Simple vs complicated vs complex decisions: a leader’s approach (HBR and Colin Powell) and a reflection

How does electronic Surgical Case Request and electronic Informed Consent illustrate decision-making in complex environments? Here is some of my own heartburn. Also, what does Colin Powell have to say about decision-making?

In our monthly meeting, our surgeon informaticist and I were discussing our Electronic Surgical Case Request and Electronic Informed Consent projects, and the swirling, interconnected decisions we are facing, and it occurred to me that we were facing a COMPLEX project with challenging decisions to be made.

In brief, I recall from an HBR article (A Leader’s Framework for Decision-making) that there are simple, complicated, complex and chaotic environments.

from Cinefin framework
  • Surgical Case Requests (SCR) are currently scribbled on paper, sticky note, email, many forms – we want to make them electronic, trackable, standardized, accurate, with few to no verbal handoffs
  • We know (from others) that Case Requests and Informed Consent (IC) forms should be implemented together, synergistically
  • There are several ways to implement SCR and IC, it is unclear which pieces of hardware, and what software packages are best to use in the peri-operative space.
  • There is an idea that combining a surgical Consent and an anesthesia Consent (as is done by our Children’s Hospital colleagues) would simplify workflow and eliminate 50% of patient-required signatures, while retaining (or improving) patient-physician discussion of consent.
  • A combined consent form is a novel idea in many circles and would require consensus from: Legal, Compliance, CMO, Surgery leaders, Anesthesia leaders, IT leaders to agree on the strategy and tactics
  • It is not at all clear that surgery leaders and our 1000+ of surgeons are ready to abandon their (potentially error-prone, but familiar) existing paper/sticky-note/email/text/other-method-here workflow for this new process
  • This project MUST be completed in the next 12 months, as per C-suite prioritization
  • At a high level, we DO have buy-in from Surgery, Anesthesia, Chief Medical Officer, Chief Operations Officer, all the right stakeholders.


Do we really want to take on “Combine Anesthesia and Surgeon Consents” at the same time as these 2 massive projects? Do we?

In this case, I think we’re encountering something Complex.

How to execute this project successfully?

This is something we are wrestling with right now. One significant decision to make now:

  • Whether to use the Burning Platform of the Surgical Case Request / eConsent project to push forward the ‘combine anesthesia and surgery consents’ at the same time, OR to skip it (as it distracts from the major goal of succeeding at Case Requests and Consents across the system

Argument FOR unification of consent

  • Reduced time pressure in the peri-op area, where patients have already fasted for hours, mentally prepped for their surgery, and NOW have to meet the anesthesiologist, have a detailed discussion of risks/benefits of anesthesia, and sign a consent form
  • Reduced number of signatures a patient needs to sign
  • Reduced hardware elements that could go wrong: a electronic signature pad connected to a PC or Workstation on Wheels, an iPad running consent form software on the right patient, a patient portal account running on a smartphone or other patient’s device, receiving a consent form.
  • Reduced management of customized consent forms, as instead the anesthesiologist can focus on having a thoughtful conversation and documenting the result in the note INSTEAD of explaining a form and chasing a signature.

Argument AGAINST

  • Too much change: eliminating a consent process that has been used for decades (on paper) might result in unintended consequences, reduced quality of documentation, missed steps in the peri-operative suite
  • Risk of delay or cancellation: if we bet everything on unified consent and we have a hard-stop disagreement from Compliance office, Legal office, CMO office, Anesthesia Leadership, Surgeon Leadership, Operations Office, Nursing, Patient Advocates, will our timeline be able to survive?
  • The IT team may not be able to delete and rebuild 2 consent forms at the last minute if our governance decisions cannot keep up with project mile-stones.


In Complex Environments, leaders must watch for emergence, as there may be no prior guidance “best practice” for THIS situation. One must “probe, sense, and respond.” From early conversations, there are many objections to the proposed consent unification, and we sense that the risk to the project may be too great to insist on adding this additional objective.

In this case, I think we must simplify. There are too many risks to the timeline and major hills we already must climb for the Case Request and Consent projects to be successful. Our metrics will include:

  • Improved Accuracy of CPT coding (reduced insurance coverage rejection for incorrect CPT code) and thus $$ we have to “write off” due to clerical or administrative error.
  • Reduced patient frustration for above billing errors
  • Improved OR scheduling (right CPT code leads to better estimates of how long the procedure will take, and the right amount of time can be set aside)
  • Improved matching of surgical equipment to the right procedure and reduced need to “emergently flash-clean equipment” that is not ready

Make Decisions with 70% of Data needed?

  • Colin Powell tells us to make decisions when you have 70% of data you need, avoid making a decision when you only have 40% of the information you need. I find this: uncomfortable, and probably about right.

How to explain complexity simply?

  • One Pager: This is another example of the usefulness of building a vision of WHY, high level explanation of HOW, predict the potholes in this big project, and explain what is needed by leaders and front line to make this happen, and what will be gained as a result.

CMIO’s take?

Simplicity is the ultimate sophistication.
–Leonardo DaVinci, Steve Jobs, maybe others

Don’t under-appreciate Complexity and how to make decisions differently in such circumstances.

Stinky, smelly fish FTW (Harvard Health Publishing) and an origin story

Why Eat Lower on the Seafood Chain? Or, Lox and Bagels or Sardines and Bagels? A personal story of setback and triumph.

CT feeds stinky fish to his kids

I’m proud to say I introduced my kids, when they were growing up, to sardines and mackerel, foods that I loved when I was growing up a son of poor immigrant parents. They routinely gross our their friends as they pick up small smelly fish and consume them, while exclaiming: “Oooh, that’s the spine! That’s the guts! Yum, that’s good!”

When the world food supply collapses, and no one else will eat stinky smelly fish, my kids and I will be fine. We’ll be out back, consuming our Costco-brand mega-pack of canned sardines on top of bagels.

Lox and Bagels origin story

I thought everyone ate like this. Turns out the origin story comes from my mom.

We were invited to a weekend brunch with my father’s work colleague, and they were serving lox and bagels. Our family had never heard of such a thing, and 12-year-old me gobbled down numerous servings and loved it.

My mom took notice and went to the store to buy lox, which, she found out, was salmon.

However, she also found out, salmon was expensive beyond my dad’s assistant college professor budget.

So, shopping around, she found sardines in a can. She brought these home, with bagels, hoping that her son would not notice the difference.

Sardine and Bagel Switcheroo

How did it go? Sardines and Bagels? I was in heaven. “Mom, can we have this every week?” And a tradition was born. I don’t even remember that someone did a switcheroo.

CMIO’s take? OK, no informatics lessons here, you can move on.

Epic Man – 2023: world premiere at AMIA CIC

The latest ukulele parody. Does it mention note bloat? GPT?

The Clinical Informatics Conference has come to a close in Chicago. I am always gratified by the community of clinical informaticists who come together to share ideas, to make each other better.

I had a chance to participate in 2 panels: Blowing up the Classroom by deconstructing training / Putting the Roadsigns on the Highway. Also: Redesigning the Inbasket, along with colleagues from UCSF, Epic and MedStar.

Here’s my contribution to the fun; an updated version of Epic Man.

The author still believes he can sing.

Home from informatics extravaganza that is AMIA

Great entry from my Zen Calendar. And reflections on AMIA Spring Conference.

Had a fascinating trip to AMIA CIC 2023. It is always great to meet up with friends old and new, catch up in the current work, celebrate new Fellows of AMIA, watch the rapid rise of GPT. Even cooler to see the gradually dawning understanding of newer AMIA attendees that communication skill, storytelling, and relationship building is the key to success in informatics.

So cool. Our future is bright, not because of new tools, but because of the smart, eager, emotionally intelligent next generation of informatics leaders. I’m so grateful to be around them this week.

APSO Notes: what Machiavelli taught me

What does a book from the 15th century, my own pediatric record, and APSO notes have to do with modern informatics?

from wikipedia

It is the year 2009. We are 8 years into our EHR journey (Allscripts Touchworks, at that time). Physicians are dutifully recording progress notes by dictation, by typing, some using templates, to record their observations and thinking about patients in the longitudinal record. We scribble in paper charts (not every clinic is electronic yet: we have a 10 year plan to convert all the clinics).

The complaint: EVERYONE KNOWS that when the EHR team comes to town, we will put our notes into the (#$^@ computer and no one will be able to read them any more.

Exchanging illegibility for unreadability

SOAP format implies: Subjective, Objective, Assessment and Plan, and has been this way since Larry Weed proposed his organized way of tracking patient data. With brief notes, and prior to all the federal regulations on what NEEDS TO BE in the note (if you didn’t write it down, it didn’t happen), SOAP notes were terrific. Even today, surgeon notes, on a global surgical fee (eg surgeon’s can’t bill on length or complexity of notes in the perioperative period), SOAP notes can be pretty darn brief:

S: Postop day 2. No complaints. Pain improving. Not passing gas yet.
O: Vitals stable. Wound looks good
A/P: Healing well. Teaching dressing change. Anticipate DC in AM if eating.

Here’s an example of MY pediatrician’s medical record on me. 16 years of my life on one piece of paper. OK, maybe just a bit TOO succinct.

In contrast, our electronic progress notes at the time were reaching 5, 7, even 15 pages long, full of regulatory language and audit trail signatures and time stamps.

A terrible example of Emergency Department note, circa 2010. Notice the red circles around the crucial elements in this 15 page note. And that the last page is all signatures and time stamps

What is worse, these long notes are particularly hard to read on a screen. In an EHR, that means: Find Chart Review – the listing of all notes, find the note you want to read. Click to open the document, then scroll 12 pages down to find the A/P. It’s not on the Last page, because that is full of signatures and time stamps. It is about page 10 out of 12. Then, Click – scroll, scroll, scroll for the A/P of the second note.

After about 3-4 of these, you get tired and STOP LOOKING for more thinking from other doctors. IT IS TOO HARD.

What a sad state of affairs. What to do?

My solution: APSO notes!

Yes, that note is 12 pages long, yes, we need to work on shortening it. In the meantime, how hard would it be to teach docs to put their ACTUAL THINKING at the top of the note? Assessment and Plan AT THE TOP.

This way, you could write your note in the same sequence: Subjective, history, past history, etc, then Objective, exam findings, lab results, and then MOVE BACK TO THE TOP and complete your Assessment (I think this is what is going on with the patient) and Plan (This is what we’re going to do about it).

By doing so, as the patient’s history and number of visits with various specialists gets longer, it continues to be EASY to click – (no scrolling) read the A/P, Click – (no scrolling) read the next A/P. Many times easier to browse the chart and get a concentrated dose of physician/APP thinking.

In my mind, I’m a genius.

How hard could it be to change doctor behavior?

You know what is coming. I did not.

I built a new note template: APSO format, to sit alongside SOAP format. I user-tested it in 1:1 meetings with about 80 colleagues, who all agreed “This seems better, easier.”

I launched the note template, held my breath …

I got to a 70% adoption rate. Woo-woo.

Many folks (EVEN AMONG MY SELF-PROCLAIMED FRIENDS) did not change behavior. “Oh, I forgot.” “Oh, I am planning on trying that sometime.” “Oh, I was very busy and running behind. Not today.”


Another failure for the Failure Resume.

About this time, I was reading Kotter’s Leading Change and also Machiavelli’s the Prince. Between the 2 texts, I had some insights.

1. The Burning Platform (Leading Change)

I knew we were headed to adopting a new EHR platform in 2011, which was sure to cause significant disruption in many ways. Never waste a good crisis. Use the Burning Platform: when everyone jumps, give them a good place to land.

If you’re going to mandate APSO notes in the EHR, why not do it from the ground-zero of installing a new EHR? This is what I set out to do. The ground-work: the standard template for all progress notes would be APSO format: Assessment/Plan/Subjective/Objective.

I told the white lie: “Sorry, our new EHR only comes with APSO notes.”

I got the leadership to back me up (see below): APSO notes are much more readable than standard scrolling SOAP. This is the right moment to make this major change in policy. Don’t let individual complainants revert back without a thorough review with all leaders.

2. How to build meeting consensus  (Machiavelli)

Having re-read my Machiavelli text, I set up my next plan. I needed medical leadership consensus on making such a broad-ranging change.

By the way, for those of you who equate Machiavelli with self-serving, power-hungry, win-at-all-costs reprobates, well sure. HOWEVER, his text is ALSO full of practical advice for leaders.

He states: if you go into a meeting and you do not already know how everyone will vote, you have not done your job.

There are 40 members of the multi-disciplinary Ambulatory Medical Directors group; they are a rowdy, tough-to-wrangle group with strong egos, lots of opinions, and rare consensus across primary care, medical specialty and surgical specialties. If you have worked any amount of time in healthcare, perhaps this is familiar to you.

I determined to meet 1:1 with the majority of the group, including of the most influential members.

My tactic:

CT: “Don’t you hate it when it is hard to read the notes of [other specialty here]?”
CT’s targeted medical director: “Yes! Their notes are TERRIBLE. Ours are fine, by the way.”
CT: “Right! Well, I’m planning on enforcing APSO format for their notes so it is easier for us to read them.”
Target MD: “That sounds great. It is SO NEEDED.”
CT: “However, in order for me to get them to change to APSO, I need YOUR specialty to change to APSO. We need to be unified and apply pressure to THEM to change.”
Target MD: “But, our notes are fine. We don’t need to change.”
CT: “I can’t do this without you. The actual change for you is minimal. Just start part way down the note at Subjective (that is F2 key pressed 2 times), your patient visits and documentation sequence doesn’t change, just the final display of the note is different. For a minimal investment on YOUR part, we ALL benefit from THEIR NOTES being more readable. How about it?”
Target MD: “Hmm. I suppose it is worth it. You can get THEM to change though?”
CT: “Yup, you give me your approval for your specialty, and I will get THEM to change.”
Target MD: “Deal. Makes sense. Minimal change for us, big improvement on their part.”

CT repeats this conversation WITH EVERY OTHER MEDICAL DIRECTOR. Each of whom have the same thing to say about every other specialty. “We’re great, but those guys are terrible.”

As a result, the following Committee discussion was a non-discussion: “CT is proposing standard APSO format for all notes written in Epic. Any discussion?” “Nope. Makes sense to me.” “Sounds ok.” And then discussing some minor concerns, we were done.


Perhaps 20 hours of planning and 1:1 meetings for a 5 minute agenda item.

What’s that? This is unworkable for the majority of decisions? You are absolutely right. We pull out all these techniques ONLY for the BIG decisions. But it can and does work. To this day, Primary care notes (we write about 1 million a year), are 100% APSO format, and specialties are about 88% APSO.

CMIO’s take?

Years later, I gave this talk at Epic UGM and it has become an Epic Classic (link requires userweb login). In subsequent years, readability and note format continue to be debated, and at one point I was referred to in a UGM session as “unlike those Radical Extremists at UCHealth who standardized on APSO, we can’t get our people to adopt it like that.”

Thanks for the … compliment?

And now you know how this particular sausage was made. Thanks to Machiavelli and Kotter, and all the smart people before us.

Dr. Rob Turer and Open Results at AMIA. What do patients prefer?

Rob Turer presenting the major Open Results paper at #AMIA #CIC2023. 95% of patients who received results PREFER to see it immediately even if not normal! precounseling MIGHT help! Thanks Dr. Turer for laying a data foundation for patient information transparency.

AMIA Clinical Informatics Conference — Live tweet

Here we are.

What strikes me first, is the number of close friends and colleagues present (yes you know who you are). It is gratifying to reconnect with ‘our people’.

So cool to hear about our colleagues building resilience, pushing to reduce technical burdens, strengthening relationships. This should be a fun few days.

Automation Complacency, The Stepladder of AI in EHR’s, “Writing a note is how I think”. WHAT NOW?

A navel-gazing reflection on GPT, human cognitive effort, and the stepladder to the future. Where do YOU stand?

The image above generated by DALL-E embedded in the new BING, with the prompt “Doctors using a computer to treat patients, optimistic futuristic impressionistic image”. Wow. Not sure what the VR doctor coming out of the screen is doing.

Thanks to Dr. Brian Montague for prompting this post with his quote during a recent Large PIG meeting:

I find that I do a lot of my thinking when I write my progress note. If/when ChatGPT starts to write my note, when will I do that thinking?  — Brian Montague MD

That stopped me in my tracks.

We are so hell-bent on simplifying our work, reducing our EHR burden, we sometimes forget that this work is MORE than just pointing, clicking and typing.

It is also about THINKING. It is about assembling the data, carefully coaxing information and patterns out of our patients through skillful interview, parsimonious lab testing, and careful physical examination. It is how we, as physicians and APP’s, use our bodies and minds to craft an image of the syndrome, the disease: our hidden opponent.

Just like inserting a PC into the exam room changed dynamics, inserting GPT assistants into the EHR causes us to rethink … everything.

Pause to reflect

First, I think we should recall the technology adoption curve.

I fully acknowledge that I am currently dancing on the VERY PEAK of the peak of over-inflated expectations. Yes. That’s me right at the top.

Of concern, viewing the announcements this week from Google, Microsoft, and many others gives me chills (sometimes good, sometimes not) of what is coming: automated, deep-fake videos? Deep-fake images? Patients able to use GPT to write “more convincing” requests for … benzodiazepines? opiates? other controlled meds?

AND YET, think of the great things coming: GPT writing a first draft of the unending Patient Advice Requests coming to doctors. GPT writing a discharge summary based on events in a hospital stay. GPT gathering data relating to a particular disease process out of the terabytes of available data.

And where do we think physician/APP thinking might be impacted by excessive automation?

Automation Complacency

I refer you back to my book review of the book “The Glass Cage” by Nicholas Carr. As I said before, although this was written to critique the aircraft industry, I took it very personally as an attack on my whole career. I encourage you to read it.

In particular, I found the term “automation complacency” a fascinating and terrifying concept: that a user, who benefits from automation, will start to attribute MORE SKILL to the automation tool than it actually possesses, a COMPLACENCY that “don’t worry, I’m sure the automation will catch me if I make a mistake.”

We have already seen this among our clinicians, one of whom complained: “Why didn’t you warn me about the interaction between birth control pills and muscle relaxants? I expected the system to warn me of all relevant interactions. My patient had an adverse reaction because you did not warn me.”

Now, we have this problem. We have for years been turning off and reducing the number of interaction alerts we show to prescribers precisely because of alert fatigue. And now, we have complaints that “I want what I want when I want it. And you don’t have it right.” Seems like an impossible task. It IS an impossible task.

Thank you to all my fellow informaticists out there trying to make it right.

GPT and automation: helping or making worse?

Inserting a Large Language Model like GPT, that understands NOTHING, but just seems really fluent and sounding like an expert, could be helpful, but could also lull us into worse “automation complacency.” Even though we are supposed to (for now) read everything the GPT engine drafts, and we take full ownership of the output, how long will that last? Even today, I admit, as do most docs, that I use Dragon speech recognition and don’t read the output as carefully as I might.

Debating the steps in clinician thinking

So, here is where Dr. Montague and I had a discussion. We both believe it is true that a thoughtful, effective physician/APP will, after interviewing the patient and examining them, sit with the (formerly paper) chart, inhale all the relevant data, assemble it in their head. In the old days, we would suffer paper cuts and inky fingertips in this process of flipping pages. Now we just get carpal tunnel and dry eyes from the clicking, scrolling, scanning and typing.

Then when we’ve hunted and gathered the data, we slowly, carefully write an H/P or SOAP note (ok, an APSO-formatted SOAP note). It will include the Subjective (including a timeline of events), Objective (including relevant exam, lab findings), Assessment (assembly of symptoms into syndromes or diseases) and Plan (next steps to take).

During this laborious note-writing, we often come up with new ideas, new linkages, new insights. It is THIS PIECE we worry most about. If GPT can automate many of these pieces, WHERE WILL THE THINKING GO!?! I do not trust that GPT is truly thinking. I worry that the physician will instead STOP THINKING.


Is this a race-to-the-bottom, or a competition to see who can speed us up so much that we are no longer healers, just fast documenters, since we are so burned out?

Who will we be?

Radio vs TV vs Internet

My optimistic thought is this. Instead of GPT coming to take our jobs, I’m hopeful GPT becomes a useful assistant, sorting through the chaff, sorting and highlighting the useful information in a data-rich, information-poor chart.

Just like the radio industry feared that TV would put them out of business (they didn’t), and TV feared that the Internet would put them out of business (they didn’t), the same, I think, goes for physicians, established healthcare teams, and GPT-automation tools.

Lines will be drawn (with luck, WE will draw them), and our jobs will change substantially. Just like emergent (unpredictable) properties like “GPT hallucinations” have arisen, we must re-invent our work as unexpected curves arise while deploying our new assistants.

Another Bing-Dall-E image of physicians at a computer. In the future, a doctor will apparently have more legs than before.

A possible step-ladder

I think physician thinking really occurs at the assembly of the Assessment and Plan. And that the early days of GPT assistance will begin in the Subjective and Objective sections of the note. GPT could for example:

  • Subjective: Assemble a patient’s full chart on-demand for a new physician/APP meeting a patient in clinic, or on admission to hospital, focusing on previous events in can find in the local EHR or across a Health information exchange network, into an easily digestible timeline. Include a progression of symptoms, past history, past medications.
  • Objective: Filter a patient’s chart data to assemble a disease-specific timeline and summary: “show me all medications, test results, symptoms related to chest infection in the past year”
  • Then leave the assessment and planning to physician/APP assembly and un-assisted writing. This would leave clinician thinking largely untouched.
  • Subjective and Objective: GPT could take the entire chart and propose major diseases and syndromes it detects by pattern matching and assemble a brief page summary with supporting evidence and timeline, with citations.
  • Assessment and Plan: Suggest a prioritized list of Problems, severity, current state of treatment, suggested next treatments, based on a patient’s previous treatments and experience, as well as national best practices and guidelines. Leave the details, treatment adjustments and counseling to physicians/APPs interacting with the patient. Like Google Bard, GPT may suggest ‘top 3 suggestions with citations from literature or citations from EHR aggregate data’ and have the physician choose.
  • Subjective and Objective: GPT could take the Moderate tools, add detection and surveillance for emerging diseases not yet described (the next Covid? the next Ebola? new-drug-associated-myocarditis? tryptophan eosinophilia-myalgia syndrome, not seen since 1989?) for public health monitoring. Step into the scanner for full body photography, CT, MRI, PET, with a comprehensive assessment in 1 simple step.
  • Assessment and Plan: GPT diagnoses common and also rare diseases via memorizing 1000’s clinical pathways and best-practice algorithms. GPT initiates treatment plans, needing just physician/APP cosignature.
  • A/P: Empowered by Eliza – like tools for empathy, takes on counseling the patient, discovering what conversational techniques engender the most patient behavior change. Recent studies already indicate that GPT can be considered more empathetic than doctors responding to online medical queries.

CMIO’s take? First things first. While we can wring our hands about “training our replacements”, there is lots yet to do and discover about our newest assistants. Shall we go on, eyes open?

Seeking and Finding Mentorship for Physician and APP Informaticists (at XGM Epic)

Thanks to Christina Jung and Esther Park, Assistant Directors of the PACmentor program, founded by David Bar-Shain at MetroHealth. They’ll be at Epic UGM looking to sign up more mentors and mentees in clinical informatics; come join!

Pictured here: this blog author, Bethany Muchow, admin extraordinaire supporting physician/APP informatics; David Little, Epic physician; Esther Park of ICHS in Seattle; Christina Jung of Altamed-CHLA in Los Angeles, Chris Alban, Epic physician. Not pictured: David Bar-Shain from MetroHealth, founder of the PACmentor program.

We had a wonderful chat about the PACmentor (Physician Advisory Council mentorship program) and how it has grown over the years, matching about 150 mentors and mentees among physicians and APPs attending the Epic UGM and XGM meetings and in the larger Epic universe.

What’s great about this, is that, we can share our lessons learned across a great spectrum:

  • How to teach best-practices in using an EHR
  • How to connect with medical and operational leaders in your organization
  • How to integrate technology tools and decisions into effective teamwork
  • How to think about information transparency with patients in an EHR
  • How to manage and lead changes in the EHR AND in organizational culture
  • How to connect with other health systems struggling with similar work
  • How to learn from others so we don’t step in the same pothole
  • How to use storytelling WITH data to defeat counterproductive stories
  • How to grow our skills by learning from senior informaticists
  • How to develop a book club and bring new ideas to the table

Who doesn’t want that? Even better, the regular human interaction in effective groups (like the PACmentor program) itself protects against burnout among informaticists.

CMIO’s take? Even CMIO’s benefit from being part of PACmentor and being a mentee and/or a mentor (I know I do). Come join us at the anticipated UN-session at UGM (User Group Meeting) at Epic in August 2023 or on the forums (coming soon!).

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