Author: CT Lin

CMIO, UCHealth (Colorado); Professor, University of Colorado School of Medicine

Laocoön, The Aeneid and Captain Picard

https://upload.wikimedia.org/wikipedia/commons/b/bd/Laocoon_and_His_Sons.jpg

https://en.wikipedia.org/wiki/Laoco%C3%B6n_and_His_Sons

My high-school aged son is avidly devouring classic literature, and the echoes of those epic struggles from my own education, float back to me. On our winter break one evening, he had left the Norton Anthology of Western Literature out on the coffee table. Soon I was in the midst of battle at Troy, at Carthage, in Rome.

Aeneas of Troy, in the classic by Virgil, faces a long journey with many trials. Even in 20 BC, storytellers mastered Story. Sometimes the smallest moments are the best parts of a story:

  • Laocoön runs out from the city to warn his fellow citizens of Troy, that the large wooden horse left behind by hastily departed Greeks, was a trick: ‘beware of Greeks, even bearing gifts.’ To punish him, the gods send a pair of serpents to devour his sons and then kill him. The image above of Laocoön dying defending his sons is such a moment. The city elders, seeing him killed by the gods, are then convinced that he is wrong, and bring the Trojan Horse inside the gates. Of course, you know the rest: the city of Troy falls that night as hidden Greek solders pour out, open the gates and ransack the city.
  • Aeneas initially resolves to stay and defend his city to the death. His touching moment with his father and their resolve to stay together and flee is a pivotal moment of change for both of them.
  • Aeneas meets Dido, queen of Carthage, in his storm-tossed journey, and falls madly in love. Soon after, the gods send him a message that he and his lineage are to become the founders of Rome. He leaves immediately. Dido kills herself in despair.
  • With supernatural help, Aeneas journeys to the underworld to see the future: that his descendants establish Rome and create the Roman Empire.

These moments, to which I’ve summarized so prosaically, are told in verse and with rich detail and sensory imagery.

Interestingly, the Norton Anthology also included the ancient translation of Gilgamesh, perhaps the oldest recorded epic story. Being a science fiction geek, perhaps I should not have been surprised that my first exposure to this classic, written in antiquity, circa 1700 BC, first reached my ears via Captain Picard, on the all-time most popular episode of Star Trek, The Next Generation TV show called Darmok (no, not the new, apparently amazing show, that is behind the CBS paywall). Careful, don’t read the links unless you have time; you won’t come out for awhile.

CMIO’s take? Great storytelling captivating, and timeless. Smart people lived thousands of years ago. Sometimes Captain Picard teaches you ancient literature.

Take a breath! and try JOMO during our pandemic

from esteemed colleague George Reynolds, former CIO and CMIO

I was chatting with an informatics colleague last week, mentioning that our family had spent some time in Utah recently.

He sent me this photo he had taken in Utah recently. Beautiful, no?

Are you taking care of yourself? It looks like we are in this for the long haul. Colorado is now under a stay-at-home order, and it looks like our infection curve is more like Italy than it is like Taiwan or South Korea: it is still accelerating, and will be awhile before the worst is past.

So, take a break. I tried hard this weekend to step away, watch a movie, hang out with the family, go for a walk, a run, a bike outing, bask in the sun, get some sleep, in between online-work. Maybe JOMO is a good word to think of at times like this.

We wrote on our family white board some daily tasks:

  • Cap your news/social media at 30 minutes a day
  • Exercise: ping pong / walk / run / bike / dance
  • Play or listen to music!
  • 3 Good Things

CMIO’s take? Do you give yourself moments of beauty? of music? of laughter? play a game?

Please do.

Consider asking your family members to do the 3 Good Things exercise (see above) , thinking of things you’re grateful for.

Hand wash. Stay healthy, best you can.

Thanks for the photo, George.

Is this our Midway moment with COVID?

https://miro.medium.com/max/1308/1*OKUbTjoOEUucPxQA3KDOUA.png
From John Lee’s article referring to: (Image: National Archives and Records Administration, 80-G-414423.) https://www.nationalww2museum.org/war/articles/battle-midway

In his lovely medium.com article, colleague John Lee MD writes about the World War II Battle of Midway, how it was a turning point in the war, and how this moment, in our battle with COVID-19, just might be our moment.

I know CMIO’s and physician informaticists around the country and world are scrambling to marshal our forces to meet the enemy:

  • Building predictive models for deterioration of COVID patients
  • Creating alerts to reduce prescribing of azithromycin and hydroxychloroquine to save our existing supplies in case this is a valid therapy
  • Building and deploying Virtual Visits throughout our organization to reduce COVID exposure to our patients, our staff, our providers
  • Teaching our colleagues and our patients how to use these new tools, using VIDYO, Epic MyChart, ECHO, ZOOM, SKYPE, Facetime, whatever tools you’ve got to connect with each other, with our patients. When everyone is working from home, and only some folks have wifi, or a smartphone, or a laptop, or …
  • Rewriting our documentation templates to keep up with federal and state requirements on what we have to say to live in this new world of virtual care
  • Implementing new COVID ICD10 codes to allow us to track COVID positive patients, as well as COVID PUI (patients under investigation while the test result is pending)
  • Figuring out what happens when we put 2 patients on a single ventilator if shortages occur, how we might automatically downlink ventilator settings directly to the chart. One unanticipated consequence is that the second patient gets NO data from the vent while the first patient might get incorrect (double volume?) data!
  • Building new rooms that are located in emergency tents set up outside the hospital for possible dramatic expansion next week (does wifi go that far? will our WOWs-workstations on wheels survive the winter weather? what is the room number for parking spot #4?)
  • Figuring out how to share resources between hospitals and health systems to see which of us is hit hardest and how to work together best we can
  • This is just off the top of my head for discussions this week.

CMIO’s take? Read Dr. Lee’s post. I like how it is challenging and hopeful at the same time. To my esteemed colleagues in informatics, in medicine. Take a breath. Get some rest. Lets GO.

Unified Theory of Design Thinking for Social Systems (thanks to d_school at Stanford)

I recently attended a 6-day course Designing for Social Systems at the Hasso Plattner d_school at Stanford University. We sent at team from our Wellness initiative at the University of Colorado Department of Medicine, cutely named “WellDOM” (more on this in a future post). It was … a mind blower.

What is design thinking and why is it so cool?

  • It is a system of thinking that both expands and focuses creative thought.
  • It encourages curiosity and diving into the ethnography of individuals
  • It also encourages thinking about positive and negative influences at many levels of social systems
  • It actively encourages play, physical manipulation of prototypes and sticky notes to build a joint vision
  • It uses storytelling, rapid cycle development, ‘what if’ and ‘how might we’ statements to spark ideas.
  • It is FUN.

I’ve been thinking and digesting what I learned over the past few months and came up with the graphic above. I’m a visual thinker, and although it is quite cluttered, I think it finally encapsulates the scope of what I now appreciate to be Design Thinking for Social Systems:

  • It is Human-Centered (focused on emotion, story, experience), the inner yellow circle
  • It is Systems-Aware (complex social systems impact your success), the outer blue circle
  • It is Strategy-Focused (keep your end-goals in mind)
  • The inner and outer circles interact, and the strategy lane underlies the whole group of activities.
  • There are perhaps 4 dozen specific activities that allow you dive deeply into every part of this diagram, in your pursuit of a creative, lateral-thinking solution to complex, ambiguous problems.

Don’t wait! Take one of these courses! And start applying it today!

CMIO’s take? Creativity, and NOT Computing Horsepower, is the next frontier.

Social Distancing: This is Not a Snow Day (Medium)

I support this, carefully written by a primary care physician and public health expert. This is a meme worth spreading to combat fear and the virus. Stay safe out there. CTL

I know there is some confusion about what to do next in the midst of this unprecedented time of a pandemic, school closures, and widespread social disruption. As a primary care physician and public…
— Read on medium.com/@ariadnelabs/social-distancing-this-is-not-a-snow-day-ac21d7fa78b4

CoronaVirus: is the Meme more dangerous than the Virus? Yes! and No!

Telehealth Visit (nounproject.com)

https://denver.cbslocal.com/2020/03/09/coronavirus-colorado-consumers-telemedicine/

Okay, everybody, take a breath. We’re in the midst of a storm of Coronavirus news, and it is bombarding us 24-7. As a physician, an informaticist, a parent, and a son of aging parents, I (like many of you) wear lots of hats and have lots of perspectives relating to this pandemic. Boiling it down, here is what I’m aware of, followed by my take:

  • BIOLOGY/HEALTH SYSTEM
  • The Coronavirus – COVID 19 has arrived in the US. Although it is orders of magnitude smaller (fewer infected, ill) than the Influenza virus, there is no vaccine, the duration of asymptomatic (no symptom) incubation is longer, and the infectivity is higher, and so spread is inevitable.
  • It is unclear as yet what the biology of the virus is, as the weather changes, will it gradually dissipate with the warmer months, as others have.
  • Countries like China, Italy and others have large numbers of seriously ill patients, mostly elderly, in cases overwhelming the capability of the health services there.
  • Areas taking severe measures to quarantine, limit exposure, travel, gatherings have had some success in reducing spread.
  • Our health service capability also has a limit, and should a pandemic accelerate here, our ICU / ventilator / hospital capacity could easily be overwhelmed resulting in rationing, having to choose “which patient gets the next ventilator that is available?”
  • It has been, apparently, 100 years since the last major pandemic will major mortality: the Spanish Flu following World War I. Most folks alive have no “gut feel” for what a real pandemic is like.
  • SOCIOPOLITICAL/MEMES
  • A Meme is an IDEA that can spread from human to human even more quickly than actual viruses, especially with the INTERNET. There are VIRUS memes and there are FEAR memes. Lets look at them separately.
  • Hmm, you might even consider THIS BLOG POST A MEME. Consider it a COMMON SENSE MEME (according to me).
  • I’m aware that toilet paper, hand gel, and other items are running out in many stores, as people stockpile. This is a symptom of anxiety/panic.
  • I’m reading about toxic interpersonal interactions as asians are targeted by others as being a source of infection, based on appearance rather than reason.
  • I’m aware that large gatherings are being cancelled, schools and large organizations switching to virtual-meetings to avoid gatherings.
  • Our organization has just put in place a travel ban related to work and the automatic cancellation of all internal gatherings >75 persons, with daily adjustments and announcements.
  • I’m aware of many folks stating “this is ridiculous; I’m going to go on with usual business and ignore these outrageous restrictions.”
  • I’m aware of physician colleagues stating (on the other hand) “This is ridiculous, why are we restricting the testing of any patients for COVID? I’m going to refer EVERYONE for screening because we need to know what the community prevalence is, regardless of symptoms.” At risk: exhausting the testing supply for those at highest risk (symptoms, and recent travel, or exposure to known case).

Whooo. Calm down everyone. Lots of valid viewpoints here.

CMIO’s take:

  • Handwashing, soap and water, as often as you can think of it. Hand-gel is a nice to have, but soap and water please.
  • Avoid touching the face (like saying … don’t think about an elephant. What do you think about?).
  • Consolidate your trips out of the house as possible. Grocery shop for somewhat more, and go out less often. Virtual meetings! Face-time! Skype!
  • Toilet paper shortage? OK, lets try to use less for now. Geez.
  • N95 masks? Save them for the healthcare providers taking care of hospitalized patients. Most plain folk don’t need them. If you desire, ok to get REGULAR masks and then use them to REMIND YOU NOT TO TOUCH YOUR OWN FACE (the major way to transmit is hand to your own face). It does nothing to avoid virus in the air, which is already incredibly unlikely in the community.
  • Go about your business and take prudent common sense measures.
  • I will be going to work at the clinic for our usual work, and screening patients, just like we always do. There are very few cases in Colorado and we are extra vigilant, but still going to work, with no masks UNLESS we encounter a high risk patient with symptoms.
  • We are scaling up our Virtual Visit capability to see patients by online 1:1 meetings over secure connection.
  • Yes, cancelling large gatherings and meetings and moving to virtual when possible is a great idea despite the inconvenience; if we can influence and slow down the pandemic spread/infection curve for our elderly relatives so that we don’t slam and overwhelm the health system, this will save many lives. I’m all for it.
  • Stay safe everyone. Be kind to each other. The FEAR meme can be more dangerous than the VIRUS, but also lets be prudent.

Has the smartphone destroyed a generation? (Atlantic)

https://cdn.theatlantic.com/thumbor/F3H99uN_Z-5hYxUD3v7YOlfniDc=/1920×1280/media/img/2017/07/26/WEL_Twenge_iGen_Web_Lead/original.jpg

https://www.theatlantic.com/magazine/archive/2017/09/has-the-smartphone-destroyed-a-generation/534198/

I’ll just leave this here.

Pharmacogenomics (PGx) at UCHealth, getting serious about Personalized Medicine (published article)

https://www.futuremedicine.com/pb-assets/images/logo-md-1533264422427.png
Thanks to Pharmacogenomics Journal at Future Medicine

https://www.futuremedicine.com/doi/10.2217/pgs-2020-0007

Thanks to Christine Aquilante, lead author and main force of nature behind our early experience with Pharmacogenomics. Pharmacogenomics is the specifc branch of Genomics and Personalized Medicine that deals purely with “drug-gene pairs” or how a patients genetic variants might affect their ability to process and metabolize medication. The upshot is: some patients don’t respond well to some medications. There are now several dozen drug-gene pairs well described in the literature, where patients won’t respond well to certain medications because of their genomic variant. However up until now, it has been difficult to get any knowledge of such variants in front of the patient and prescriber at the most important time: when deciding on a new prescription.

UCHealth has a Biobank where we have obtained research lab samples from over 100,000 patients (drawing an extra lab tube in the course of routine clinical care) and have been testing samples for pharmacogenomic markers. In a few cases, we have found clinically relevant genetic variants that we are beginning to deliver back into the Electronic Health Record in the form of test results for clinician, in the form of test results and notification to the patient in the patient portal, and finally and most importantly, to the prescriber of the affected drug AT THE TIME OF PRESCRIBING for any affected patient.

This is groundbreaking, and hard work on so many levels:

  • Have to educate providers about pharmacogenomics: something that most did not learn in school
  • Have to educate patients on complexities of homozygous, heterozygous, population risks and multiple gene variants, balancing transparency with unintended alarm
  • Have to figure out when/how to alert prescribers at just the right time, for exactly the right population so that we don’t overstep what the science tells us is true in the research. In other words, don’t alert ALL patients with the genetic risk and a particular prescription if 99% of them will NOT ultimately have a problem with that prescription.
  • Lots of other things to think through (we just spent an hour just starting the conversation on our next drug-gene pairing)

CMIO’s take? We are happy to be among the few organizations setting up, and scaling up our efforts on Biobanking: conducting research AND benefiting patients in clinical care with PGx. Here we are expanding the boundaries of medical knowledge, and turning around to translate this into better decision making for our providers and patients.

The EHR fights Hepatitis A outbreak!

From UChealth.org

https://www-uchealth-org.cdn.ampproject.org/c/s/www.uchealth.org/today/hepatitis-a-outbreak-colorado/?amp

Always excited to see awesome work from smart, altruistic colleagues. Our own Kelly Bookman, Senior Medical Director, Emergency Department and physician informaticist, helped develop and deploy a Clinical Decision Support alert in our Electronic Health Record, in conjunction with Michelle Barron, infectious disease specialist and Infection Control director, among other analysts and experts.

With a major outbreak across the country, including the regions we serve at UCHealth, the team built an alert for Emergency department docs, scouring patient charts for those who are at increased risk for Hep A, and reminding docs to prescribe the vaccine during the course of their ER visit, regardless of original reason for the visit. This resulted in hundreds of additional vaccinations to protect our most vulnerable patients.

When patients can’t afford it, UCHealth covers the cost.

Finally, our team shared our design and code with other hospital systems in our region, to protect more patients.

CMIO’s take? THIS is what the EHR does well. I’m grateful to awesome colleagues, and hopeful about our future.

Bowling Alone or Kicking in Groups? Wellness concerns…

https://upload.wikimedia.org/wikipedia/en/thumb/f/f5/Bowling_Alone.jpg/220px-Bowling_Alone.jpg

I’m part of WellDOM, the Wellness initiative within the Department of Medicine at University of Colorado. As such, I continue to support the idea of Sprints, the way we boost physician and team efficiency and effectiveness using the Electronic Health Record. However, we know that a large part of physician burnout and wellness have to do with other components: a Culture of Wellness and Personal Resilience, in addition to Practice Efficiency.

In thinking more about these broader components, I’m reminded of the work of Robert Putnam’ Bowling Alone, a towering work, documenting the decline of civic virtue and engagement in this country, illustrated most profoundly by the fact that membership in bowling leagues has declined 40% from 1980 to 1993, while individual bowlers rose by 10%. There has been a dramatic drop in face-to-face social gatherings outside of work in the past few decades, and the thought is that this decline in the social fabric has led to isolation, loneliness, and a general decline in civility and personal resilience. See the recent Atlantic article “Kicking in Groups” on this, also.

We’re looking for objective measures that might allow us to survey for and detect burnout and resilience, that might get past ‘soft’ measures like “do you feel burned out” and perhaps measure “Do you have social groups that you meet with regularly at work” or “Do you have social groups that you meet with regularly outside of work”, and also “Do you meet regularly with a mentor or mentee?” We believe that measuring such behaviors MIGHT be a more objective way to determine who is more protected, and who is vulnerable, to burnout.

CMIO’s take? Physician/provider burnout is a real thing; difficult to address; and may be embedded in a larger change in the social fabric. Are you having success thinking about and intervening in this fraught area? Let me know.