Why make folks go to training or read a tip sheet if you could guide them just-in-time as they do their work?
Here’s a lovely example of our Physician Informatics Group (Large PIG) evolving as we improve the “intelligence” that our Electronic Health Record (EHR) supplies to our hardworking providers (physicians and advanced practice providers).
In the past
clinicians might have pulled up an app on their smartphone dedicated to the ASCVD: atherosclerotic cardiovascular disease RISK CALCULATOR, punch in some numbers and get a result to type back into the EHR.
Later on, some well known national websites would do the calculation for you. Still requires finding the website and typing in numbers.
Even later, we would put hyperlinks within the EHR to link you automatically, but the typing was still required to get an answer.
we have built a smartphrase (while using the EHR, in any text field, type “.ASCVDRISK”, hit the RETURN key, and Voila, the answer above:
Risk calculated based on what the EHR knows about your patient: age, sex, diabetes, smoking, blood pressure, cholesterol. AND THE ANSWER: 9.1%. FURTHERMORE, disappearing help text guides you to use this information appropriately, and only saves the relevant info to keep in your progress note.
My colleague’s wonderful metaphor for Clinical Decision Support like this?
Put the road signs on the road, not in the garage.
It is already hard enough to use an EHR with patients. Don’t make me go looking for that training document from weeks or months ago, don’t make me think. Make it easy to do the right thing. It is a small celebration every time we can do this right.
CMIO’s take? Thanks to Rich Altman MD for a beautiful new tool in our system. What road signs can YOU take out of the garage and put on the road?
I love these stories about entrepreneurs coloring outside the lines. “That can’t be done” or “There is a big gulf between theory and reality”. These are statements everyone faces when trying to change the status quo, including in healthcare.
The proposal in brief, use a massive centrifuge to speed a rocket up to 5000 mph and launch it like a slingshot so that it can coast up to the stratosphere and then a tiny rocket pushes it into orbit: it avoids the Tyranny of the Rocket Equation – that most of the mass of a rocket is dedicated to massive engine and the fuel it must burn to put a relatively tiny payload into space.
More power to folks like these. Yes, they might flame out as they get closer to a real trial, but imagine if they succeed:
Launch costs of $400k, instead of 10x as much
Being able to launch 5x month instead of 5x a year
Commoditizing access to space without massive rockets
CMIO’s take? Color outside the lines! I give it a 50:50 chance this is viable as a commercial enterprise after vaulting all the potential hurdles.
Clergy embody the trust to heal our communities. They may be the boost the Covid Vaccine needs.
This article is an elegant discussion
of the importance of clergy in addressing vaccine hesitancy among those with doubts; they are the trusted community leaders we need right now. Click the image above to go to the article.
the article discusses UCHealth’s partnership with Shorter AME (African Methodist Episcopal) Church in Denver, with a photo of Yours Truly.
Even more amazing,
Shorter’s Fellowship Hall, where we gave vaccines, is named for Omar D. Blair, a Tuskegee Airman who went on to be a civil rights advocate. This is particularly poignant, as ALL clinical researchers at University of Colorado, and across the United States, must learn about the Tuskegee Syphilis Experiment, an unfortunate chapter in the early history of medical research in the US, and a source of great distrust on the part of the black community towards American medicine.
We are therefore so grateful to develop and grow a trusting partnership between UCHealth and black churches and community centers, to fight the pandemic with our best medical tools.
A Church-based Vaccine clinic
Some interesting ways vaccination at a Black Church is different from a vaccination on-site at a UCHealth facility.
Most people know each other; these are strong communities; folks getting shots spend more time waving and chatting than getting nervous about a vaccine.
Lots of church leaders guiding, comforting, coordinating a smooth vaccine clinic, alongside our UCHealth clinicians and leaders.
As a UCHealth worker, feeling like we are invited into the inner sanctum of a close-knit extended family
When I suggest to a vaccination recipient: “You can go be observed in the chapel for 15 minutes by our nurses and doctors. However, that observation time is optional and you can leave now if you like.” The response is: “Oh, I’m going in there! I haven’t seen these folks for a YEAR! I’m gonna talk to EVERYBODY.”
Some Churches UCHealth has been to in recent weeks
PBS and Black Churches
If you missed it, PBS recently ran a special on Black Churches in American History, that is a fascinating look at how the DNA of America runs deeply through these communities (from slavery, the Underground Railroad, Civil Rights, Women’s Suffrage, Martin Luther King, and the rise of black clergy in political life). Amazing and well-told.
CMIO’s take? It is a privilege (and also the right thing to do) to partner with strong community organizations to get minorities and medically under-served communities vaccinated. It is a privilege to be part of this effort.
Because we laid all the groundwork and also felt it to be the RIGHT THING FOR PATIENTS, we went ahead and launched our changes in November, and SURPRISE: I still have a job, wasn’t fired. Thanks to our MMOLC sharing community.
A brief reminder
The rule stipulates that patients should be able to receive a copy of
Test Results (laboratory, pathology, radiology) and
Their Provider’s (physicians and advanced practice providers) Progress Notes
upon request. The interpretation was that if a patient had a Patient Portal account in the EHR (electronic health record) of the clinic or health system, this meant immediate release of this information. This is a major change for many health systems who had not yet adopted Open Notes (release of progress notes) or delayed the release of test results by several days.
Since our adoption of Immediate Release
of Progress Notes and Test Results since November of 2020, I have had exactly 2 complaints reach my desk, both from oncologists representing unhappy patients who read their CT imaging study on Friday evening and had difficulty reaching their doc until Monday. This is in the setting of about 1 million clinic visits, 800,000 radiology studies, 30,000 hospital stays, millions of lab and pathology results in these last 4 months.
So, not perfect, but not nearly the “sky is falling” result, as anticipated by many colleagues.
In case you’re still working through this, here are some documents (some updated) that we used. Some are actually named Information SHARING instead of BLOCKING, just a more hopeful attitude. I hope these might help you. Images here, links to full PDFs further down.
Even better, our colleagues at OpenNotes.org are doing some terrific office hours with experts online where you can hear the real-life experience of leaders ALREADY doing this work in various fields, successfully.
CMIO’s take? Are you ready? Do you have documents YOU can share? Lets do this!
One death is a tragedy. 500,000 deaths is a statistic. Don’t let the statistics numb us to the tragedy of singular deaths. Please listen to these stories. We MUST bring this pandemic to an end. We still lose over 1000 people a day.
This was a remarkable event, and I’m glad I was there to see it.
For those who may not know or remember; Greeley’s JBS meatpacking plant was the center of Colorado’s first major outbreak of COVID illness, resulting in numerous deaths and hundreds of workers getting sick and hospitalized. Meatpacking requires close quarters, and one infection spread rapidly to many.
I watched on the news with horror as the disease spread, and Greeley, a small town in rural Colorado became national news. Greeley also led the state in COVID illness early in the pandemic.
Public Health Effort
The great news NOW, is that Colorado’s Public Health coordinated a multi-health-system effort to vaccinate the nearly 5000 employees there. When I heard of the opportunity, I dropped everything and headed up there last Friday to be part of the effort.
It would seem an insurmountable task: How do you coordinate nearly 100 volunteers who don’t know each other, in a noisy, unfamiliar plant? How do you incent workers who may have questions about the vaccine, to come discuss and be vaccinated? Will you have enough translators (at least 8 languages are spoken by employees)?
7 health systems coordinated
Soon, however, we got organized into 14 tables of 3 vaccinators, taught how to load vaccine syringes from defrosting Pfizer -70 degree vials, supplies distributed, and employees started rolling in, paper consents in hand.
We vaccinated over 2500 employees on Friday, a great day and smooth operation. See above for the write-up by the Greeley Tribune, among many news organizations on site.
The “Education Room”: Stories NOT Data
Here is where it gets interesting. I found out that I was assigned to the “Education Room” upstairs. Management at JBS was serious about maximizing employee engagement with this big push for vaccination.
The plant was closed for 2 days.
All workers would be paid for 4 hours of shift work JUST TO SHOW UP.
All workers who got vaccinated would receive an additional $100.
All workers who declined vaccine could sign a paper … AFTER they went to the EDUCATION ROOM where Dr. Lin and other physicians and nurses were waiting
Hmm. I thought I had signed up to vaccinate today …
When I heard this, my life flashed before my eyes. Not really, but I had a rapid sequence of thoughts:
I hoped they had enough translators (turns out, yes: Somali, Spanish, Amharic/Ethiopian, many more)
I hoped I had heard most of the rumors and misinformation about the vaccine before and be ready to respond
I hoped that I could avoid STATISTICS and DATA, since most vaccine-decliners have (mostly misinformed) STORIES. Data never beat a compelling Story. Only Stories have a chance to fight Stories in the battle for feelings and changing minds.
I thought back to a book I read recently, The Righteous Mind, about values, moral thinking, and how those with liberal values, and those with conservative values see morality with very different lenses. Would I be able to speak a common language to connect with those who saw the world differently?
Reasons why NOT?!?
Yes, it turns out, we only had about 100 people come through for the 6 hours I spend there. Of the 100 we spoke with, I heard a dramatic range of reasons why people were declining the vaccine:
“Well, it’s not a real disease anyway.”
“I heard the vaccine kills people.”
“The vaccine is only 95% effective. So what is the point? Like, it doesn’t even work.”
“I heard it is made from dead babies.”
“Only old people have a problem with COVID.”
“I am healthy. I don’t live with old people. I don’t need it.”
“My roommates will make fun of me. We are not getting it.”
“My parents told me not to get it.”
“Why are WE the guinea pigs, before everyone else?”
“I’m going to wait and see.”
“I’m pregnant. I heard it is dangerous for my baby.”
“I already had COVID. So, I’m immune.”
“I never get ANY shots, flu, nothing. I don’t need it.” (and more)
This was a daunting task. However, we had a room full of translators for all languages, 3 tables set up with information sheets and 3 cultural ambassadors to explain the importance of the vaccine and WHY JBS managers and leaders thought this was important, and even Union Leaders who would show videos of themselves getting the shot themselves (thank you JBS; very organized!). THEN, if the participant was adamant about their decision, fine, go sign the paper and get paid.
Less Helpful Conversations?
IF they had a question, one of us would get called over, and we could chat. I heard a few discussions in the room. Some less effective approaches:
Employee: “I don’t want the shot. I already got COVID. I’m immune.” JBS Supervisor: “I haven’t got COVID. I’m not immune. You don’t care about me?” Employee: “Nah man, stop talking. Where do I sign the paper.” (Confrontational)
Employee: “I don’t want the shot. I’m healthy.” Medical advisor: “You know, the shot is 95% effective. Even though it doesn’t protect everybody, the data shows that almost everyone gets immunity. Even if you DO get the infection, it is likely milder and you won’t have symptoms.” (Data-heavy, confusing, and not addressing the issue)
Employee: “It is not a real disease.” Medical advisor: “Yes it is. People die all the time. Here are 5 reasons the shot is safe and the evidence that it works…” (Not enough reflective listening, eliciting thoughts, trying to find common ground, and too much talking)
Whew. I could see myself falling into each one of these traps. I set myself a goal to find STORIES to match and counter their STORIES and to suppress temptation to exhibit my command of the DATA (sooo hard).
Here are some of the better ones we came up with. Importantly, ALWAYS begin with “What questions do you have?” and “Tell me more about what you understand.” and “Anything else?” and “I like that you are trying to get good information before making a decision. This can be very confusing and scary. I would like to help.”
Employee: “I’m pregnant. I’m afraid for my baby.” Me: “Yes, there is less information from the vaccine tests about pregnant women. HOWEVER, MOST of the women doctors and nurses at University Hospital who are pregnant have gotten the shot. And we are confident it is safe for the mom and baby.” (result: agreed to shot)
Employee: “I heard the shot makes you sick.” Me: “Well, most people do not get sick. If they do, some get a sore arm, or a headache or fever, like getting the flu. Tylenol helps. For me, I had a fever for about 3 hours overnight.” (result: agreed to consider it later)
Employee: “Why are we the guinea pigs and getting it early?” Medical advisor: “Actually, the doctors and nurses were the guinea pigs; they got the shot back in December and January. We are all healthy and staying safe, with no major side effects. We want YOU to be protected too.”
Employee: “I just don’t want to do it.” (unable to state a clearer reason) Me: “I hope you see all the doctors and nurses in this room. We are all volunteers, took a day off to come here, because we WORRY about you and your community. You are Essential workers. Last year, many of your co-workers got sick and died, and we did not protect you. We don’t want this to happen again.” (result: thanked us for volunteering, and promised to consider vaccination)
Of 100 people, about 20 agreed to the shot during our session, about a 20% conversion rate. Is this normal? I have no idea. One of my colleagues noted:
“Compared to vaccinating, this is soul-crushing. To do your best explaining why a crucial vaccine would save lives IN THIS PLANT, and not to connect. So hard.”
Nurse Practitioner in the Education Room at JBS
At the same time, we all agreed that many of the decliners also said they would think about it some more, and would consider getting it later. In motivational interviewing lingo, perhaps they were moving from “pre-contemplative” to “contemplative.” Even a mild attitude shift like that, is a win.
Some of the more effective strategies:
Listening more than talking
Finding common values: “The Broncos!” or “Protecting elderly parents”
Telling a personal story of COVID or getting vaccinated and how it felt
Talking about “looking out for each other” “protecting our community” “making Colorado safe” “keeping Covid out of your family”
Using metaphors: “Which vaccine? Its like, Dodge, Ford, Chevy. Just get in the car. We will all get there.”
Dr. Steve Hoffenberg, Emergency Medicine Physician, coordinated the vaccine efforts at JBS. Thank you, Steve.
FINALLY: Will you look over this document with me? I wrote a ONE PAGE summary of what I thought were the BEST STORIES to fight misinformation about COVID Vaccine. What do you think?
CMIO’s take? Wow, there is a lot more to vaccine work than “give shot, call next patient.” Coordinating a public health effort: massive. Focusing on high risk populations: important. Listening, connecting and changing minds: some of the hardest work of all. In the coming months, THIS will be the conversation.
I find it does not serve the needs of the community or the world to be merely a scientist. One must also be a communicator. In this age of disinformation, we are drowning in the social media morass. The voice of science, of reasoned, thoughtful scientifically based research is too quiet. Our Filter Bubbles allow us to read online articles that only confirm our biases instead of finding objective, reports that speak to actual evidence. This article is a clear explanation of why journalists and scientists should work hand in hand to raise our voices and be heard.
Dancin’ away troubles at UCHealth’s SNAFU tent for Covid Mass Vaccination
Optimizing the Mass Vaccine Event
This will be a fun exploration from a CMIO’s perspective. Let’s think about individuals and work our way up to national optimization, from a personal perspective. And, don’t miss the SNAFU Tent Vaccine Dance at the end…
Seven Levels of thinking
Level 1: Make myself efficient
Level 2: Make my pit-crew efficient
Level 3: Make all pit-crews efficient
Level 4: Make the entire Mass Vaccine efficient
Level 5: Optimize Mass Vaccine for volume or cost
Level 6: Optimize Health System Vaccination plan
Level 7: Optimize National Vaccination
1. Make myself efficient
Readers may remember recent writeups where I incrementally overcome my lack of skill as a physician at vaccinating. I’m a quick study, and when great nurses and medical assistants are around to teach, I got better quickly. See above, with the pre-peeled bandaid/ vaccine/ alcohol swab grip, and second hand to manage the smartphone electronic documentation. I’m MOB-ILE.
Here’s the set up: have an assistant play “keep ahead” by peeling bandaids. The hardest part of the job is peeling bandaids with gloves on.
The next hard part is that vinyl gloves stiffen in cold weather. So, use the sani-wipe jug to elevate your glove box closer to the propane heater. Smart! Actually even that wasn’t really warm enough, so I took to doing this:
I call this “praying to the propane gods.” Or, holding the gloves up for 5 seconds of warmth: makes a huge difference in the ease of putting them on (150 times that day).
Handwarmers: Even better idea
Of course, Bernice comes to me near the end of the day and tells me “Dr. Lin, put 2 handwarmers in your coat pockets and put your next pair of gloves in them, so you always have warm gloves to swap.
“D’oh!” as Homer Simpson would say. Why didn’t I think of that?! Thanks, Bernice.
Colorado Rockies’ Dinger drops by
2: Make my pit-crew efficient
This section is actually mis-labelled. My pit crew made ME efficient. Unlike previous days, where I built up such an efficient process that I was able to stay ahead of my pit-crew colleagues in our 4-car pit-stop, today I was teamed up with 3 outstanding medical assistants from Lowry Internal Medicine, my own UCHealth clinic in Denver: Marina, Yanira and Bernice. The tables were turned: now, every time I looked up from my completed vaccination, the other cars in my pit had already gone! Too fast, gals! You’re too fast for me. 😦
Team Lowry, with my BFF’s.
View of the Mega tent with 4 of the 8 rows, and the pharmacy (vaccine reconstitution tent to the right). The other 4 rows are out of sight to the right of the pharmacy tent. We can vaccinate 32 cars in 8 rows at a time this way. Furthermore, we would huddle and learn from each other “How are you going so fast? What is your set up? How do you ask the screening questions? Where do you put the sharps container?” etc. Thank you, smart colleagues, for teaching me.
3: Make all pit-crews efficient
To further smooth the process, given what we had learned on previous weeks, we posted 4 SNAFU tents after the Mega-tent that we would refer to for any slow-downs or technical concerns. For example, one car pulled up with 3 people to be vaccinated. I would perform one vaccination, and since my row was ready to roll by then, I would place a red card on the windshield, indicating SNAFU and the flaggers would direct the car to receive the remaining 2 shots about 100 yards away. This simple workflow adjustment (4 SNAFU tents for all 8 pit-crews) kept ALL 8 lines moving. This was a difference (for me) between vaccinating 124 people one day and 158 the next. Super smooth.
Another example: a patient drove up and their Electronic Record account showed “second vaccine already administered.” I couldn’t solve it with my smartphone Rover app, so I referred him to the SNAFU tent.
After some investigation, we found out later that day, it turns out that another organization in town had incorrectly registered that patient (a common first and last name and somehow erroneously documented date of birth) so that the mistaken vaccine APPEARED in OUR system on this patient (our separate Epic EHR’s share vaccine records now) that he had already had his second shot (incorrectly). We presume this was because some institutions are still using a paper-vaccination process with “document later” staff (as we did last month, in favor of speedy vaccinations). This re-introduces errors that the EHR was supposed to eliminate (bad handwriting and transcription errors). Hmm.
We are glad we are now using the Rover smartphone app. We’ve tinkered with it so that it is now possible to be as fast with Rover as with paper (AND eliminating the transcription step). 50 seconds with paper, and 50 seconds with Rover. Ha!
4: Make the entire Mass Vaccine efficient
We had lots of competing concerns to keep in mind, when thinking about the entire effort. Police were concerned about backing up waiting cars into nearby streets. (whew, we avoided this). How many total staff were needed to register patients? (too many in version 1) How many tents to rent for these events? (originally 1 mega and 18 cabana-style tents, now 1 mega and 2 cabanas) How would we deal with inclement weather? (snow, rain, black ice, wind: the mega-tent is superior to cabanas for keeping staff out of the weather and minimizing wifi and cell-booster mesh network issues; FYI, my new 5G iPhone 12 pro max was awesome in our pilot testing for speedy smartphone documentation)
Our diligent road crew out there dodging and managing tent-avalanches.
We have been pleased to constantly drive down out patient-throughput times, down to 22 minutes (including the 15 minute observation period)! And this past week on Sunday, we drove our total time down to 16 minutes in some cases: 1.5 minutes for registration, vaccination, a couple minute driving time, and then a 10-minute observation period. Wow. We believe we are the fastest Mass Vaccine service in the country at this rate. Even better, we are making observation OPTIONAL going forward, because of our non-existent severe reaction rate.
We believe we can expand beyond 10,000 per weekend, and believe we can do 20,000 or possibly 26,000 per weekend, if the State has vaccine supply and would like us to.
5: Optimize Mass Vaccine for volume or cost
So, what is the goal of a Mass Vaccine event? Publicity for vaccination? Sure, we had news helicopters circling, lots of press, lots of people commenting on how easy it was, and how much they’re looking forward to hugging grandkids.
We can optimize for convenience for frail elderly. Sure, stay in your car from home, back to home, no walking. Can we help people avoid healthcare settings? Sure.
We can optimize for speed: in which case, bring more vaccinators, and rent a second mega-tent. There is room in this massive parking lot for more staff, we can create more lanes and instead of 32 at a time, we could do 48 cars or more. 20,000 per weekend is entirely conceivable, if vaccine supply were up to it (not yet).
Or, we can optimize for lower cost. With our original full teams in the early weeks, we overstaffed and calculated a per-vaccine operating cost in the mid $20’s. Of course, the vaccine itself, is free to us and patients, paid for by the feds. But, tents, staff, project managers, coordinators with police, state, county and city government, vaccinators, training team, pharmacy team, coolers and vaccine supply chain management, traffic tents, snow removal, medical observation team, volunteer-coordinating managers, paramedics, command center coordinators, walkie-talkies, workstations on wheels, smartphone devices, wifi repeaters, cellular repeaters, scheduling of appointments, design of vaccine clinics… pretty soon it is a big operation. After a couple days, and constant re-design, we were able to trim operations down into the $17 range.
6: Optimize Health System Vaccination plan
First Covid Mass Vaccine design, last month, at Coors Field, Denver
Vaccinating patients on-site at University of Colorado Hospital, Bruce Schroeffel Auditorium
Outdoor vaccine guy vs Indoor vaccine guy
AND THEN. We compare our Mass Vaccine efforts to our ongoing (but less splashy) vaccine clinics in 10 facilities across UCHealth, spread across the entire state of Colorado, at even lower per-vaccine cost, with the capability of 5,000 to 10,000 per day. We are hiring permanent staff to run these vaccine clinics and stop borrowing from clinical teams across our system, as we think we will be doing this for quite some time.
It is gratifying that we have lots of folks (many retired) willing to volunteer their time. The challenge with accepting this help is: it can be more expensive to run a scheduling calendar and training for hundreds (?thousands) of part-time (or one-time) volunteers than it is to have a reliable, skilled steady crew to take care of business. For the rare volunteer who COULD come regularly (for 8 or 10 hour shifts!) (for months!), that would be a blessing. And, as this vaccine saga goes on, we may indeed need more help.
Pop-up Outreach Clinics for the medically Under-served
Another effort I’m grateful for, are our Pop-Up vaccine clinics. We are taking our show on the road to multiple community centers and churches in medically under-served neighborhoods, where leaders are helping us schedule thousands of vaccination appointments among their neighbors. I’m heading to several in the coming weeks. (stand by for more posts from the front lines!)
UCHealth has given 270,000 vaccines, about 20% of Colorado’s total to date.
Yup, you read that right.
From this graph, you see our green Mass Vaccination events occurring on 2 weekends. Dark blue is University Hospital with over 13,000 vaccines given per week, and our other regions similarly. Light blue is South region, Purple is North region. Red includes our small hospital and outreach clinics at about 10,000 a week. Again, limited by supply.
We need to focus on bringing humanism back into healthcare, to combat the temptation of the e-patient (EHR computer chart and electronic or telehealth communication) numbing us to the suffering of real patients out there. This is a terrific read.