Where does creativity come from?*

“Where does creativity come from? We don’t know but we are certain that it doesn’t come from our laptops” –John Cleese

Thank you, Sir Cleese. I have enjoyed your movies, your quips, your oeuvre, and even the way you say “oeuvre.” And now, you give talks on creativity.

In my readings, I must agree, working on computers, on laptops is simple, is portable, allows us to store our thoughts in the CLOUD to avoid getting our papers lost in some stack. And yet, the non-verbal result of our tapping away at our computers, our laptops, our tablets, our phones, is an implied communication that we are in our own bubble.

Furthermore, using keyboards seems to reduce the ability for our brains to engage in encoding incoming information, with research showing that students learn better when they take notes ON PAPER as opposed to using an electronic device, maybe because SLOW handwriting forces a brain to choose the important words rather than take down words verbatim, and maybe because having an open laptop (often open to SOME other interesting website) distracts us AND OTHERS SITTING BEHIND US to losing focus and not really listening.

Finally, numerous books on creativity talk about how computers may be terrific at creating beautiful documents and flyers, but are generally terrible at restricting the free flow of ideas that is only possible with pencil, colored markers, sticky notes, lots of paper and scissors. Some advocate for having TWO desks in your office: one for creative work that has NO electronics, only paper manipulatives, and one for the computer, when the creative work is done, to put the completed work into a pretty format for printing or electronic storage and transmission.

I’ve taken to this model and try to do creative work away from my computer now. I also take notes in a small black book, not on my phone, and I’ve found this (although not searchable) a great way to better encode and remember discussions.

CMIO’s take? Keep in mind where creativity comes from
and where it doesn’t come from.

Book review: Artemis

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Five stars.

Maybe the best sci-fi book of the year? Well, it is in the running. I’m sure it is difficult for an author to follow-up a first-novel blockbuster book with a successful second novel, but Andy has pulled it off. It is NOT the paradigm-shifting story of a marooned human on Mars, but a gritty, near-future story about a super-smart deliveryman (gal) who is sick of people telling her she’s “not living up to her potential.” And she is a smuggler: she smuggles goods in from Earth to the Moon colony called Artemis. But then her smuggling gets her involved in something a lot bigger than she intended.

Andy unwinds this tale with a huge dollop of delicious hard-science fully integrated into the storytelling and into the problem-solving. This key is the same key that unlocked The Martian for me and so many others. Feels like the 1970’s TV show “The A-team” except with hard science instead of those rapid-action cut scenes where they’re building something cool that will get them out of trouble by the end of the episode. That kind of feeling. Except better.

CMIO’s take? Science rocks. Artemis rocks. Two thumbs up.

The Glass Cage by Nicholas Carr (book review)

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One of our book club books, for the ‘clinical decision support’ team for the electronic health record at our institution. We have now read it in our Large PIG book club meeting (the Physician Informatics Group: we try hard not to take ourselves too seriously). Some of us were depressed after reading. The initial optimism of the ‘glass cockpit’, the fancy new computerized design of the complex Airbus aircraft, are instead proving to be a ‘glass cage’, which isolates us and anesthetizes us from the real world. The author provides riveting examples of glass cages: the Inuit who lose their cultural skills of navigating brutally inhospitable landscapes because of GPS and snowmobiles, also, the pilots who make error because of automation, leading to automation bias and automation complacency: thinking the computer must be right, and the computer will know, so I don’t have to. Further, our attention wanders as we cede responsibility for moment to moment control of the task. How do we fight such a trend and temptation, as designers?

Yet the author speaks about ‘adaptive automation’ where a computer could detect the cognitive load or stress in a human partner, and share the cognitive work appropriately. He speaks of Charles Lindbergh, describing his plane as an extension of himself, as a ‘we.’ Can we aspire to improving the design of our current electronic systems to such a partnership that avoids the anesthetic effect and instead becomes more than the sum of the partners? Chess is now played best by human-computer partners; could health care and other industries be the same? And what could that look like? The Glass Cage gives us an evidence-based view into that future (and hopeful) world.

UPDATE: We had a great discussion during our recent book club. As an indicator, several of my colleagues told me: “I don’t like this book.” Perfect! It made for a juicy, spirited conversation about the benefits and risks of automation and how the stories in the book did or did not apply to healthcare and what we were building. Maybe we can consider “adaptive automation” so that the computer scales up and down its assistance as the clinician comes under crisis so that the human can focus on problem solving and the computer can increasingly assist with routine tasks. And then, we need to take care that “automation complacency” does not increase. We already have heard of clinicians saying “Well, EHR did not pop up an alert for a drug interaction, so that means it must be safe to prescribe this new med for this patient.” Whoa, are we giving away the primacy of our own training and experience to an algorithm already?

CMIO’s take: keep reading, keep learning. It is only through extensive experience from reading and books that we can learn from others in healthcare, and from others in other industries divergent from our own. There are more smart people who DON’T work for you, than who do.

 

Augmented Reality: the Homecourt app on iPhone XS: wow!

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https://www.si.com/tech-media/2018/09/12/steve-nash-homecourt-app-apple-event-iphone-xs-camera-watch-shot-tracker

More whiz-bang tech. The latest iPhone now supports more augmented reality, by allowing the app access to a video stream of someone practicing shooting hoops and giving feedback in REAL TIME as to the spots from which shots are attempted and made. In other words, AI now auto-processes video that used to take hours of video TAPE pored over by coaches and players, and simplifies this into a device we already carry. (OK, those of us with >$1000 disposable income and a desire for the latest and greatest geek toy).

But, think, if we applied this to healthcare, would we use this to:

  • Monitor patient meals by automatically calculating what is being consumed?
  • Watch how patients are flowing through clinic to learn how to optimize efficiency?
  • See how ER patients are doing in the waiting area and triage and in the treatment areas?
  • Watch for improved efficiency in procedural areas like endoscopies, bronchoscopies, cath labs?
  • Watch how minor procedures are performed and suggest tweaks to clinician performance without the shame of having a human supervisor around?

CMIO’s take? Interesting to see how and where Augmented Reality might show up in healthcare, based on bleeding edge ideas in other fields like sports.

“What is a Large PIG”? or, How to set up a Physician Champion for success during a hospital EHR go-live. Guest Post by Jonathan Pell MD

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UCHealth, like many other health systems, are extending their EHR network to affiliate hospitals and facilities. Whether a hospital is coming from a paper charting system or from a different EHR, there is dramatic culture change for independent physicians as they get ready to adopt the system-wide EHR. Here are some challenges presented by physicians working at these hospitals joining the system:

  • Independent physicians were loosely affiliated with the hospital previously. Some surgeons were used to handwriting their H&P or faxing in a preoperative H&P they dictated via their office chart. They did the same with paper preoperative orders. Will they be allowed to continue?
  • Independent hospitals have had paper-based or electronic order sets developed over decades of tradition which are often customized for each of the providers even though they address the same clinical condition. Will they be allowed to keep the many physician-specific versions of these local, non-standardized order sets in the system EHR? How about if they have no-longer-standard-of-care medications and care instructions?
  • Independent hospitals have medical staff committees, often with committee attendance paid by hospital. When assembling leadership committees, will the system pay for physician attendance at EHR committee meetings preparing for go-live?
  • Inevitably, some services and specialties are more engaged than others. In the worst case, physicians will ignore the calls to attend mandatory training and readiness evaluations. As a result, these same physicians and specialties will disproportionately think that “your EHR is a piece of #(&$.”  How will you work with these physicians?
  • Similarly, some services will need more support after go live than others. These are typically the least-engaged physicians in the hospital. How will you develop relationships with these physicians to help them be successful?

Our solution (after several trial-and-error experiences…) is to create ONE Physician Champion for that hospital, and to pay for 0.2 FTE (20% of a full time equivalent, or about 8 hours a week) to serve as THE Physician Champion for that hospital for 6 months prior, 2 weeks intensively during go live, and about 3-4 months after.

We anticipate this Champion would spend less than 8 hours a week in months leading up, and spend quite a bit MORE than 8 hours a week just before and during go live, as long as the total engagement over the 9 months, averages out.

Here are the relationships that will make this Champion successful (see graphic):

ChampionAndPhysicianReadinessLeads

  • Senior (system-level) Physician Informaticist with hospital go-live experience to be a partner and coach (model of “see one, do one, teach one” from residency training)
  • Project Manager who represents the IT analyst team that builds the EHR tools and infrastructure and tracks deliverables and deadlines, and Nurse Informaticist who represents clinical staff roles and shared workflows.
  • Physician Readiness Leaders working group to create consensus and disseminate knowledge back to front-line clinicians

To extend the reach and influence of the Champion, we establish a working group of pre-go-live Physician Readiness Leaders. The specialties represent a majority of patients admitted to that hospital. We emphasize the inclusion of particular specialties like surgery, obgyn, emergency medicine, hospitalists, AND infrequent consultants and primary care referring physicians.

This committee is co-chaired by the senior Physician Informaticist and the hospital Physician Champion, comprises about 6-9 Physician Readiness Leaders. The nurse informaticist and project manager also are crucial (see above). This whole group meets monthly in the 6 months prior to Go Live, then twice a month in 2 months after Go Live.

Physician Readiness Leads are required to: attend early EHR training, and attend extra EHR training sessions to reinforce collegial discussions and problem-solving during training, and make rounds in the hospital in the first couple weeks of go live to commiserate chat with colleagues. Depending on the hospital and local culture, these Leaders may continue to meet sporadically after go live for ongoing maintenance concerns and EHR updates. The hospital Physician Champion is contracted for about a year, and is expected to step down several months after the go live is completed. In some cases, that person or an alternate Physician Champion is selected for ongoing participation in the system-level Large PIG to help with ongoing EHR improvements and be the bi-directional relationship for that region/hospital with the larger informatics and physician community.

HERE IS OUR INTERNAL DOCUMENT FOR
Benefits and Responsibilities of Physician Champion

IMPORTANT: Strong Physician Relationships are directly proportional to effective clinical care and the successful implementation of electronic health records. It is even more important than the configuration of the actual EHR technology.

Benefits of the role:

  1. Develop a global perspective of the IT provider plan and how the unified integrated EHR system (Epic) can benefit your group.
  2. Hit the ground running in regards to workflow efficiency at go-live and staying ahead of the curve after go live
  3. Opportunity to be operational and clinical leaders in the hospital configuration decisions
  4. Decrease patient safety risk when providers’ groups are involved in order set build, training engagement and attendance at pre-flight sessions
  5. In the absence of provider participation in EHR meetings, nursing and administrator decisions may have unintended impact on provider workflow.
  6. Help to shape physician go-live support which can be focused for your providers that will have their first shifts and procedures after go-live
  7. Attend meetings where your feedback is highly valued and affects change rather than informational only meetings
  8. Start to develop partnerships, communication lines, and understanding of workflows that affect your day-to-day job
  9. Nurses want to know that the providers are on board with the change. Participating in the decisions of this committee allows you are to be seen as the leaders.
  10. Opportunities to visit and collaborate with same-specialty providers at other system Epic hospitals
  11. Develop relationships with colleagues to help improve the system prior to and after go-live

Responsibilities of the role:

  1. Attend 1 hour monthly physician readiness meetings for the 6 months prior to Epic go-live
  2. Review specialty-specific order sets to assure appropriate content is available for go-live
  3. Communicate with colleagues in your specialty at your hospital and inform the working group about your colleague’s readiness or participation in training, order set review, and pre-flight readiness.
  4. Bring specialty-specific concerns to the readiness group, particularly around multi-disciplinary workflows (e.g. is faxing/scanning of paper H/P’s allowed? Who will enter order set orders if/when verbal orders are permitted?)
  5. Communicate concerns to the Physician Champion
  6. Communicate information discussed during readiness meetings to your respective specialty colleagues
  7. Participate in early Epic training and at least one additional training session with specialty colleagues
  8. Participate in Clinical Informatics Journal Club as part of monthly physician readiness meetings

Some sample books included in our Journal Club:

  • Leading Change (Kotter)
  • Managing Transitions (Bridges)
  • Design of Everyday Things (Norman)
  • Nudge (Thaler)
  • Crucial Conversations (Grenny)
  • Getting To Yes (Ury)

Jonathan Pell MD

CMIO’s (and guest’s) take? Create a clear set of expectations and responsibilities and a small multi-disciplinary team with STRONG relationships. Success in informatics is about relationships. (Thanks, Jon!)

Book review: the Chemist

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Three stars? Four?

I have never been a Twilight fan (and proud to say it). But Stephanie Meyer is on to a new heroine now, the Chemist. How interesting that it interleaves with my current TV series obsession “Breaking Bad.” My wife and I are powering through season 4, maybe 5 by the time I post this (We have a tradition of only discovering years-old dramas long after everyone else has forgotten about them).

Hey, its trashy, fun, life-and-death, good-guy-bad-guy action, with some romance thrown in. And laced with chemistry. It could have been a bit more detailed on the science-y chemistry side, instead of the drama side, but who’s complaining? A fast, fun read.

By the way, if you’re a reader and looking for a community of readers who like discussing books they like, consider Goodreads.com. I used to post my reviews there, as I could automatically cross-post them to WordPress, but no longer. With the Goodreads website redesign, the API no longer works. 😦

I still like tracking my TO READ, CURRENTLY READING and READ books there, and visit with friends (bookworms?) of similar interests.

CMIO’s take? Sometimes reading a lot does NOT mean reading for work. And, reading a lot always makes you and your perspective more interesting. And, non-work reading often makes you more useful at work. Even, dare I say, sci-fi.

Wait But Why: the wisdom ladder by Tim Urban

“Religion for the nonreligious”

https://waitbutwhy.com/2014/10/religion-for-the-nonreligious.html

Okay, don’t get put off!

I love this kind of writing. WARNING: navel gazing ahead. The idea that we are on a stepladder of consciousness, beginning on the one end, from one-celled, barely alive organisms, rising up through insects and up to chimpanzees and then Einstein-level humans, is interesting. And then, if we believe consciousness is a spectrum, are WE necessarily the top of that spectrum? Is there someone (or something) else above us?  And, on our human-level step of consciousness, what if there were several mini-steps? This is the premise of Tim Urban’s brilliant essay. He postulates (I will paraphrase here);

Step 1: FOG obscures everything. You’re terribly small minded because the ANIMALS (our ancestral hind-brains) are running the show, amok with emotion, and the fog is too thick, you can’t see the bigger picture.

Step 2: Using meditation, learning and active reflection to “thin out the fog” and begin to see context. It is like having a cashier at the store be rude to us. On step 1, we lash out, on step 2, we understand some context that it is “not about me” and that he/she may have had a bad day.

cashier

Step 3: When spending enough time in Step 2, occasionally you will have WHOA moments, when you are in “flow” or deeply thinking about context, and have an enlightened moment about how truly small we are, how briefly we are alive, how much else is OUT THERE, and how much we STILL DO NOT KNOW. For that cashier, we are amazed that, we are billions of cells collected together to form an ENTIRE CONSCIOUSNESS and that cashier is, amazingly, another collection of billions of cells that has also managed to achieve CONSCIOUSNESS. Whoa!

cashier-2

Step 4: The GREAT UNKNOWN. What is out there anyway? We make silly comments about how dumb humans from 2 centuries ago knew SO LITTLE ABOUT EVERYTHING, not seeing the HUGENESS that we still do not know.

I love this long read. Find some time, put it aside and read the whole thing. Entire books I have read, have not been this eloquent, about our human journey to seek knowledge and self-enlightenment.

This is by deep thinker Tim Urban.

Also, he has written and given a TED talk on his procrastination monkey. A worthwhile and thoughtful listen. Having just discovered his blog, I think I will be perusing his stuff for quite a while.

CMIO’s take? Seek out people who challenge your thinking. Learn something new. Think uncomfortable thoughts. Stretch your brain muscles. What happens next?