Book review: Artemis

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Five stars.

Maybe the best sci-fi book of the year? Well, it is in the running. I’m sure it is difficult for an author to follow-up a first-novel blockbuster book with a successful second novel, but Andy has pulled it off. It is NOT the paradigm-shifting story of a marooned human on Mars, but a gritty, near-future story about a super-smart deliveryman (gal) who is sick of people telling her she’s “not living up to her potential.” And she is a smuggler: she smuggles goods in from Earth to the Moon colony called Artemis. But then her smuggling gets her involved in something a lot bigger than she intended.

Andy unwinds this tale with a huge dollop of delicious hard-science fully integrated into the storytelling and into the problem-solving. This key is the same key that unlocked The Martian for me and so many others. Feels like the 1970’s TV show “The A-team” except with hard science instead of those rapid-action cut scenes where they’re building something cool that will get them out of trouble by the end of the episode. That kind of feeling. Except better.

CMIO’s take? Science rocks. Artemis rocks. Two thumbs up.

The Glass Cage by Nicholas Carr (book review)

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One of our book club books, for the ‘clinical decision support’ team for the electronic health record at our institution. We have now read it in our Large PIG book club meeting (the Physician Informatics Group: we try hard not to take ourselves too seriously). Some of us were depressed after reading. The initial optimism of the ‘glass cockpit’, the fancy new computerized design of the complex Airbus aircraft, are instead proving to be a ‘glass cage’, which isolates us and anesthetizes us from the real world. The author provides riveting examples of glass cages: the Inuit who lose their cultural skills of navigating brutally inhospitable landscapes because of GPS and snowmobiles, also, the pilots who make error because of automation, leading to automation bias and automation complacency: thinking the computer must be right, and the computer will know, so I don’t have to. Further, our attention wanders as we cede responsibility for moment to moment control of the task. How do we fight such a trend and temptation, as designers?

Yet the author speaks about ‘adaptive automation’ where a computer could detect the cognitive load or stress in a human partner, and share the cognitive work appropriately. He speaks of Charles Lindbergh, describing his plane as an extension of himself, as a ‘we.’ Can we aspire to improving the design of our current electronic systems to such a partnership that avoids the anesthetic effect and instead becomes more than the sum of the partners? Chess is now played best by human-computer partners; could health care and other industries be the same? And what could that look like? The Glass Cage gives us an evidence-based view into that future (and hopeful) world.

UPDATE: We had a great discussion during our recent book club. As an indicator, several of my colleagues told me: “I don’t like this book.” Perfect! It made for a juicy, spirited conversation about the benefits and risks of automation and how the stories in the book did or did not apply to healthcare and what we were building. Maybe we can consider “adaptive automation” so that the computer scales up and down its assistance as the clinician comes under crisis so that the human can focus on problem solving and the computer can increasingly assist with routine tasks. And then, we need to take care that “automation complacency” does not increase. We already have heard of clinicians saying “Well, EHR did not pop up an alert for a drug interaction, so that means it must be safe to prescribe this new med for this patient.” Whoa, are we giving away the primacy of our own training and experience to an algorithm already?

CMIO’s take: keep reading, keep learning. It is only through extensive experience from reading and books that we can learn from others in healthcare, and from others in other industries divergent from our own. There are more smart people who DON’T work for you, than who do.

 

Augmented Reality: the Homecourt app on iPhone XS: wow!

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https://www.si.com/tech-media/2018/09/12/steve-nash-homecourt-app-apple-event-iphone-xs-camera-watch-shot-tracker

More whiz-bang tech. The latest iPhone now supports more augmented reality, by allowing the app access to a video stream of someone practicing shooting hoops and giving feedback in REAL TIME as to the spots from which shots are attempted and made. In other words, AI now auto-processes video that used to take hours of video TAPE pored over by coaches and players, and simplifies this into a device we already carry. (OK, those of us with >$1000 disposable income and a desire for the latest and greatest geek toy).

But, think, if we applied this to healthcare, would we use this to:

  • Monitor patient meals by automatically calculating what is being consumed?
  • Watch how patients are flowing through clinic to learn how to optimize efficiency?
  • See how ER patients are doing in the waiting area and triage and in the treatment areas?
  • Watch for improved efficiency in procedural areas like endoscopies, bronchoscopies, cath labs?
  • Watch how minor procedures are performed and suggest tweaks to clinician performance without the shame of having a human supervisor around?

CMIO’s take? Interesting to see how and where Augmented Reality might show up in healthcare, based on bleeding edge ideas in other fields like sports.

“What is a Large PIG”? or, How to set up a Physician Champion for success during a hospital EHR go-live. Guest Post by Jonathan Pell MD

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UCHealth, like many other health systems, are extending their EHR network to affiliate hospitals and facilities. Whether a hospital is coming from a paper charting system or from a different EHR, there is dramatic culture change for independent physicians as they get ready to adopt the system-wide EHR. Here are some challenges presented by physicians working at these hospitals joining the system:

  • Independent physicians were loosely affiliated with the hospital previously. Some surgeons were used to handwriting their H&P or faxing in a preoperative H&P they dictated via their office chart. They did the same with paper preoperative orders. Will they be allowed to continue?
  • Independent hospitals have had paper-based or electronic order sets developed over decades of tradition which are often customized for each of the providers even though they address the same clinical condition. Will they be allowed to keep the many physician-specific versions of these local, non-standardized order sets in the system EHR? How about if they have no-longer-standard-of-care medications and care instructions?
  • Independent hospitals have medical staff committees, often with committee attendance paid by hospital. When assembling leadership committees, will the system pay for physician attendance at EHR committee meetings preparing for go-live?
  • Inevitably, some services and specialties are more engaged than others. In the worst case, physicians will ignore the calls to attend mandatory training and readiness evaluations. As a result, these same physicians and specialties will disproportionately think that “your EHR is a piece of #(&$.”  How will you work with these physicians?
  • Similarly, some services will need more support after go live than others. These are typically the least-engaged physicians in the hospital. How will you develop relationships with these physicians to help them be successful?

Our solution (after several trial-and-error experiences…) is to create ONE Physician Champion for that hospital, and to pay for 0.2 FTE (20% of a full time equivalent, or about 8 hours a week) to serve as THE Physician Champion for that hospital for 6 months prior, 2 weeks intensively during go live, and about 3-4 months after.

We anticipate this Champion would spend less than 8 hours a week in months leading up, and spend quite a bit MORE than 8 hours a week just before and during go live, as long as the total engagement over the 9 months, averages out.

Here are the relationships that will make this Champion successful (see graphic):

ChampionAndPhysicianReadinessLeads

  • Senior (system-level) Physician Informaticist with hospital go-live experience to be a partner and coach (model of “see one, do one, teach one” from residency training)
  • Project Manager who represents the IT analyst team that builds the EHR tools and infrastructure and tracks deliverables and deadlines, and Nurse Informaticist who represents clinical staff roles and shared workflows.
  • Physician Readiness Leaders working group to create consensus and disseminate knowledge back to front-line clinicians

To extend the reach and influence of the Champion, we establish a working group of pre-go-live Physician Readiness Leaders. The specialties represent a majority of patients admitted to that hospital. We emphasize the inclusion of particular specialties like surgery, obgyn, emergency medicine, hospitalists, AND infrequent consultants and primary care referring physicians.

This committee is co-chaired by the senior Physician Informaticist and the hospital Physician Champion, comprises about 6-9 Physician Readiness Leaders. The nurse informaticist and project manager also are crucial (see above). This whole group meets monthly in the 6 months prior to Go Live, then twice a month in 2 months after Go Live.

Physician Readiness Leads are required to: attend early EHR training, and attend extra EHR training sessions to reinforce collegial discussions and problem-solving during training, and make rounds in the hospital in the first couple weeks of go live to commiserate chat with colleagues. Depending on the hospital and local culture, these Leaders may continue to meet sporadically after go live for ongoing maintenance concerns and EHR updates. The hospital Physician Champion is contracted for about a year, and is expected to step down several months after the go live is completed. In some cases, that person or an alternate Physician Champion is selected for ongoing participation in the system-level Large PIG to help with ongoing EHR improvements and be the bi-directional relationship for that region/hospital with the larger informatics and physician community.

HERE IS OUR INTERNAL DOCUMENT FOR
Benefits and Responsibilities of Physician Champion

IMPORTANT: Strong Physician Relationships are directly proportional to effective clinical care and the successful implementation of electronic health records. It is even more important than the configuration of the actual EHR technology.

Benefits of the role:

  1. Develop a global perspective of the IT provider plan and how the unified integrated EHR system (Epic) can benefit your group.
  2. Hit the ground running in regards to workflow efficiency at go-live and staying ahead of the curve after go live
  3. Opportunity to be operational and clinical leaders in the hospital configuration decisions
  4. Decrease patient safety risk when providers’ groups are involved in order set build, training engagement and attendance at pre-flight sessions
  5. In the absence of provider participation in EHR meetings, nursing and administrator decisions may have unintended impact on provider workflow.
  6. Help to shape physician go-live support which can be focused for your providers that will have their first shifts and procedures after go-live
  7. Attend meetings where your feedback is highly valued and affects change rather than informational only meetings
  8. Start to develop partnerships, communication lines, and understanding of workflows that affect your day-to-day job
  9. Nurses want to know that the providers are on board with the change. Participating in the decisions of this committee allows you are to be seen as the leaders.
  10. Opportunities to visit and collaborate with same-specialty providers at other system Epic hospitals
  11. Develop relationships with colleagues to help improve the system prior to and after go-live

Responsibilities of the role:

  1. Attend 1 hour monthly physician readiness meetings for the 6 months prior to Epic go-live
  2. Review specialty-specific order sets to assure appropriate content is available for go-live
  3. Communicate with colleagues in your specialty at your hospital and inform the working group about your colleague’s readiness or participation in training, order set review, and pre-flight readiness.
  4. Bring specialty-specific concerns to the readiness group, particularly around multi-disciplinary workflows (e.g. is faxing/scanning of paper H/P’s allowed? Who will enter order set orders if/when verbal orders are permitted?)
  5. Communicate concerns to the Physician Champion
  6. Communicate information discussed during readiness meetings to your respective specialty colleagues
  7. Participate in early Epic training and at least one additional training session with specialty colleagues
  8. Participate in Clinical Informatics Journal Club as part of monthly physician readiness meetings

Some sample books included in our Journal Club:

  • Leading Change (Kotter)
  • Managing Transitions (Bridges)
  • Design of Everyday Things (Norman)
  • Nudge (Thaler)
  • Crucial Conversations (Grenny)
  • Getting To Yes (Ury)

Jonathan Pell MD

CMIO’s (and guest’s) take? Create a clear set of expectations and responsibilities and a small multi-disciplinary team with STRONG relationships. Success in informatics is about relationships. (Thanks, Jon!)