Help! Secure Chat in Epic, a ukulele EHR parody

The latest ukulele song. Yet another illustration of how Culture Eats Technology for Lunch.

We’re working on a Unified Communications strategy at UCHealth. We have a history of implementing multiple communications channels over the years:

Bell-boys

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Bell-boys (the precursors to pagers), with verbal alerts. You call a phone number, you record your 8 second message, and a minute later, someone, somewhere in the hospital hears this coming from the bell-boy at at their hip. Usually, you say: “This is East-8. Please come to bed 8217. Patient vomited blood.”

Worst case, you have excited nurses who don’t give you complete information. My favorite bell-boy utterance: “Doctor! Come Quick!”

Hmm. Which floor wing of the hospital? Which of the 12 floors?

Pagers

motorola2bpager

Then, there have been actual pagers, those infernal beeping machines that were the bane of residents and attendings worldwide (but the badge of honor for medical students offered one for the first time).

Of course, there’s Pager Inversus, but that is a blog for another day.

Doc Halo, Vocera, Tiger Text

And then came the flowering of 100 new ideas. “Hey, I think my department could really use X. We don’t really like Y because, X is better. Everyone know that. And because our organization in years past did not have a well-centralized decisionmaking body, every department went and did as they liked. As a result …

Pandemonium

Why can’t the nurses and operators page me in time? They are SOOOO SLLOOOWWWW. We need to hire more.

Well, imagine this. The number of places a nurse has to look in the paper or electronic chart to find the contact information for any one physician or APP was in non-overlapping, non-cross-indexed dictionaries:

  • Handwritten pager number in the progress notes
  • Call my service and my staff will then reach me on my private cell. I don’t give that out
  • Look me up in Doc Halo’s website
  • Look me up in Tiger Text index
  • Look me up in Vocera

Fortunately, we finally have a tool in Secure Chat in Epic EHR that will replace all these technologies.

Network Effects

(image from wikipedia.com)

Over years, the building of telephone networks made owning a telephone increasingly valuable. The larger the network and more people you can reach, the more useful the tool.

The opposite is also true: the more different and non-connected communications tools you use in an organization, the worse it gets, and the harder it is to reach anyone.

I think we’ve finally learned this lesson: Secure Chat it is.

Culture Eats Technology for Lunch

Of course, the IDEA of unified communications and getting rid of older networks, like pagers, other secure chat tools in favor of one, seems simple. Don’t under-appreciate the need for LOTS of meetings and discussions.

In fact, it might be time to re-read Leading Change.Have to think about finding the Burning Platform, building Buy-In, building a Guiding Coalition, and so on. Informaticists would say, it is the classic 80:20 rule. Technology, as hard as it is to create, is only 20% of your success. The other 80% is the socio-political skill of those deploying the tech.

CMIO’s take? We are, after years of effort, growing our success. And to celebrate, this song (youtube link above).

 

How to write an effective 1-PAGER (Informatics PIG-let series)

Ever done this? You have a major presentation, and as the expert, you want to anticipate ALL questions, so you write a 17 page white paper to CRUSH ALL DISSENT. HA! You think, TAKE THAT! I’m sure to win everyone over.

The Internist’s Problem

This is the story of my life. As a detail oriented (read: Obsessive-Compulsive) Internal Medicine physician, I’m trained to sweat all the details, think through complex situations, and explain them as carefully as I can to my patients and colleagues. That’s what I’m good at.

Do you have a few hours? Let’s get into it! (Sorry, you’re right, this is a blog, just kidding).

The problem is, this is NOT the skill you need in organizational leadership. No one has time for an hour-long PhD dissertation. You get maybe 5 minutes, maybe just 10 seconds, to make your point in a board room, a steering committee.

Furthermore, as an introvert, I’m not good at punchy one-liners, off-the-cuff banter, deft debate skills to win over recalcitrant colleagues. What to do?

Don’t do THIS!

That is exactly what I did wrong in 2001. I helped conduct a research study to show that Open Notes and Open Results (releasing notes and test results online to patients) was safe and effective. I wanted to win over my colleagues in a large, multi-specialty University practice. I wrote a 17-page Q/A handout answering ALL POSSIBLE QUESTIONS. It did not go well. Maybe you heard of me and my disaster? –> My 16 year journey to Open Notes. 

So, what to do?

In the intervening, wound-licking years, I developed a solution: the 1-PAGER. Other names you may hear me say: The Executive Summary, the SBAR (Situation, Background, Assessment, Recommendation; a format familiar to nurses, and their effective communication analog to the physician SOAP note).

General Principles of a 1-pager

  • Don’t exceed one side of one page. This restriction forces clear thinking and writing, like a newspaper article with limited space, cutting away unnecessary words and information.
  • The title should be specific and direct, START WITH WHY
  • An executive summary, in 3-4 sentences, giving some nuance to WHY and WHAT needs to be done.
  • Include both data AND ALSO stories and quotes. (Daniel Kahneman: “No one ever changed their mind because of a number. They need a story.”
  • With every item on the page, ask yourself “Who is my audience? Do they care about this item? Does it help tell the story? Does this align with the audience’s or organization’s goals?” Slash ruthlesslessly.
  • Include interesting graphics; no one will pick up a boring paper with dense small font, but a picture? or a curious graphic? Maybe you have a chance.

Here are some examples to consider

My 1-pager describing our move to adopting OurNotes patient questionnaire across 80 primary care clinics, about 400 primary care providers, where patients co-author their own progress notes. Proposal: accepted.

Download document: 2022-0208 OurNotes Patient Questionnaires Future Exec Sum

My 1-pager describing the benefits of our outpatient Sprint program, both data and stories: “I no longer seek early retirement to escape EMR.” Similar documents helped get Sprint teams funded.

Download document: 2018-08-ExecSum-Sprint-Aggregate

My 1 pager describing “How long will my IT/EHR request take?” Our leaders better understand why some things take a longer time than others.
Download document: 2020-0707 EHR Pyramid of Possibility CTL

My 1-pager advising patients what to expect when expecting a test result. Download document: 2020-1026-for-patients-getting-a-test-at-uchealth

My 1-pager advising clinicians how to avoid potholes in writing a progress note that will be read by patients. Notice: it is no longer 17 pages long. Download document: 2017-0904OpenNotesDocuTipsCTLin

Beginner’s Mind

Heres’ the thing. An expert knows a LOT of detail and has trouble holding back all those details. A beginner / learner / leader needs to know just enough to make a judgement whether to support a project or not. How can an expert adopt a beginner’s mind? Start with WHY, write a disciplined ONE PAGE argument, tell a STORY backed with data. Revise, revise, revise until it is clean, succinct, and passes muster with a colleague or mentor who is willing to critique your writing.

Piglet?

Oh, are you still reading? What is a PIG-let, you ask? One of my newer physician informatics colleagues, poking fun at our Large PIG / Small PIG meetings, wanted a PIG-let meeting, for the newbies. Cute. Like Tony Hsieh did, for Zappos in “Delivering Happiness”, I’m looking to build an on-boarding set of skills for our PIG-lets. Skills, tools, books.

CMIO’s take: What do you think? Have you tried this? Do you disagree? What has worked for you? 1-pagers for everybody!

90 x 4, don’t bother me no more (ukulele)

Thanks to Chris Sinsky’s saying “90×4, don’t bother me no more”. Here’s a ukulele ditty go along with that. We’re making these changes to our inbasket for noncontrolled, maintenance meds.

We’ve been noodling on various ways to reduce the Electronic Health Record burden for our docs. One thing we’re going to change, across our system, is the way we set defaults for new prescriptions and for prescription renewals, for non-controlled, long term maintenance medications, like for diabetes (eg insulin, metformin), hypertension (lisinopril, hydrochlorothiazide), heart disease (metoprolol, spironolactone), and so on.

What does it mean? In the past, we have prescribers writing for 30 days, 60 days or 90 days supply of medication, and then some random number of refills, up to 1 year. As our practices get busier (and with the pandemic, as we have fewer clinical staff in our offices), the volume of prescription renewal requests are growing quickly. Why not, with these low-risk, unchanging medications, to reduce the burden for both prescriber and patient by writing for a 90 day (maximum allowed) supply and specifying 4 refills?

Our previous default, 3 (three) refills gets you to 360 days, for the patient who renews on time, so adding a 4th refill allows you to fill within 365 days (maximum allowed by federal law).

The countervailing federal law, for Medicare patients, is that annual visits will not be paid by insurance within 365 days, it must be AT LEAST 365 days since last annual visit. So… you can see how patients could routinely run out of their meds a week before their earliest annual appointment.

Hence, the song above: “King of the Code.”

CMIO’s take? The Solution: “90 by 4, don’t bother me no more.” Thanks to Christine Sinsky for the pithy rhyming couplet. This will take a chunk of unnecessary work out of our inbaskets and get us back to more important patient care.

My black book for non-device note taking (Informatics PIGlet series)

According to my smart younger sister, all west-coast startup CEO’s carry black books, wear blazers, ironic T-shirts, and sneakers. I figure I could at least carry a black book. What’s in it? What’s it good for?

Let’s start at the top. Having read Steal Like an Artist (Kleon), I love the idea of separating my desk into a CREATIVE desk (no computer or devices, just glue, pencils, pens, stickies, shapes, yellow pads) and then a PUBLISHING desk when the creating is done (PC, smartphone, printer, etc), I have a stash of kindergarden-grade stuff I like to play with. It helps me think. So, I covered my staid black book with stickies.
So, I’m still a kid. I don’t care if you judge me. 

 

 

Then, I take a set of 3 inch square post-it notes and cut them up the to the size I like so I can use them to index my black book (see the sharpie marks on the right edge, to index the sections), and then use my opening page for major projects so I can glance at what I and my team are working on. In short: too many priorities. 

I know. It is. A struggle.

 

My BHAGs are aspirational. BHAG: Big, Hairy, Audacious Goal. The idea: setting small goals and achieving them doesn’t inspire dramatic action. For that, you need a BHAG. From Great by Choice (Collins). Something I’ll aspire to. One day I will sleep 8 hours every night. I do read regularly and am happy with that. I enjoy mentoring and want to keep getting better. I like seeing the forest for the trees, when I remember to do so. I constantly remind myself to prune down the priorities to ONE THING and use Pomodoro technique to manage my time. And who couldn’t use a dose of mindfulness through the day? 

 

I have a terrible memory for names, so as I meet new people, or continue to struggle with names, I write them here. My cheat sheet. And then I track the talks that I have given and the ones I’m thinking about and planning.

 

And… here’s the mess. The daily meetings, the jotted notes, Anything that I want to highlight gets an accent color. My to do list also gets a checkbox and sometimes a color highlight. My direct reports get a dedicated page or two to improve my continuity of notes. 

 

When you cut up your own stickies, you need a supply on the back page to draw from when you’re away from your creative desk. 

 

And then, if I take my book on trips, I’ll find time to sit and sketch. Ideally I do the sketching on-site, but sometime (like this), I sketch from a photograph, shown on my phone, propped up, by lamplight, just before bed. I find sketching to be relaxing, all-absorbing, focus. I know I’m not good. 

The only point of showing you, is to say, spend an hour, don’t self-judge, and see what art you can churn out. Do it when you can, and you might surprise yourself. I do sometimes. 

 

Here’s the Seattle Public Library, a feat of architecture and engineering and art. And my poor attempt to recreate a corner of it. 

OTHER IDEAS. at times in the past I’ve written THREE GOOD THINGS as a daily reflection. Think of three things you’re grateful for from that day, that your action may have helped. That lasted about a week. Pretty cool. 

I’ve tried a daily sketch. That lasted about a week. 

I’ve tried “One thing I learned today.”

In short, there is no end of interesting things you can scribble in a book. 

My preference is for paper with no lines so I can sketch something anytime. Others like lines, or like a grid. I LOOOOVVEE going to stationary stores to buy pens, new moleskin books, stickers, tape. 

Finally, I try to avoid taking notes on my laptop or phone, as doing so is indistinguishable (by others) as drifting away, not being present, doing some other work when you could be paying attention. Another reason, is that research shows that when others in an audience can see your screen, NOT ONLY is your screen decreasing your comprehension of the lecture/session, it is decreasing the comprehension (increased distraction) for EVERYONE WHO CAN SEE YOUR SCREEN, even if they can’t see it clearly.

I know, electronic note take allows “search” and “indexing”, and also that there are Rocketbooks and other hybrid devices, but I have not tried them as yet. 

Finally, I do love the tactile nature of paper, the expressive personality of handwriting, the ease of drawing lines and sketches to link ideas, and also know that handwritten notes INCREASE COMPREHENSION compared to electronic notes. Go figure. 

CMIO’s take: Make your black book anything you like. And then when you inevitably run out of pages to draw, sticker, jot, doodle in, get a new book and try a different design, a different strategy. My sister tells me that “All start-up CEO’s carry a black book, and consult it. It’s where all their good ideas come from.” What do you do for creativity, note taking, tracking? Do you like it? 

Tips on Mentorship (a conversation)

The PAC mentor program

I recently had the chance to sit down with David Bar-Shain MD, of MetroHealth, who single-handedly started the a mentorship program in the PAC (Physician Advisory Council), hosted at Epic in Verona Wisconsin.

The program has been running for 4 years now and has matched over 70 mentor-mentee pairs, over 170 people involved, supporting young physician and APP informaticists by matching them with mid- and late-career informaticists (and some who serve as both mentee and mentor!).

We recently had a chance at the Epic 2022 User Group Meeting to sit and chat about the fundamentals of mentorship, and what I find interesting and fun about being a mentor.

What did we talk about?

  • The importance of having more than one mentor
  • Mutual curiosity: telling our own journeys
  • Who sets the agenda for our meeting?
  • War stories and are they appropriate?
  • 1-pagers
  • Storytelling
  • 80:20 rule of informatics: socio-political vs technical skill
  • Book club and leadership
  • Learning from outside of healthcare
  • Mentorship is about asking open ended questions
  • 3 psychological principles that apply to therapy as well as mentorship
  • Rowing downstream, not upstream
  • Advocacy, offering connections from your network
  • Peer mentorship
  • Blind spotting
  • Validation and encouragement
  • Lateral thinking
  • The Failure Resume

Here’s the audio-only interview (33 minutes).

CMIO’s take? Let us know what you think! From YOUR experience as a mentor or mentee, what have YOU learned?

Where do you keep the (informatics) pixie dust? (borrowed from NYTimes)

This is hilarious: angsty flowcharts to help guide readers. Must-read article.

Fawzy Taylor, social media and marketing manager of the bookstore: A Room of One’s Own, Madison, WI, via NYtimes “These Memes Make Books More Fun”

Thank you to Fawzy Taylor, whose brainchild this is. Fantastic in so many ways.

Why can’t we build our informatics and our internal education this way? For example, for newbie informaticists, how about my book-recs graphic above, based on the same idea?

CMIO’s take? What do you think of the graphic? of the style? of the content? Guess what? It doesn’t matter, if it gets us talking!

How the Sugars in Spit tame the Body’s Unruly Fungi (WIRED.com) [aka Spit or Sputum?]

https://www.wired.com/story/how-the-sugars-in-spit-tame-the-bodys-unruly-fungi/

Years ago, my pulmonologist spouse threatened to start a new journal called “Spit? or Sputum?”

The idea was rooted in our challenge, when we were medical interns, tasked with obtaining sputum (the thick mucus from deep in the lung that we needed) to spot the predominant organism responsible for a patient’s pneumonia. When done correctly, a patient would bring up a deeply-coughed sputum sample teeming with many copies of one species, that would jump out in technicolor when the correct stain was applied, and voila! We have a diagnosis under the microscope. When the patient gives us spit, however, we would see a veritable smorgasbord of organisms, and a disappointing lack of clarity.

So often, when collecting such sputum samples from patients (“Sir, please cough something up from deep inside”), we ended up with “spit”, the mucus that is generated in the mouth, home to millions of species of organism, and unhelpful in the diagnosis of pneumonia. When we run from the patient’s bedside to the closest microscope, we apply our stains and breathlessly wait to see: was it truly sputum? or just more spit?

Hence the burning question:

Is this SPIT or SPUTUM?

Not that funny? I guess you had to be there. Nevertheless, the title remains stuck in my head.

Reading this article brought that random thought out of the depths.

Fascinating read: researchers identified that Candida Albicans, a common fungus, is often present in our mouths. In this moist, seemingly ideal growth environment, does this organism not cause yeast infections in everyone?

It is a story worthy of Sherlock Holmes. From oral mucus to sugars to glycans to oxygen linking and then …

This is science AND science writing that educates and elevates. Worth a read.

Exercise: your organs are talking about you (nytimes)

How did I miss this the first time around? in a 2018 article, Gretchen Reynolds informs us that our organs are signaling each other with vesicles and communication molecules that change our physiology in response to exercise. This prompts more cooperation and health benefits and explains more of our internal workings.

We think we are one organism, walking and talking and stressing about our daily schedules. Instead, depending where you put your focus, you are: a human being OR a collection of organ systems (nervous system, respiratory system, cardiovascular, gastroenterological, etc) OR a bag of organs (heart, lungs, pancreas, liver, etc) OR a system of transport tubes (arteries, veins, lymphatics, nerves, or the most recently discovered: highways in the space outside of venules in the brain, activated during sleep!) OR a packed freeway of vehicles (red cells, white cells, platelets) OR a ghoulash of chemicals (thyroid hormone, insulin, interferon, cytokines that trigger fever or attract your immune defense, etc) OR a growing number of signaling vesicles (see the article above).

The rabbit hole goes very deep, my friends. And it is glorious.

“It’s like riding an escalator”: Burro racing isn’t likely to go mainstream, but it’s having a moment in Colorado (Colorado Sun)

I love living in Colorado. I’m not likely to do a burro race myself, but I totally enjoy the crazy friends and neighbors who do stuff like this. What are YOU doing this weekend for fun?