John Green channels teenage angst like no one, and he parlays them, unaccountably, into riveting novels of pathos and the teen journey. He broke my heart with The Fault in Our Stars, and he did it agai with Turtles. The title of course comes from the story that some old woman was arguing in favor of the Flat Earth theory with a modern scientist who was of course discussing that the Earth is a sphere. The woman then patiently explains, when the scientist asks, that the Flat Earth is, of course, sitting on the back of an enormous turtle. Ah ha! thinks the scientist, who asks, “Well, what is the turtle sitting on, then?” And the immortal response: “Well, it’s turtles ALL THE WAY DOWN.” Duh.
Green parlays that saying into the mental health cycle of the protagonist, whose Obsessive Compulsive Disorder (OCD) pervades the narrative and prevents our heroine from achieving so many great things. Throw in a murder mystery, and you THERE, you’ve lost another full day of your vacation marinating in someone’s fever dreams.
CMIO’s take? I always feel rewarded, when I come out the other side of a novel, feeling like I just lived someone else’s life for a day or so, my adrenal glands all squeezed out, my emotions having been through the wringer, and somehow, my own head a bit clearer for it, and my own problems just a little bit less pressing.
Congratulations to Amber Sieja, Katie Markley, Jon Pell, Christine Gonzalez, Brian Redig, Patrick Kneeland, co-authors on our published article in Mayo Clinic Proceedings this week. I’ve spoken of some of the details on this blog, so I’ll let the paper speak for itself. Nice to be recognized! Coming soon: a video by Dr. Sieja explaining some of the highlights of the paper.
What would you do with the following research requests?
The CEO of the health system would like for all patients using the EHR patient portal to be asked to sign a consent form to participate in our system-wide strategic BioBank. In this strategic project, we aim to capture an “extra tube of blood” when a patient is already getting blood drawn for a lab test for clinical care. Then we would apply genetic analysis to large populations of patients to see if we can discover gene-disease linkages that may be useful to patients. May we set up this consent form and present it to patients?
A researcher would like to survey ALL patients in the health system to ask them their opinions about marijuana use, both recreational and medical. It would be about 20 questions. The researcher does NOT have an existing relationship with most patients he/she wishes to survey.
A physician specialist would like to ask all the patients in his/her own clinic about their symptoms of arthritis, to understand how he/she can improve their own clinic’s care process and maybe publish the improvements when completed.
Such are the challenges of our MHC (My Health Connection) patient portal Clinical Leadership Advisory Group. Our goal is to protect our patients, who have signed up for MHC primarily as a communication tool between patient and clinic/physician, and not allow unsolicited research requests (potentially from hundreds of researchers) or “quality improvement” surveys or projects from “email spamming” their patient portal message inbox. AND YET, we believe that a large fraction of our patients might welcome the chance to participate in a research trial and increase our medical knowledge. How to do this? We struggled and discussed for hours, and came up with the following principles, that we are gradually implementing:
White Paper: Research
queries using My Health Connection (MHC)
Executive Summary: How shall we decide on permitting
researchers to use MHC for recruiting and contacting patients? Until now,
research recruitment has been off-limits. We propose a framework for
permissible MHC use for research recruitment and a path forward.
My Health Connection is the UCHealth rebranded MyChart patient online portal to the EHR. Patients sign up for MHC with the express intent of using it to communicate with their healthcare team directly. We have had repeated complaints from patients when they hear from unexpected sources (Administrators sending messages regarding “flu shots” or other health maintenance, as required by Meaningful Use federal regulations). We have thus been very careful about protecting patient’s presumed interest in using MHC as a purely clinical communication tool.
other hand, Researchers at UCHealth have great interest in using MHC for
research recruitment. We have not yet (Dec 2018) implemented the Research
Module within Epic for recruitment and management of potential and patients currently
engaged in research trials.
Our IRB (institutional review board to protect patient rights) has been an excellent partner in restricting use of EHR for research recruitment, balancing patient needs, clinic needs, researcher needs.
date, the only exception to research use within MHC has been: the UCHealth
BioBank for recruitment, processing and notification of patient’s genomic data
such as pharmacogenomics and other screenings, approved by Strategic Executive
Group (SEG) at UCHealth.
Additionally, the MHC clinical leadership group have previously declined a research request to broadcast a marijuana survey to all 400,000 MHC patients.
clinical leadership HAS allowed broadcasts through MHC for drug or device
recalls when there are patient safety concerns.
It has also allowed general health broadcasts as required to meet
federal Meaningful Use regulations for patient portal implementation and use
Assessment/Recommendations for MHC research framework
Large UCHealth strategic initiatives (including research) using MHC are approved by System Executives. IRB approval is also necessary. MHC clinical group also informed.
Research requests by a Principal Investigator (PI) recruiting patients within his/her own clinical practice (where there already exists a treatment relationship between that investigator and/or his/her colleagues and their cohort of patients), should meet ALL the following criteria:
IRB authorizes this project to use MHC for recruitment and communication
Recruited patients have all been seen in the clinic(s) where the principal investigator and co-investigators work, so that there is an EXISTING physician-patient relationship
The Principal Investigator (PI) or authorized study team members, send and receive MHC messages individually. This is not the responsibility of the MHC IT team.
Online MHC recruitment should mirror any paper- or phone-based IRB-approved process
COUNTER-EXAMPLE: System-wide targeted patients across many clinics WILL NOT BE APPROVED AT THIS TIME. An existing physician-patient relationship must already exist between recruited patient and the investigator(s)
There will be ongoing assessment of any complaint received
The MHC team will investigate a method for PI’s to update a patient’s chart in case of DECLINING FURTHER RESEARCH RECRUITMENT.
If patient declines for an individual study it will be up to the PI to track that
If patient declines for ANY research outreach via MHC, we anticipate creating an FYI flag called “NO MHC RESEARCH RECRUITMENT” that we can query later to prevent outreach errors
MHC team will and will not:
WILL: require investigators to ask permission of Clinical Advisory Committee prior to start
WILL: permit 1:1 MHC recruitment messaging from PI to patient when project approved
WILL NOT construct research questionnaires for online transmittal
WILL NOT have patients sign online consents via MHC
WILL NOT help track patients in study via reports or alerts
Approvals thus needed:
MHC Clinical Advisory Committee
UCHealth Marketing for allowable messages in MHC
UCHealth Patient Literacy Team for 8th grade wording or clearer
PI would present MHC component of research plan to MHC Clinical Advisory
PI would present 6-monthly updates during study to MHC Clinical Advisory
Patient recruitment numerator/denominator
Assurances about only recruiting from permitted clinics/units
Refusal rates and other concerns from patients, clinicians, staff
Anticipated close of research or translation into standard practice
NOT PERMITTED: Patient recruitment outside of an investigator’s clinic (eg: show me all diabetes patients; maybe 40,000 patients or please facilitate the outreach to all DM patients). Not allowed at present
FUTURE opportunities: Epic does have a Research Module that we have not yet implemented. It may be possible to integrate research recruitment that follows all IRB necessary protocols to protect patient privacy. UCHealth will partner with UCD School of Medicine leadership to consider implementing this module in the future. As our tools evolve and with patient feedback, we will discuss the tools at MHC clinical group to review and update this guideline.
CMIO’s take: Have YOU implemented a research module within your EHR? Does it solve this problem? Please let me know in the comments!
Here we are (again)! How can I review this? An incredible landmark of a book, it has sat on my bookshelf for more than a decade, and then on my ‘actively reading coffee table’ for another few years. Despite its mention in almost every important other book I have read, and my repeated abortive attempts to push through, I found this book alternatively revelatory and then densely incomprehensible. I frequently dove in, underlined many passages, got stuck, and put this book down for prolonged periods.
Finally I convinced my book club friends to tackle this, set a discussion date (Jan 2019), and that was my trick to completing the massive read.
What I’ll take away is the idea of linking happiness NOT to acquisition and idle pleasure, but to difficult challenges that are just outside my comfort zone and skill set, where with maximal concentration, I can succeed.
Fortunately for me, I have had many times in my life when I have achieved such Flow, and now I have a framework for thinking about it and setting up my day, my home, my work life to achieve this as often as possible for myself and for colleagues.
Incidentally, I have recently completed the massive tome ‘Alexander Hamilton‘ by Chernow, another incredible read (I was drawn in by, of course the immensely popular musical), and I am led to reflect that Hamilton must, in his voluminous lifetime of groundbreaking writings, must have set up conditions to achieve Flow for quite extensive parts of his life, despite tremendous tragedy, political rancor and his final demise at the business end of a duelist’s pistol. For example, he would read all day, head to bed, then wake up the next morning and just write, with no interruptions, for hours. As a result, his subconscious worked on problems overnight. Often his manuscripts had NO corrections, as he would scribble furiously a final draft, fully formed. This was how he tackled many of the Federalist papers, papers that are studies in minute detail by constitutional scholars to this day.
My favorite Flow pointers:
Attention is how you create your experience and consciousness, and psychic entropy is the opposite: the chaos that detracts from focus and intentional effort.
Flow requires: clear goals and feedback; concentration on the task; a sense of control; loss of self consciousness; transformation of time.
Flow occurs when the top of your skills barely match the presented challenge. Otherwise you get boredom or anxiety.
Source of dissatisfaction at work: lack of variety and challenge; conflicts with other people/boss; too much pressure, too little time. All CAN BE under our control.
Autotelic self: easily translates external threats into enjoyable challenges and maintains inner harmony, transforming potential entropy into creating flow.
CMIO’s take? I defer to these great words by Chuang Tzu: ‘When I come to a complicated place, I size up the difficulties, tell myself to watch out and be careful, keep my eyes on what I’m doing, work very slowly, and move my knife with the greatest of subtlety, until–flop! the whole thing comes apart like a clod of earth crumbling to the ground. I stand there holding the knife and look all around me, completely satisfied and reluctant to move on, and then I wipe off the knife and put it away.”
How do you give thanks and acknowledge your teams each year? I know WE don’t do it nearly enough. Here’s a partial list of our PIG achievements from 2017-18, now that we’re into 2019 (I know, I know, I can’t blog fast enough to keep up with smart amazing colleagues, a great problem to have).
Physician Informatics Group Annual Executive Summary Submitted by CT Lin MD, August 20, 2018
Vision statement: We improve physician/APP and team wellness and effectiveness by building extraordinary relationships and innovative tools.
Go Lives: MANY Clinics, 2 Hospitals
Sprint: 17 Sprints in 2 years, 496 providers, 315 staff
PI’s conduct specialty-specific and general projects to improve provider and staff efficiency and effectiveness in patient care
PI’s create and educate via newsletters, tip sheets, videos, meetings
PI’s help review, test, educate and implement Epic upgrades
PI’s develop and lead service linegovernance for UCHealth
PI’s chair or co-chair or participate in at least 2 dozen UCHealth governance committees to guide both Epic EHR development as well as UCHealth provider leadership overall.
Conversion of OIC (infusion) orders from “referrals” to “Therapy Plans” for safety, efficiency
Creation of 5 new UCHealth-wide service lines to facilitate Epic EHR build, reduce unnecessary variation
Creation of an APP Epic Concierge meeting to improve effectiveness and training
Dragon Speech expansion and elimination of Partial Dictation
Creation of a PI onboarding document, training, getting-up-to-speed
Creation of an Opioid management steer and Epic customizations to support initiative
Implementation and expansion of innovation partner tools within Epic: AgileMD, RxREVU, APPRISS
Implementation of Radiology Indications software, phase I
Implementation of patient access to images via My Health Connection
Use of EHR, scheduling and billing data to improve clinic operation efficiency, effectiveness
Creation of an Universal APSO note to improve both standardization AND customization
Creation of an MA-smartform to dramatically improve consistency of data capture in Practice Transform
Connection of Epic data to ORIEN (oncology research network) with dramatic efficiencies
Implementation of iECG, physician informatics/organizational change support to change EKG capture platforms across all hospitals/clinics
EPCS: E-prescribe Controlled Substances deployment of 2-factor authentication
Support of Palliative Care and Spine Surgery smartforms, note templates, registry reporting tools
Standardization of UCHealth Order Sets, physician leadership, phase I
Support of AMC Neurology Practice Transformation, note templates, flowsheets
Book Club: Read books this year on Organizational Change, Communication, Connection: Design of Everyday Things, Good to Great, Great by Choice, Crucial Conversations, Leading Change, Nudge
Creation of Small PIG program to mentor newer PI’s
Counseling and coaching of PI(s) to further improve internal and external communication and leadership skills in a rapidly growing organization
More emphasis on analytics, use of information in our PI role, beyond “go live” and “optimization”
Plans for Coming Year
Implementation of approved Sprint Team 2, improvements on process for Team 1
Implementation of expanded rollout of Practice Transformation (changing the MA:MD ratio to 2:1), and supporting EHR tools
Support of ongoing hospital go lives
Ongoing redesign of PI support of clinic go-lives and onboarding individual providers
Incorporate analytics into Sprint
Dragon speech QI/research project: Dragon in the exam room
Radiology imaging shown to patients QI/research project
Expansion of Innovation projects
Expansion of MHC questionnaires, possibly PROMIS questionnaires
Acceleration of the Order Set Synchronization project
Further reducing the EHR burden, improving patient care and human connection, in everything we do
CMIO’s take? What’s YOUR take? What do you plan for the coming year?
This article speaks for itself. Having visited the Verona, Wisconsin campus of Epic’s Intergalactic Headquarters, with its dozens of campus buildings, its massive Voyager Training Hall, and its equally massive 11,000+ seat auditorium (the largest in the state), it is an impressive site. Equally impressive is the young talent that this company recruits out of college, how quickly they learn the necessary lingo and communication skills of health professionals, and dive into the constantly evolving code-base of the Epic EHR. Privately held, this company is NOT at the whim of the shareholder, which I think is a key success factor in its market dominance.
Yes, there are tons of criticisms for this and every EHR. Yes, there is a national outcry of physician burnout, directed at EHR’s in general.
Instead, you’ll read here, that the guiding vision of the reclusive CEO and founder, Judy Faulkner, holds true today; have fun, do good, recruit smart talent, improve patient care.
CMIO’s take? Having been part of the Epic community since 2010, I’ve seen lots of innovations and improvements and look forward to many more.
I constantly enjoy the creativity of my colleagues. In this case, Steve Hess, our CIO at UCHealth, made this statement during a discussion about our fax-server software linked to our EHR. As our organization has grown, we have added hundreds of clinics, and now we’re approaching a dozen hospitals in our network, all on a single instance of an EHR.
Consequently, our communication and IT architecture is primarily based on within-EHR communications, the so-called Inbasket. However, we often communicate with healthcare entities (insurance companies, out-of-network clinics and hospitals, skilled nursing and rehab facilities, etc). To force others to use our EHR’s inbasket is unrealistic.
So, even in this 21st century, the lowest common denominator for communication between healthcare entities is … FAX. Our organization faxes millions (yes, MILLIONS) of virtual sheets of paper each month, a veritable blizzard of paper. Furthermore, our faxing volume now is bumping against our licensing limit, and Steve, very rightly, is pushing back against any increase in our faxing capability, and this is where he notes:
“The E in EHR does NOT stand for Fax.”
Which is hilarious. And sad at the same time. Where is our national interoperability? Haven’t we been working toward electronic seamless communication for over a decade as we furiously install EHR’s in every clinic, every ER, every hospital? Yes, and nothing is ever that easy.
So, thinking through our fax problem, several things became clear:
Faxing STILL is the lowest common denominator. If our clinic notes and other messages to other clinicians MUST go through, fax is still the best most reliable method. Who wants to go back to stamps and envelopes? (let’s not talk about mailing test results to patients, as we still do that for some patients: don’t get me started)
For all clinics and hospitals willing to use our web-based secure portal, what we call “Provider Connection”, we can set our communication strategy to send e-messages through that portal. Independent clinics and hospitals who are closely affiliated with use, do use this, and this works well.
For all clinics and hospitals (independent of us) who use their own licensed version of the Epic EHR, we are gradually learning to turn on between-organization messaging, and these e-messages will gradually replace fax. This is getting going.
For all clinics and hospitals on our instance of our EHR, we should be sending ALL notes and messages electronically through EHR e-messaging to our respective inbaskets.
For all clinics that have connected to CORHIO (the Colorado Regional Health Information Organization and other Health Information Exchanges cannot get up to speed fast enough for us) we should be able to turn off our point-to-point communications like Fax because we deliver all notes and results from our EHR to CORHIO’s exchange, which then can deliver results to ANY EHR in the state.
There are still hundreds of organizations out there who use a non-Epic EHR with no capacity for electronic interconnection to CORHIO, or who still use NO EHR. Then, these clinics only have ONE method to send or receive all these incoming messages: FAX. Sad.
Here is where we run into some surprises. Turns out, not ALL of our clinicians in our OWN ORGANIZATION have agreed to use e-messaging and still rely on Fax. What? Old habits die hard. It turns out, while our attention was elsewhere, some of our clinicians and clinic managers were able to convince someone in the IT organization to alter the setting for delivery of test results and referral letters from e-messages BACK TO FAX. On the one hand, I can see a reason why. Some clinicians are used to having the sound of the fax and the presence of paper in the fax-received tray as their TO DO task list, and never “got into email” (really?!). Some clinicians work at multiple healthcare organizations and do not want to check the inbasket of their general email, and the inbasket of the EHR for hospital 1, and the inbasket of the EHR for hospital 2, etc. I could see this being a huge hassle, where ONE fax machine could be the single TO DO list. SO, THIS PROMPTS SOME ACTIONS on our part:
All employed clinicians at UCHealth MUST use e-messaging. We will embark on a clean-up of our internal process. Why install an EHR and then let people continue to fax within our organization? It is like buying a Porsche and then cutting out the floorboards and pushing with our feet like Fred Flintstone.
Re-examine every affiliate clinic and hospital and figure out how to switch as many communications from fax to e-messaging with Provider Connection. In some cases, like the clinician with multiple hospitals, such a switch might dramatically worsen their clinical work, and we would make exceptions there.
Push on CORHIO and other HIE’s to improve between-organization messaging and link our EHR to their systems to make such messaging seamless.
Accelerate our investigation of Epic EHR interconnect messaging so that we can send/receive messages from other organizations that also use Epic.
Consider a drop-dead date (like “killer app”, this is a terrible term in healthcare) when we might say: “Fax is dead. In order to receive clinical messages from us, you must use Epic EHR or Provider Connection.” I think we’re not quite there yet.
CMIO’s take? Quotable quips are easy to say, and make us feel ridiculous sometimes. But then you have to take a hard look at yourself, and your organization, and the state of healthcare technology, and decide what to do. Do you have a similar story? Let me know.