recognition for your assessment and plan IN THE ROOM with the patient. I find it to be magical, when trained and used properly! More on this in another blog post.
Here we are again, learning from a MOOC (massive, open, online course). This time, I read an article by the NYTimes regarding Laurie Santo’s massively popular Yale course for undergraduates called Psychology and the Good Life. It was apparently, the most popular course at Yale, ever. So, it was with great pleasure I noted that Dr. Santos was adapting it to an online course via Coursera called The Science of Well-Being, and I was immediately in-line to sign up for the free course.
Over 6 weeks, Dr. Santos takes us through the science, and the practical tips needed to identify “mis-wanting” or, wanting things that do NOT make us happy (eg, higher salary, bigger house, engaging in social media, wanting solitude). She also outlines and compares ancient traditions of meditation and compassion with modern science and functional MRI studies where we can see where blood flow goes to which regions of the brain. Having heard of some of this research, I was really happy (!) to have Dr. Santos pull this science all together into a cohesive narrative.
I won’t ruin it for you; you HAVE to take this course. She goes over the big habits that improve happiness, among them: gratitude, compassion, exercise, sleep. I will however, give you the trick that Dr. Santos teaches, originally from Gabrielle Oettingen at NYU, called WOOP: wish, outcome, obstacle, plan. Wish means, to spend time thinking about what what you REALLY want, some habit that if you could change to make your life better, what would that be, and figure out how to say it in 3-5 words. For me, maybe that’s Sleep More. Outcome means, to envision all the great things that you imagine will accrue when you achieve this goal, and to summarize it in a few words. Maybe this is: I will be rested, happier and more creative. Obstacle means, to envision the SPECIFIC road blocks that you can foresee to meeting your goal. Plan means, to create SPECIFIC ways to overcome the obstacles.
Here’s the insight that BLEW my mind. Are you familiar with the book Thinking Fast and Slow? Daniel Kahneman and Amos Tversky discuss System 1 (the automatic, gut-feeling, rapid, doesn’t-take-much-brainpower, lazy system that is always working in your mind) and System 2 (the effortful, rational, give-me-a-minute-and-I’ll-figure-this-out, this-is-who-I-really-am part of your mind). Despite our self-perception that we are always using System 2 to be rational human beings, it is clear that MOST of the time, we are lazy and use System 1. This is why new year’s resolutions so often fail, System 1 takes over and thinks “Oh, I’m tired right now, what’s the harm in starting my resolution TOMORROW. I feel like some ice cream.” System 2 goes and sits in the back seat, waiting for another day.
Turns out, if you think of OBSTACLE and PLAN very very specifically, you can speak directly to System 1!!! Yes, you heard that right. Lazy System 1 actually listens to very specific instructions, even when generalized resolutions are completely ignored.
FOR EXAMPLE: Don’t say “I’m going to get more sleep.” System 1 laughs at this. DO say: OBSTACLE: “I want to go to sleep at 11pm every night, but I always get more energy that time of night.” PLAN: “I’m going to set an alarm at 10:30pm every night, to stop whatever I’m doing, and go read a book for 30 minutes, and go to sleep at 11pm.”
Dr. Oettingen’s research indicates that student grades improve a full grade, and that all sorts of participants improve their lives when setting WOOP goals, with effects persisting for at least 10 weeks after initial goal setting.
CMIO’s take? Sign me up for WOOP! Will you join me?
YVMC’s head nurse Maria took me aside yesterday: “I have BIG favor to ask of you.” With trepidation, I stepped aside for a brief chat. “I need you to write a song about Mark and Heather; they’ve been amazing and led the teams to our EHR go-live success. And, can you put it together by tomorrow’s 9am Safety Huddle?”
What!?! Seriously? Does she know how hard it is for me to write these, learn to play the song (badly), practice enough to be willing to play in public?
Turns out, looking through my song parody library on my Notes app on my phone, I had a parody song, I called “Anschutz Roads” written in 2011 for our initial Epic go live at University of Colorado Hospital. With growing relief, I found that I could adapt it for our purposes here. I also recruited Juliette Callander, Manager of the UCHealth Rev Cycle team, and equally important, a wonderful singer, whose harmonies added a lot to the song.
She took me up on the challenge of learning the melody and the words, as I struggled to get my chord progressions and my strum pattern down. A few minutes of rehearsal in the nearby board room the next morning, and we were on stage at the end of Safety Huddle.
CMIO’s take? You can’t always get what you want, but if you try sometimes, you get what you need. I enjoyed how embarrassed Mark and Heather were during the song. Thanks, you guys are great. Also, I’m winding down my daily coverage of YVMC EHR go live, and returning to our regularly scheduled weekly posts starting tomorrow. See you then!
Finally, the Command Center begins to fill out with analysts supporting the full spectrum of IT areas: ambulatory, scheduling, inpatient, informatics, nursing, staff, health info management, security, networking, desktop support, interfaces, speech recognition, implementation specialists (jack-of-all-trades support).
Overall we are doing well. No big fires, just a steady stream of the usual. Printers not mapped to the right spot, meaning that printouts (after visit summary, printed orders for external labs, etc). Security challenges. Some clinics switched from ‘community connect’ to employed clinics, so all the clinicians have new security for logins an their previous personalized settings were ‘lost.’ Some test results are not flowing exactly as expected. So each of these requires investigation and fixing. It is rewarding to see issues come in and watch them be fixed within minutes to hours, since we are focused.
Fun fact: we’re using Microsoft Teams to communicate internally. All of my physicians in the Large PIG (physician informatics group) are on Teams. We have set up a communication channel called YVMC go live (Yampa Valley Medical Center), and conversation threads regarding clinic support as well as hospital support. As issues come and go, we post our conversation there, Facebook-like (except stored securely and not polluted by silly cat videos or rogue-bots), so that my entire team is not spammed by me, and anyone interested can dip into the conversation as needed, as each of them will rotate through Steamboat for 1-2 days, and can see all the issues posed and resolved previously. Teams is not perfect, but it is good-enough. We can link to shared calendars, to common file storage, to best practice tip sheets, for addresses of all the clinics. We can set it to “ping” us on our phones and our desktops, and can treat it as both email-like, file storage-like, as well as instant-message like. And our email congestion is slightly less.
Finally, another uke song:
CMIO’s take? Whew. Going back to the hotel to put my feet up. Back at it tomorrow.
I love hospital art. Why not improve the lives of employees by showing something beautiful?
Day 2 is going well. It is fascinating to see each department with very different concerns come together to solve problems.
We have a doc who can order tests and prescriptions but can’t place billing charges without ‘changing context.’ Call the command center. We can fix it.
We have a doc whose USB Dragon mic doesn’t work. Solution: call in a ticket to command center with details, move to a different computer until it is fixed.
Some breast milk scanning process is not well known. Send a red shirt with expertise. Teach the new workflow, get staff up to speed. Done, this morning.
Someone in respiratory therapy is trying to place a lactate order, as they always used to. Can’t do it in the new system. Ok, something we didn’t find out during our ‘discovery’ interviews. It is always something. We’re on it.
Of course when you can sneak in a song…
If You’re Going to Yampa Valley. Based on the Scott Mackenzie song ‘If you’re going to San Francisco.’
CMIO’s take? Good news: everything we solve today is one less crisis tomorrow when we are back to full speed patient care.
These suspicious looking characters are Jon Pell MD, Hospitalist and informaticist, Mark Clark, CIO YVMC, Dave Corry MD, informaticist and vascular surgeon, and yours truly. We’re here wearing red shirts and supporting the physicians and staff for day ONE.
Remarkably few calls to the command center, scant login issues, only 20 open issues on the tracker. Very quiet and quite calm for day one.
Unlike other industries where one may have to remind oneself of the larger mission of IT (eg not just supporting users and making sure the network and software is working) it is abundantly clear who we serve as we walk around. Beautiful photos of moms and babies on the Women and Infants unit.
Magically, these computers went from inoperable to fully functional overnight.
We are SET! Dozens of fresh red shirts, ready to be donned. We have invaded the local hotels and will be set for go live in the morning.
Furthermore, lots of pens and papers to sketch out issues, problem solve. And of course lots of tissues for the tears … of empathy. Yes, we anticipate being sad for everyone for whom we will have ‘moved their cheese‘ in the process of replacing their previous medical record system with UCHealth’s system EHR. For this, we anticipate saying ‘sorry’ all week long.
Meantime, behind the scenes, feverish activity in the Cutover room. In front of these dozen computers, hospital and IT teammates are gathering data on the handful of patients who we anticipate will stay overnight in the hospital and thus will need to have their data moved by hand (some copy and paste) from one EHR to another so that the docs will ‘hit the ground running’ in the morning. This means all the demographic information, their med list, their IVs, their diagnoses, any treatment plans for nurses, their active treatment orders and any pending labs or tests.
The cutover moment will be 2am when the old system is retired and the new one is live. We have databases to convert, interfaces to move, we have to unhook the transcription system and move it, we have to unhook the speech recognition system and move it. We have to add hundreds of new physicians to the database and grant them the correct security access. There are tons of mini settings to get right: hospital admit privileges? Ability to dictate? License to use Dragon speech? Ability to badge into the OB suite? Privileges to do EPCS? (E-prescribe controlled substances?) did we capture their digital signature? Did they come to training and get certified to use the EHR? Are they a surgeon and need access to the OR schedule? Do we have them set up in the right clinic? Do they have the right ER tools if they work in the ER? Months of planning come down to tonight and tomorrow.
And this is just the stuff that a CMIO cares about.
The CIO’s team also handles: Cloud storage, network traffic, downtime plans, Outlook integration, single sign on, employee badge management, coordinating meals for about 100 workers, hotel accommodations, network interfaces, wireless access points, brand new WOWs (workstations on wheels) retiring the old EHR and old habits and workflows, etc. Whew.
CMIO’s take? It is an exciting time. Stay tuned! We’ll be live blogging all weekend and into next week. We’ll try hard to bring you the pitter-patter excitement of a Go Live. One of my colleagues compares it to ‘replacing an aircraft engine in mid flight.’ He’s not wrong.