Optimization Sprints: Improving Clinician Satisfaction and Teamwork by Rapidly Reducing Electronic Health Record Burden (published in Mayo Clinic Proceedings Feb 2019)

Sprint team action shot!

Congratulations to Amber Sieja, Katie Markley, Jon Pell, Christine Gonzalez, Brian Redig, Patrick Kneeland, co-authors on our published article in Mayo Clinic Proceedings this week. I’ve spoken of some of the details on this blog, so I’ll let the paper speak for itself. Nice to be recognized! Coming soon: a video by Dr. Sieja explaining some of the highlights of the paper.

https://ac.els-cdn.com/S0025619618307882/1-s2.0-S0025619618307882-main.pdf?_tid=c94d2fe7-8f2b-4e66-9852-277fb952f3eb&acdnat=1551313804_a8d687bb190fdb632cd1ed9f45c8ef41

CMIO’s take? When team members do great work, we all get better.

How Do You Balance Patient Care and Research with Online Patients? Our Proposed Protocol

Flask from nounproject.com

What would you do with the following research requests?

  • The CEO of the health system would like for all patients using the EHR patient portal to be asked to sign a consent form to participate in our system-wide strategic BioBank. In this strategic project, we aim to capture an “extra tube of blood” when a patient is already getting blood drawn for a lab test for clinical care. Then we would apply genetic analysis to large populations of patients to see if we can discover gene-disease linkages that may be useful to patients. May we set up this consent form and present it to patients?
  • A researcher would like to survey ALL patients in the health system to ask them their opinions about marijuana use, both recreational and medical. It would be about 20 questions. The researcher does NOT have an existing relationship with most patients he/she wishes to survey.
  • A physician specialist would like to ask all the patients in his/her own clinic about their symptoms of arthritis, to understand how he/she can improve their own clinic’s care process and maybe publish the improvements when completed.

Such are the challenges of our MHC (My Health Connection) patient portal Clinical Leadership Advisory Group. Our goal is to protect our patients, who have signed up for MHC primarily as a communication tool between patient and clinic/physician, and not allow unsolicited research requests (potentially from hundreds of researchers) or “quality improvement” surveys or projects from “email spamming” their patient portal message inbox. AND YET, we believe that a large fraction of our patients might welcome the chance to participate in a research trial and increase our medical knowledge. How to do this? We struggled and discussed for hours, and came up with the following principles, that we are gradually implementing:

White Paper: Research queries using My Health Connection (MHC)

Executive Summary: How shall we decide on permitting researchers to use MHC for recruiting and contacting patients? Until now, research recruitment has been off-limits. We propose a framework for permissible MHC use for research recruitment and a path forward.

Background:

My Health Connection is the UCHealth rebranded MyChart patient online portal to the EHR. Patients sign up for MHC with the express intent of using it to communicate with their healthcare team directly. We have had repeated complaints from patients when they hear from unexpected sources (Administrators sending messages regarding “flu shots” or other health maintenance, as required by Meaningful Use federal regulations). We have thus been very careful about protecting patient’s presumed interest in using MHC as a purely clinical communication tool.

On the other hand, Researchers at UCHealth have great interest in using MHC for research recruitment. We have not yet (Dec 2018) implemented the Research Module within Epic for recruitment and management of potential and patients currently engaged in research trials.

Our IRB (institutional review board to protect patient rights) has been an excellent partner in restricting use of EHR for research recruitment, balancing patient needs, clinic needs, researcher needs.

To date, the only exception to research use within MHC has been: the UCHealth BioBank for recruitment, processing and notification of patient’s genomic data such as pharmacogenomics and other screenings, approved by Strategic Executive Group (SEG) at UCHealth.

Additionally, the MHC clinical leadership group have previously declined a research request to broadcast a marijuana survey to all 400,000 MHC patients.

MHC clinical leadership HAS allowed broadcasts through MHC for drug or device recalls when there are patient safety concerns.  It has also allowed general health broadcasts as required to meet federal Meaningful Use regulations for patient portal implementation and use (see above).

Assessment/Recommendations for MHC research framework

  1. Large UCHealth strategic initiatives (including research) using MHC are approved by System Executives. IRB approval is also necessary. MHC clinical group also informed.
  2. Research requests by a Principal Investigator (PI) recruiting patients within his/her own clinical practice (where there already exists a treatment relationship between that investigator and/or his/her colleagues and their cohort of patients), should meet ALL the following criteria:
    1. IRB authorizes this project to use MHC for recruitment and communication
    1. Recruited patients have all been seen in the clinic(s) where the principal investigator and co-investigators work, so that there is an EXISTING physician-patient relationship
    1. The Principal Investigator (PI) or authorized study team members, send and receive MHC messages individually. This is not the responsibility of the MHC IT team.
    1. Online MHC recruitment should mirror any paper- or phone-based IRB-approved process
    1. COUNTER-EXAMPLE: System-wide targeted patients across many clinics WILL NOT BE APPROVED AT THIS TIME. An existing physician-patient relationship must already exist between recruited patient and the investigator(s)
    1. There will be ongoing assessment of any complaint received
    1. The MHC team will investigate a method for PI’s to update a patient’s chart in case of DECLINING FURTHER RESEARCH RECRUITMENT.
      1. If patient declines for an individual study it will be up to the PI to track that
      1. If patient declines for ANY research outreach via MHC, we anticipate creating an FYI flag called “NO MHC RESEARCH RECRUITMENT” that we can query later to prevent outreach errors
    1. MHC team will and will not:
      1. WILL: require investigators to ask permission of Clinical Advisory Committee prior to start
      1. WILL: permit 1:1 MHC recruitment messaging from PI to patient when project approved
      1. WILL NOT construct research questionnaires for online transmittal
      1. WILL NOT have patients sign online consents via MHC
      1. WILL NOT help track patients in study via reports or alerts
    1. Approvals thus needed:
      1. IRB
      1. MHC Clinical Advisory Committee
      1. UCHealth Marketing for allowable messages in MHC
      1. UCHealth Patient Literacy Team for 8th grade wording or clearer
    1. Monitoring
      1. PI would present MHC component of research plan to MHC Clinical Advisory
      1. PI would present 6-monthly updates during study to MHC Clinical Advisory
        1. Patient recruitment numerator/denominator
        1. Assurances about only recruiting from permitted clinics/units
        1. Refusal rates and other concerns from patients, clinicians, staff
        1. Anticipated close of research or translation into standard practice
  • NOT PERMITTED: Patient recruitment outside of an investigator’s clinic (eg: show me all diabetes patients; maybe 40,000 patients or please facilitate the outreach to all DM patients). Not allowed at present
  • FUTURE opportunities:  Epic does have a Research Module that we have not yet implemented. It may be possible to integrate research recruitment that follows all IRB necessary protocols to protect patient privacy. UCHealth will partner with UCD School of Medicine leadership to consider implementing this module in the future. As our tools evolve and with patient feedback, we will discuss the tools at MHC clinical group to review and update this guideline.

CMIO’s take: Have YOU implemented a research module within your EHR? Does it solve this problem? Please let me know in the comments!

Book review: Flow (second time review)

Here we are (again)! How can I review this? An incredible landmark of a book, it has sat on my bookshelf for more than a decade, and then on my ‘actively reading coffee table’ for another few years. Despite its mention in almost every important other book I have read, and my repeated abortive attempts to push through, I found this book alternatively revelatory and then densely incomprehensible. I frequently dove in, underlined many passages, got stuck, and put this book down for prolonged periods. 

Finally I convinced my book club friends to tackle this, set a discussion date (Jan 2019), and that was my trick to completing the massive read.

What I’ll take away is the idea of linking happiness NOT to acquisition and idle pleasure, but to difficult challenges that are just outside my comfort zone and skill set, where with maximal concentration, I can succeed. 

Fortunately for me, I have had many times in my life when I have achieved such Flow, and now I have a framework for thinking about it and setting up my day, my home, my work life to achieve this as often as possible for myself and for colleagues. 

Incidentally, I have recently completed the massive tome ‘Alexander Hamilton‘ by Chernow, another incredible read (I was drawn in by, of course the immensely popular musical), and I am led to reflect that Hamilton must, in his voluminous lifetime of groundbreaking writings, must have set up conditions to achieve Flow for quite extensive parts of his life, despite tremendous tragedy, political rancor and his final demise at the business end of a duelist’s pistol. For example, he would read all day, head to bed, then wake up the next morning and just write, with no interruptions, for hours. As a result, his subconscious worked on problems overnight. Often his manuscripts had NO corrections, as he would scribble furiously a final draft, fully formed. This was how he tackled many of the Federalist papers, papers that are studies in minute detail by constitutional scholars to this day. 

My favorite Flow pointers:

  • Attention is how you create your experience and consciousness, and psychic entropy is the opposite: the chaos that detracts from focus and intentional effort. 
  • Flow requires: clear goals and feedback; concentration on the task; a sense of control; loss of self consciousness; transformation of time. 
  • Flow occurs when the top of your skills barely match the presented challenge. Otherwise you get boredom or anxiety. 
  • Source of dissatisfaction at work: lack of variety and challenge; conflicts with other people/boss; too much pressure, too little time. All CAN BE under our control. 
  • Autotelic self: easily translates external threats into enjoyable challenges and maintains inner harmony, transforming potential entropy into creating flow. 

CMIO’s take? I defer to these great words by Chuang Tzu: ‘When I come to a complicated place, I size up the difficulties, tell myself to watch out and be careful, keep my eyes on what I’m doing, work very slowly, and move my knife with the greatest of subtlety, until–flop! the whole thing comes apart like a clod of earth crumbling to the ground. I stand there holding the knife and look all around me, completely satisfied and reluctant to move on, and then I wipe off the knife and put it away.”

Large PIG Annual Summary FY-2017-18: our successes, challenges, and plans for the coming year

Our Large PIG (actually JIG: Joint Informatics Group)

How do you give thanks and acknowledge your teams each year? I know WE don’t do it nearly enough. Here’s a partial list of our PIG achievements from 2017-18, now that we’re into 2019 (I know, I know, I can’t blog fast enough to keep up with smart amazing colleagues, a great problem to have).

Physician Informatics Group Annual Executive Summary
Submitted by CT Lin MD, August 20, 2018

Vision statement: We improve physician/APP and team wellness and effectiveness by building extraordinary relationships and innovative tools.

FY2017-18 Achievements

  • Go Lives: MANY Clinics, 2 Hospitals
  • Sprint: 17 Sprints in 2 years, 496 providers, 315 staff
  • PI’s conduct specialty-specific and general projects to improve provider and staff efficiency and effectiveness in patient care
  • PI’s create and educate via newsletters, tip sheets, videos, meetings
  • PI’s help review, test, educate and implement Epic upgrades
  • PI’s develop and lead service line governance for UCHealth
  • PI’s chair or co-chair or participate in at least 2 dozen UCHealth governance committees to guide both Epic EHR development as well as UCHealth provider leadership overall.

Examples of successful projects:

  • Conversion of OIC (infusion) orders from “referrals” to “Therapy Plans” for safety, efficiency
  • Creation of 5 new UCHealth-wide service lines to facilitate Epic EHR build, reduce unnecessary variation
  • Creation of an APP Epic Concierge meeting to improve effectiveness and training
  • Dragon Speech expansion and elimination of Partial Dictation
  • Creation of a PI onboarding document, training, getting-up-to-speed
  • Creation of an Opioid management steer and Epic customizations to support initiative
  • Implementation and expansion of innovation partner tools within Epic: AgileMD, RxREVU, APPRISS
  • Implementation of Radiology Indications software, phase I
  • Implementation of patient access to images via My Health Connection
  • Use of EHR, scheduling and billing data to improve clinic operation efficiency, effectiveness
  • Creation of an Universal APSO note to improve both standardization AND customization
  • Creation of an MA-smartform to dramatically improve consistency of data capture in Practice Transform
  • Connection of Epic data to ORIEN (oncology research network) with dramatic efficiencies
  • Implementation of iECG, physician informatics/organizational change support to change EKG capture platforms across all hospitals/clinics
  • EPCS: E-prescribe Controlled Substances deployment of 2-factor authentication
  • Support of Palliative Care and Spine Surgery smartforms, note templates, registry reporting tools
  • Standardization of UCHealth Order Sets, physician leadership, phase I
  • Support of AMC Neurology Practice Transformation, note templates, flowsheets
  • Book Club: Read books this year on Organizational Change, Communication, Connection: Design of Everyday Things, Good to Great, Great by Choice, Crucial Conversations, Leading Change, Nudge
  • Creation of Small PIG program to mentor newer PI’s

Opportunities for Improvement

  • Counseling and coaching of PI(s) to further improve internal and external communication and leadership skills in a rapidly growing organization
  • More emphasis on analytics, use of information in our PI role, beyond “go live” and “optimization”

Plans for Coming Year

  • Implementation of approved Sprint Team 2, improvements on process for Team 1
  • Implementation of expanded rollout of Practice Transformation (changing the MA:MD ratio to 2:1), and supporting EHR tools
  • Support of ongoing hospital go lives
  • Ongoing redesign of PI support of clinic go-lives and onboarding individual providers
  • Incorporate analytics into Sprint
  • Dragon speech QI/research project: Dragon in the exam room
  • Radiology imaging shown to patients QI/research project
  • Expansion of Innovation projects
  • Expansion of MHC questionnaires, possibly PROMIS questionnaires
  • Acceleration of the Order Set Synchronization project
  • Further reducing the EHR burden, improving patient care and human connection, in everything we do

CMIO’s take? What’s YOUR take? What do you plan for the coming year?

Willy Wonka and the Epic EHR: behind the scenes at the behemoth of Wisconsin (NYTimes)

This article speaks for itself. Having visited the Verona, Wisconsin campus of Epic’s Intergalactic Headquarters, with its dozens of campus buildings, its massive Voyager Training Hall, and its equally massive 11,000+ seat auditorium (the largest in the state), it is an impressive site. Equally impressive is the young talent that this company recruits out of college, how quickly they learn the necessary lingo and communication skills of health professionals, and dive into the constantly evolving code-base of the Epic EHR. Privately held, this company is NOT at the whim of the shareholder, which I think is a key success factor in its market dominance.

Yes, there are tons of criticisms for this and every EHR. Yes, there is a national outcry of physician burnout, directed at EHR’s in general.

Instead, you’ll read here, that the guiding vision of the reclusive CEO and founder, Judy Faulkner, holds true today; have fun, do good, recruit smart talent, improve patient care.

CMIO’s take? Having been part of the Epic community since 2010, I’ve seen lots of innovations and improvements and look forward to many more.