“E in EHR does not stand for Fax” — Steve Hess, CIO

I constantly enjoy the creativity of my colleagues. In this case, Steve Hess, our CIO at UCHealth, made this statement during a discussion about our fax-server software linked to our EHR. As our organization has grown, we have added hundreds of clinics, and now we’re approaching a dozen hospitals in our network, all on a single instance of an EHR.

Consequently, our communication and IT architecture is primarily based on within-EHR communications, the so-called Inbasket. However, we often communicate with healthcare entities (insurance companies, out-of-network clinics and hospitals, skilled nursing and rehab facilities, etc). To force others to use our EHR’s inbasket is unrealistic.

So, even in this 21st century, the lowest common denominator for communication between healthcare entities is … FAX. Our organization faxes millions (yes, MILLIONS) of virtual sheets of paper each month, a veritable blizzard of paper. Furthermore, our faxing volume now is bumping against our licensing limit, and Steve, very rightly, is pushing back against any increase in our faxing capability, and this is where he notes:

“The E in EHR does NOT stand for Fax.”

Which is hilarious. And sad at the same time. Where is our national interoperability? Haven’t we been working toward electronic seamless communication for over a decade as we furiously install EHR’s in every clinic, every ER, every hospital? Yes, and nothing is ever that easy.

So, thinking through our fax problem, several things became clear:

  1. Faxing STILL is the lowest common denominator. If our clinic notes and other messages to other clinicians MUST go through, fax is still the best most reliable method. Who wants to go back to stamps and envelopes? (let’s not talk about mailing test results to patients, as we still do that for some patients: don’t get me started)
  2. For all clinics and hospitals willing to use our web-based secure portal, what we call “Provider Connection”, we can set our communication strategy to send e-messages through that portal. Independent clinics and hospitals who are closely affiliated with use, do use this, and this works well.
  3. For all clinics and hospitals (independent of us) who use their own licensed version of the Epic EHR, we are gradually learning to turn on between-organization messaging, and these e-messages will gradually replace fax. This is getting going.
  4. For all clinics and hospitals on our instance of our EHR, we should be sending ALL notes and messages electronically through EHR e-messaging to our respective inbaskets.
  5. For all clinics that have connected to CORHIO (the Colorado Regional Health Information Organization and other Health Information Exchanges cannot get up to speed fast enough for us) we should be able to turn off our point-to-point communications like Fax because we deliver all notes and results from our EHR to CORHIO’s exchange, which then can deliver results to ANY EHR in the state.
  6. There are still hundreds of organizations out there who use a non-Epic EHR with no capacity for electronic interconnection to CORHIO, or who still use NO EHR. Then, these clinics only have ONE method to send or receive all these incoming messages: FAX. Sad.

Here is where we run into some surprises. Turns out, not ALL of our clinicians in our OWN ORGANIZATION have agreed to use e-messaging and still rely on Fax. What? Old habits die hard. It turns out, while our attention was elsewhere, some of our clinicians and clinic managers were able to convince someone in the IT organization to alter the setting for delivery of test results and referral letters from e-messages BACK TO FAX. On the one hand, I can see a reason why. Some clinicians are used to having the sound of the fax and the presence of paper in the fax-received tray as their TO DO task list, and never “got into email” (really?!). Some clinicians work at multiple healthcare organizations and do not want to check the inbasket of their general email, and the inbasket of the EHR for hospital 1, and the inbasket of the EHR for hospital 2, etc. I could see this being a huge hassle, where ONE fax machine could be the single TO DO list. SO, THIS PROMPTS SOME ACTIONS on our part:

  • All employed clinicians at UCHealth MUST use e-messaging. We will embark on a clean-up of our internal process. Why install an EHR and then let people continue to fax within our organization? It is like buying a Porsche and then cutting out the floorboards and pushing with our feet like Fred Flintstone.
  • Re-examine every affiliate clinic and hospital and figure out how to switch as many communications from fax to e-messaging with Provider Connection. In some cases, like the clinician with multiple hospitals, such a switch might dramatically worsen their clinical work, and we would make exceptions there.
  • Push on CORHIO and other HIE’s to improve between-organization messaging and link our EHR to their systems to make such messaging seamless.
  • Accelerate our investigation of Epic EHR interconnect messaging so that we can send/receive messages from other organizations that also use Epic.
  • Consider a drop-dead date (like “killer app”, this is a terrible term in healthcare) when we might say: “Fax is dead. In order to receive clinical messages from us, you must use Epic EHR or Provider Connection.” I think we’re not quite there yet.

CMIO’s take? Quotable quips are easy to say, and make us feel ridiculous sometimes. But then you have to take a hard look at yourself, and your organization, and the state of healthcare technology, and decide what to do. Do you have a similar story? Let me know.

Letting patients file their Advance Care Planning (Advance Directives) online via Patient Portal (Hillary Lum et al)

Dr. Hillary Lum

https://www.sciencedirect.com/science/article/pii/S0885392418310479

Thanks to Dr. Lum for her persistence and clarity of purpose. She led a team of physician leaders and IT staffers through a complex process, resulting in a first-of-its-kind online tool:

The ability for patients to complete their Advance Care Planning and upload the results using an EHR (electronic health record) patient portal. 

Why is this so important 

  • Very few patients, much less US adults, have an Advance Care Planning document (including Advance Directive, Living Will, 5 Wishes, No CPR, or any other document that records the wishes of the patient in regards end-of-life care)
  • It is difficult for patients to find the form, to understand the form, complete the form, return the form, AND THEN to have clinical staff file or record the form and its wishes in a way that is easily accessible by both healthcare providers as well as patients themselves.
  • Patients without any advance care planning documents risk the possibility of receiving unwanted care at the end of their lives; since patients are so often non-communicative as their health deteriorates, unless the doctors and nurses have a clear statement from the patient, we must assume that the patient wants CPR and other aggressive measures, even if it borders on inappropriate. This tragedy can easily be avoided with easily available documents expressing the patient’s wishes.

And now, at UCHealth, patients can avoid this risk! From the privacy of home, patients can now log in, launch the Advance Care Planning module, complete the questions, and even upload any signed documents in regards to their wishes, into their online Patient Portal, in a permanent storage location easily accessible by the patient (or their permitted proxy) or any of their healthcare providers at UCHealth.

This is pretty cool, and a big leap forward. In fact, even without any publicity to patients (the module just appeared in the portal), over 1000 patients recorded a NEW advance care plan in the first month after this module went live. And, patients continue to sign up at a constant rate.

We hope this continues at UCHealth, and more importantly, that other organizations start doing this as well. Only 36% of US adults (studied in 2017) have an advance directive; meaning that about 2/3 do NOT!

CMIO’s take? We have a lot of work to do, people. Let’s get the rate of advance care planning much closer to 100% of US adults; we never know when we’re going to need one, and by then it is often too late.

Arborealization and the Ping Pong Robot (from Omron)!

OMRON’s ping pong robot is a demonstration

Interesting. OMRON, maker of the blood pressure measuring device that I recommend to patients, is moving into human-augmenting AI. Purely as a demonstration project to showcase technologies, they built a Ping Pong robot that will play with you to:

  1. Rally with you
  2. Assess your ping pong skill
  3. Assess your emotion from facial recognition
  4. Use the “net” as a screen to tell you what it is thinking and doing
  5. Coach you to be a better player, using what it knows about you

From the video, it is not infallible, but it will rally with you, it will serve the ball, it will give you a ranking, it will speed up or slow down based on how you are doing and feeling, it will note that ‘we are having fun!”

Part of the idea of “arborealization” of technology (a made-up word), this is a term I heard about a decade ago. In short, with technology acceleration powered by Moore’s law and the constant doubling of computing power, tech acceleration is NOT in just a single direction (eg: self-driving cars, faster personal computers), but in ALL directions (eg: ping pong robots, poetry-composing AI, symphony-composing AI, deep-sea diving AI, Google Duplex being able to book an appointment by telephone for you, etc).

Still, weak AI and strong AI are different things. Pointing software at a difficult single problem (Weak AI solution) is very different from building an AI that can tackle ALL problems (Strong AI). I’m reading Life 3.0, a easy-to-read NYT bestseller that is the latest foray into describing the exploding fields of AI and general intelligence.

CMIO’s take? I need one of these robots in my basement ping-pong room. Humans are so disappointing; no one will take me up on my nightly ping-pong challenge.

Book review: Singularity Sky

61funbhaa-l

Four stars.

Stross’s Accelerando is perhaps my favorite book of his so far. I like his writing, the ideas that he sprinkles along the way.

In Singularity Sky, for example, that the economic takeover of a planet begins with a rainfall of portable telephones from the sky, and that those who pick them up are asked to “Entertain us! Tell us a story!” And the surprises continue to develop from there.

He throws in ideas like, nano-machines that can manufacture goods from a ‘storage locker’ of solid metal, on demand as molecules, textiles, objects, working machines are programmed and created upon request. What would that look like at personal scale? within a family? at city scale? nation scale? planetary scale? Is it the result of, or the cause of, revolution?

CMIO’s take: what are you reading? Reading is the ultimate form of empathy, which is the root of compassion, which is the root of communication, which is the root of community and teamwork. We can all read more.

Holy Geez! Storm surge animation takes imaging to the next level

storm-surge_crop

https://www.wired.com/story/weather-channel-hurricane-florence-storm-surge-graphic/

We are living in a wondrous time. Read this WIRED article about how the Weather channel very quietly deployed a brand new imaging technology to very viscerally depict Storm Surge data in a way that WILL GET FOLKS OUT OF THE FLOOD ZONE. Some do not leave because there is a lack of understanding of “how bad will it be, really?” After watching the video above, I don’t think there will be ANY question.

It is a fascinating illustration of how far we are coming with virtual reality, and combining this with real images to create augmented reality.

CMIO’s take: We need this in EHRs and healthcare IT to bring home the visceral impact of our care and our decisionmaking. Who’s in?