Kevin Kelly: 68 bits of advice (Technecium)

From amazon.com and Kevin Kelly

https://kk.org/thetechnium/68-bits-of-unsolicited-advice/

Kevin Kelly: co-author of the defunct but world-changing Whole World Catalog, publisher of Cool Tools, author of What Technology Wants, and generally smart guy, is 68 (or was when he posted this). Brilliant observations. This is me Plus-one-ing his post. Some teasers:

  • Learn how to learn from those you disagree with, or even offend you. See if you can find the truth in what they believe.
  • Being enthusiastic is worth 25 IQ points.
  • Always demand a deadline. A deadline weeds out the extraneous and the ordinary. It prevents you from trying to make it perfect, so you have to make it different. Different is better.

CMIO’s take? Happy new year. Go read it, link above.

News: (WIRED) 30 lines of code blew up a generator

from wired.com

https://www.wired.com/story/how-30-lines-of-code-blew-up-27-ton-generator/

In what is an insider’s view of what our cyber warfare unit, and the cyber-criminals out there are working on, a view of the inner workings. I believe this may have been part of that the STUXNET attack on Iran’s nuclear facilities (and centrifuges) reported in 2010 (WIRED.com article).

CMIO’s take? The real world and the cyber-world are colliding in more intricate ways.

Oumuamua: the edge of reason?

from The New Yorker article

https://www.newyorker.com/magazine/2021/01/25/have-we-already-been-visited-by-aliens

A nicely written discussion by Elizabeth Kolbert at the New Yorker. In it she discusses the details of recent findings of the Oumuamua object that blasted through our solar system at 4x the speed of usual asteroids, did not move as expected, and must have been “an interstellar object”. Some are calling it an alien artifact, others are pooh-pooh’ing such a description as “unscientific.”

Farhad Manjoo at the NYTimes also comments. Fermi’s paradox talks about how to calculate the very large number of planets out there and the unknown fraction of those that might support life.

 In 1992, NASA spent $12 million on a project to listen for radio signals from other planets; the next year, Congress cut the funding, with one senator joking that “we have yet to bag a single little green fellow.”

In years since, scientific funding in this area has been paltry.

Here is the Fermi Paradox equation about the likelihood of extraterrestrials: https://www.space.com/25325-fermi-paradox.html

Why not consider alien life? Is it so ridiculous? As a scientific community, we pride ourselves on being open-minded, but our history sometimes indicates otherwise.

Is this is the edge of reason? Does our group-think ridicule those on the edge?

Some of what we do in healthcare is also at the edge of reason (see: Open Notes, APSO Notes). It is often ridiculed. Until it is not.

CMIO’s take? Perpend.

Misleading Patient Portal Data Due To Covid-19?!

What is the Covid Bump in our Patient Portal data, and what does it mean?

Patient Portals and Covid

Okay, everybody knows we are all pushing patients to go online (in our case to UCHealth’s My Health Connection -MHC – patient portal) in order to be a candidate for our “vaccine scheduling” randomization. Because we are so constrained in our vaccine supply, we can NOT offer vaccine to everyone who wants it, and as a result, we can only send out several thousand invitations or so per day for patients to schedule themselves online.

The reason we had to randomize the invitation for vaccine: Can you image if we did it the other way, opened up Vaccine scheduling to EVERYONE over age 70 in Colorado (we think there are 400,000 in the state) and then RAN OUT with people still in line? We do NOT want to replicate other state’s experiences of patients standing in line overnight hoping for a vaccine. Yikes.

Disparity concerns

Keep in mind, we have now set up “popup” clinics for patients in disadvantaged neighborhoods, churches, etc, as well as a phone number: UCHealth COVID-19 Vaccine Hotline: 720.462.2255; and website for additional folks to sign up: http://www.uchealth.org/covidvaccine .

Growth

Having said this, we have seen a TREMENDOUS growth in our patient portal numbers, from 800,000 several months ago, to 1,200,000 now, about a 30% growth in that amount of time. Yes, we realize some of these are patients who never felt the need to sign up for a portal account, and some are community members who are NOT UCHealth patients, signing up JUST FOR access to vaccine.

Anomalous age peak > 65?

Having said all this, look at the chart above. Unlike our previous age distribution of Active MHC accounts that peaked around age 30, we now have this anomalous peak above age 65! Twenty-four percent of our active population.

In hindsight, I am sad that our Slicer tool only sees “Activated patient portal accounts” as of right now, and that I no longer have access to snapshots in time from last year, to show you. To do that would require skills beyond this Data Dilettante, sorry.

65? 75?

So, what if you subdivide >65 into 65-75 and then >75? Lets see!

From my vague recollection, both >65 and >75 age groups with Portal accounts have nearly doubled in percentage.

Can we see the Vaccine Clinics in our Visit data?

Let’s see. Here is a graph (again with CURRENTLY ACTIVE patient portal accounts), by week, from September through end of January, of patients WITH MHC accounts, who are age > 70 (the previous criteria for phase 1b vaccination, and yes I know Colorado has lowered Covid vaccine candidacy to age 65+ this week).

Aha! Since we started vaccinating in December, we focused, as per state and federal guidelines, on healthcare workers and first responders. Thus, we should NOT see any bump in the patient visits for those with a portal account AND age over 70.

However, I can convince myself I see a bump at the end of December where we were telling patients to sign up for MHC to enter the lottery for next phase of vaccination, and then BOOM, a significant growth in visits with patients with MHC and over age 70 in January, scaling up and up. I think this is our in-hospital vaccine clinics, vaccinating about 5000 per day and our 2 weekend Coors Field Mass Vaccine events, the most recent vaccinating 10,000 over the weekend. Do you see me waving from those last 2 data points? Hi!

CMIO’s take? This is more than just an aging boomer population; this is Covid at work in interesting ways. I will be fascinated to see where Colorado, our online populations, and our healthcare will go in the coming months and years. What are you guys learning out there?

Covid Be-Gone. 10,000 Vaccines, One Weekend: UCHealth @ Coors Field.

Billie, Alex, and some crazy doctor, newly recruited Pit Crew. Biggest innovation? Billie’s smiling face on her button! Why haven’t we all done this!?

Our team is at it again!

The Rockies and Coors Field welcomed the UCHealth crew, this time for a 2-day, 10,000 vaccine event Jan 30 and 31. It was a smashing success, and tremendous fun, to boot.

Our fearless leader, Ali Hererra, giving last-minute tips to an eager 630am crew.

The new kid on the block

The new kid on the block: a neck-lanyard, battery-pack augmented iPhone with the EHR mobile app installed for on-the-fly vaccine documentation from QR bar-codes.

Gratitude!

Our vaccine clients show tremendous gratitude; we love the spontaneous cheering and applause that break out at times while the cars are moving through. One even handed us an unexpected gratitude card today!

What’s the count?

Here’s my tally for one day of vaccination: 150 for each day, 300 for the weekend. Unanticipated outcome? Donning and doffing gloves 150 times in quick succession causes some hand irritation and a need for heavy doses of vaseline petroleum jelly at the end of the day.

I proudly showed my clinical informatics colleague my collection of vaccine caps in my pocket (see how clever I was to keep track of my productivity?), and she promptly told me: Well, it is easier just to run a report (Thanks, Kristin). Um-hm. And I call myself a CMIO.

Efficiency tip?

Efficiency tip? Here’s the latest: Non-dominant hand: bandaid on the thumb, half peeled. Vaccine, ready to go. Pre-peeled alcohol swab. Dominant hand: Mobile device on a lanyard or in a coat-pocket, QR code scanner ready, some quick screening questions and screen-taps, vaccine documented in EHR, give vaccine, walk back to tent and re-supply while our student hands out the vaccine card and follow-up instructions. Rock-and-Roll.

First of all, our team CRUSHED the scheduled volume today. At our peak, we vaccinated more than 1000 people per hour, with average throughput times of 22.5 minutes (that’s INCLUDING the 15 minute observation).

To say that another way: we timed cars arriving at Check-in Registration at time ZERO, got screened, registered, consented, and vaccinated in about EIGHT MINUTES. And 15 minutes after that, they were rolling out of the observation area. WAT?!

We had numerous people exclaiming: “This is unreal, how smooth it is.” With masks on, we’re getting good at reading the smiling eyes. Wave after wave of grateful vaccine recipients.

Current Vaccine Tent workflow

The Tent 8 “A-team.” Billie Martinez, medical assistant, Brittney Poggiogalle, PA student, Alexander Jimenez, medical assistant (working hard). Thanks for making us all look good!

Turns out it is easy to “infect” colleagues with the enthusiasm I have for optimizing our workflow, which is now:

  1. Vaccinator sets up the non-dominant hand with vaccine, bandaid and swab (see above)
  2. Patient arrives with QR bar code ready on their phone (from My Health Connection or a printout). No Bar code? No problem, a last name search is only a few seconds more. Beep! 3 screening questions, done!
  3. Vaccinate! (previously described)
  4. Pivot our positions, and our student volunteer steps up and hands the vaccine card with followup instructions to proceed to observation area and to NOT MISS their next appointment (already booked for 3 weeks from now).
  5. DONE! our best cycle time: ABOUT 70 SECONDS INCLUDING DOCUMENTATION.
  6. Perhaps even more exciting, talking to each other about Lean process, discussing throughout the morning, how to stay safer: remember to tell drivers to put it in Park! Remind each other as we walk up and down, to stay out of the driving lane! When standing at your work table, prep your supplies with your body turned facing the line to be aware of your environment. Tell each other if you see something to improve.
  7. All 3 vaccinators have their own neck-lanyard mobile documentation tool, and we can give about a vaccine every 1.5 to 2 minutes including drive-up time, and one student keeps us supplied with peeled bandaids, filled-out vaccine cards, and explains next steps to the drivers, allowing the vaccinators time to re-set for the next care. It is a beautiful dance.

A Lean Lecture?

Talking with a colleague later, I reflected that I got so excited about our efficiency, that I gave a mini-lecture during the morning to our team and student volunteer on Lean process. My colleague then replied: “Oh no, Student! Wrong Tent! Wrong Tent!” implying that no student needs a lecture from an over-enthusiastic CMIO on a weekend. (Thanks for the commentary, Dr. Bajaj).

Our previous worries about backlog of paper charting needing later data entry?Gone!

The cool thing about this setup is: we did not pre-identify which cars had slow-down factors like: more than one scheduled vaccine recipient per car, no bar-code, occasional technical glitch, or lots of clinical questions. Occasionally, if one car took a little longer, the other 2 vaccinators would walk up the line and greet the next car. Once the line opened up, everyone slid forward easily. A handheld mobile and a one-hand vaccine supply made us nimble. None of us was waiting around, unless our line of cars emptied out entirely.

I enjoyed hearing the pharmacists on-site, who were mixing up batches in real-time (the Pfizer: needing to defrost and reconstitute from -70!), on the walkie-talkies discussing which tents needed more vaccine: “We’re almost out again at Tent 8.” “Okay, on the way with another batch of 25.” With our throughput (3 vaccinators, cycle time about 2 minutes simultaneously), that batch would only last us about 18 minutes. Loved every minute of it.

The CMIO in me wanted up-to-the-minute vaccine stats from the other tents. Not that I was feeling competitive. No. Not me.

The Pit Crew

Not being satisfied with even this, mid-morning we were asked to transition to a Pit-Crew method being piloted by our Clinical Informatics nurses. In our standard lanes, cars would pause at one of 6 Registration lines, drive down a lane and then be split into 16 vaccine tents. The Pit Crew were doing both Registration AND Vaccination in the Registration (big white) tent. Then, no second stop, straight to Observation. It was going so well, we recruited additional people to run a second line.

INSIDE the big tent. Four cars in a row. One stop to do it all. We don’t have all the timing numbers yet, but we believe this may take additional seconds or minutes out of our cycle time. There are some potential downsides to this configuration VERSUS our vaccine tent configuration; the registration workstations on wheels (WOWs) aren’t as nimble in traffic compared to our handhelds, so walking upstream when there is a delay is not practical, and if one car takes longer inside the tent, there is more potential delay. The upside: one stop could make the transit time much shorter per vehicle.

At the end of the weekend, ZERO DOSES WASTED. 10,000 given. ZERO significant complications in the observation area. Dr. Richard Zane calculates that the 10,000 vaccinated patients means that 157 fewer people will die of Covid as a result of our actions this weekend. Wow.

Stay tuned! We’re already performing at a high level, but we think there are yet improvements to make, while keeping patient and team safety our top priority. The work of our Incident Command structure has been a joy to watch, with team leads in constant communication with the Rockies, the Denver Police, the State, County and City.

Here’s a CBS Denver news article about us, with more photos from a drone.

CMIO’s take. Who knew that Toyota Lean Process could help vaccine administration? Furthermore, I’ll say it again: Get us more vaccine! We can handle it.

Covid-19 Sea Shanty

It was social media blowing up with Sea Shanties that got me into this. What is a Sea Shanty, anyway? My wife thought it was a tiny house on the edge of an ocean. Hmm.

Turns out, Nathan Evans from TikTok sings a New Zealand Whaling song “The Wellerman” with a beautiful Scottish lilt. It is the perfect antidote for Work From Home Loneliness. 10.4 million views later, lots of folks agree. The New York Times covers the story.

My favorite quote from the story: “It’s not the beauty … it’s the energy”, “You’re not supposed to sing pretty.” I think they’re talking about me!

I am so tired of working from home, of not seeing anyone, that I fantasize about working together, singing in cadence on a crew of a ship.

CMIO’s take? Fighting Covid is a little like a high-seas adventure. Hope you like my version.

The Invite-Only Mass Vaccination Trial Run by UCHealth at Coors Field: an Insider’s Peek

Outdoor vaccine guy says: come along, I’ll show you what I learned.

Indoor vaccine guy dresses differently from Outdoor Vaccine guy

The UCHealth team held its first Mass Vaccination trial at Coors Field on Sunday 1/24. This was the first Mass Vaccine effort in Colorado, and was coordinated with the City and County of Denver, CDPHE (Colorado Department of Public Health and Environment), Denver Police, Verizon, Denver Health, Stadium Medical and the Governor’s Office. Weeks in the planning, dozens of clinicians, staff and coordinators swarmed the location assembling, arranging, tweaking.

2 hours: 1000 vaccines?

For this event, we planned to give 1000 vaccines in 2 hours to stress-test our design plan and to see if we could maintain or exceed this pace for future events. This was an invite-only event with 500 patients selected from UCHealth existing patients and 500 from newly-signed-up for vaccine from the UCHealth website for the general public aged 70+ per State current guidelines.

Between 6 and 7am, we assembled, got last-minute instructions for our many roles: runners, flaggers, registrars, traffic control, vaccinators, timers, process engineers, clinical observers, flow coordinators, etc etc. Here, I’m standing under a heat lamp, warming my hands for the day to come. The big white tent is registration-confirmation. Sorry, no drop-ins.

Team Number ONE!

With Dr. Jenny Bajaj, CMO of UCHealth Medical Group and Andrew Mariotti, medical student and process timer. We, of course, snagged Vaccine Tent #1. For work like this, snow pants recommended.

The UCHealth team set up a small batch of cars to arrive between 8 and 9am, to work out the kinks at every vaccine station; each station received 2-4 cars to test our supplies and workflow, and see if the runners, pharmacists, flaggers, observers had any questions about their jobs.

We then huddled between 9-10am to debrief questions from the team, then BOOM. Our full-speed test was from 10-12am with 1000 cars to come through in that time.

From the fourth floor of the Coors lot parking garage, the command center station. The RTD commuter trains run along the left, Blake Street on the right, the big white registration tent, where we catch and release any folks without appointment. The Mass Vaccine event (like EVERY Covid vaccine clinic) is highly calibrated down to our last vaccine. If we accepted drop-ins or family members, we would run out for our scheduled patients.

In the right row of tents, the first (most distant from us) tent is for registrations taking longer than usual, so that no registration line gets held up. Vaccine Tent 1 is thus the second (tiny) tent on the right. See me waving? No? No.

Our observation area (not shown) is actually behind the photographer, on the other side of the parking garage, with flaggers guiding the way.

Work station setup.

We re-arranged our area to be increasingly efficient. Working in teams of 2 allowed us to iteratively reduce our cycle time for each vaccination. Orange bucket 1: our vaccine supply (closely guarded by pharmacy and defrosted just-in-time). Orange bucket 2: pre-opened bandaids. Nothing is harder than cold, gloved hands opening bandaid packets when in a rush. Supply of gloves, alcohol swabs, gauze if needed. Raise the Yellow laminated card to indicate to runners if we needed supplies. Red card: help needed. Pink ribbon: attach to drivers side mirror for those warranting extended observation (eg previous history of anaphylaxis).

Workflow:

*One person waves down the car, checks “Please put it in Park!” (about 1/3 don’t unless asked!) asks the screening questions, confirms which arm, which passenger.
*Simultaneously, second person (vaccinator) doffs/dons gloves, opens alcohol swab, snags a pre-peeled bandaid, grabs a syringe
*Pivot! first person files the screening paper with identity and signatures for later data entry and grabs the vaccine card
*Simultaneously, vaccinator: Swab, Pre-attach 1/2 bandaid, Vaccinate in one motion, auto-retract needle (more on this below), Swipe bandaid across, Done!
*Pivot! first person explains the card, answers any questions, reinforces importance of second appointment, directs driver to proceed to next flagger to wait for the standard 15 minute observation time.
*Simultaneously, vaccinator disposes the syringe, clears trash, dons/doffs gloves and preps the next setup.

With this setup, Dr. Bajaj and I started with about a 90 second cycle time, and with iterative adjustments, pushed our best time down to 59 seconds, with our average running 1:15 to 1:20, if no questions (or profuse thankfulness) from the patients.

On debriefing this, we had several thoughts: the time it takes to chat and manage paper is about the same amount of time to swap gloves, manage supplies, setup. Seems like the 2-person team is, at present, an optimal setup.

In the coming weeks, it may be possible to incorporate a clinician-mobile-app adjunct to our Electronic Health Record that would allow on-the-fly documentation that would take the place of paper questionnaires and signatures when in the field.

Paper is fast, but…

From an informatics perspective, the paper process was a win from a through-put perspective, but an opportunity to streamline data-flow. We had runners taking our paper to the Documentation Tent to be keyed into the EHR in near-real-time.

Contrast that with our in-hospital based vaccine clinic (see my last post) where vaccination and documentation occur in real-time, the EHR and the State Vaccine Registry being updated almost immediately, and with a cycle-time (with one vaccinator/documentor) at about 3 minutes.

Teamwork. One step pivot, the choreographed dance of a one-minute vaccine cycle.

A “Fauci-Ouchie”

as my sister is fond of saying. At the end of our time, Vaccine Station 1 reported 67 vaccines given in 90 minutes. That is EIGHTY (80) seconds per shot. Taking into account the times when our station did not have a car, we think we could have completed 10-20% more shots. We are NOT Throwin’ Away OUR SHOT.

Here’s our high-level debrief. Team leaders from each of our major roles reported in: paramedics, police, City and County and State leaders, the Rockies (THANK YOU FOR OUR USE OF YOUR MASSIVE PARKING LOT AND TRAFFIC EXPERTISE). Very smooth. We think we could increase the pace beyond 1000 per 2 hours. We are targeting 5000 vaccines per day for 2 days next weekend. We’ll see!

Total throughput time per car?

Measured another way, we found that cars moved from Arrival at the Registration Tent to Leaving the 15-min Observation Area: 21-27 minutes. TOTAL.

Zero anaphylaxis events. No paramedic transports. There were very infrequent side effects observed in the observation lots. Everyone drove away successfully.

Local news coverage of our event

Sky9 aerial footage (about half way down the linked article). Tent 1 and my white coat is visible at 20 minutes. Woo!

https://www.9news.com/article/news/health/coronavirus/vaccine/uchealth-to-test-out-covid-19-vaccine-site-at-coors-field/73-96ede931-ad3a-45eb-8778-01de38562844

9News, Sky9 footage

Fox 31: https://kdvr.com/news/coronavirus/covid-19-vaccine/appointments-required-at-denver-mass-vaccination-site/

Denver Post: https://www.denverpost.com/2021/01/24/covid-vaccine-coors-field-drive-thru-clinic/

Denver Channel 7: https://www.thedenverchannel.com/news/local-news/uchealth-plans-to-test-run-mass-vaccination-event-at-coors-field

Auto-retracting needle?

Oh, and here’s a gif of the auto-retracting needle. So cool. How did they even fit a spring into the barrel of this tiny thing?

When done correctly, depressing the plunger completely means that the needle retracts from the patient, completely into the barrel of the syringe, eliminating the chance of unintentional needle-stick. Innovation FTW!

CMIO’s take? Mass Vaccination: another chance to innovate, another chance to take a chunk out of the Covid pandemic. Send us more vaccine. We can handle it.

Xenobots are coming: Tiny Blobs of Programmable Tissue (WIRED)

From WIRED.com, the application of DNA engineering not only to the sequencing and reading the DNA and RNA of viruses and organisms, but now to CREATE “tiny blobs of programmable tissue.”

REALLY?

Watch it above, and read it yourself: https://www.wired.com/story/synthetic-biology-plan/