I have wanted to read this book for decades. Now, with my emphasis on reading consistently (both via Audible.com and in print, but alas only rarely on my Kindle app or Kindle device that my son discarded), I’m finally making progress on that enormous mountain of backlogged titles.
I love coming home, seeing the stack of tantalizing covers on the coffee table (apologies to my spouse, who is forever trying to keep the house tidy), and picking one up to spend hours lost in the worlds within.
Yes, I loved the recent Blade Runner 2049, yes, I watched the online shorts that led up to it. Yes, I re-watched the original, including the directors cut (and the hilarious back-story to the poorly-performed Harrison Ford voice over in the actual released movie: look it up yourself). And yet.
(side note: Amazon Originals now has a one season series: Electric Dreams, that is a fantastic collection of video interpretations of Dick’s short stories. Don’t miss ‘Autofac.’)
The book blows all the movies away. Philip K. Dick was not only decades ahead of his time, even now, his writing and thinking are too complex, too interweaved, too subtle for the movie screen. Electric sheep, artificial owls, animals figure prominently in the book, and are only briefly referenced in the movie. And the title finally makes sense. I really enjoyed this.
I’ve been fascinated recently (as you may know, reader) with meals, modified fasting, weight management, meditation. I guess I’m turning into one of those hippie, birkenstock-wearing, health-food-pushing, “hey, just use lemon juice for that” doctors from from a too-cool-for-school non-metropolitan back-to-earth backwaters.
Not really.
I’m always interested in non-traditional ideas that maybe mainstream medicine has not yet embraced. Chrono-biology for instance (perhaps a future blog post). In short, I find that the ways of our healthcare system are perhaps too ego-centric and too shortsighted to encompass the breadth of human experience, and that maybe, just maybe, folks in other cultures have figured out smart, healthful things as well.
In this case, Michael Pollan, who re-popularized the old adage, appears to be right. Not only his original: “Eat food, not too much, mostly plants” but also “Eat breakfast like a king, lunch like a prince, dinner like a pauper.”
This NYTimes article refers to a book called The Circadian Code by Satchin Panda, a professor at the Salk Institute. One of the main ideas is to consider eating all your meals within a 6 hour window each day, guaranteeing your body an 18 hour fast, which apparently is a healthy and a cycle that your tissues and organs and body expect. It results in less weight gain, easier weight loss, and lots of other downstream benefits.
CMIO’s take? Look outside your usual sources of inspiration for ideas on living healthier.
A little over a year ago, CT Lin, CMIO at UCHealth asked “How might we reduce physician burnout associated with the use of the electronic health record?” as part of an initiative he coined EHR2.0. Through collaboration with Physician Informatics, Epic Certified Analysts, and Trainers, the optimization sprint pilot was quickly out of the starting blocks. Would the experience be the 100 meter sprint or the 110 meter hurdles?
The team accelerated quickly generating ideas. They sent out surveys, evaluated provider efficiency profiles, created checklists, investigated prior optimization requests, and observed providers interacting with the system. The team included Ambulatory Analysts, Trainers, a Scrum Master, a Nurse Informaticist, and a Physician Informaticist. They had two weeks to accomplish as much as possible through interaction in the provider’s clinic establishing a medium for collaboration in real time.
The hurdles could be anticipated; “everything is critical!”, governance, change control, communication, capacity constraints, time, trust, and differing opinions. Next, too much work in progress could create a residue effect as the analysts bounce between ideas instead of focusing on immediate next steps towards completion. Finally, how do we identify and address assumptions, inferences, and facts?
The team leveraged agile methodologies in running the sprint to help address some of these obstacles. They used a Kanban board (Backlog, To Do, Doing, Done) as a way to visualize their work and agree to the work in progress, a Burn Up chart to show their accomplishments, and a Daily Scrum (Huddle) to discuss challenges, priorities, next steps, and context for the upcoming work.
The key to the sprint became the stakeholder participation in prioritizing what was important to them and assisting with trade-offs. Instead of ideas having a static prioritization of critical, they float relative to other ideas. There was also simultaneous exploration of the problem and solution domains as the immersion provided immediate feedback loops. The focus quickly shifted from linear/more is better to high value deliverables.
The team was thinking through doing expressed best by the Chinese proverb,
“What I hear, I forget; What I see, I remember;
What I do, I understand.”
–Confucius
Early results across the finish line demonstrate high impact to Epic flow sheets, SmartLinks, note templates, In Basket efficiency, Synopsis, and Med Rec along with positive net promotor scores.
The experience was neither a 100 meter sprint nor a 110 meter hurdle, it was a Tough Mudder!
The fastest way to the finish line was to lower hurdles through collaboration and provide performance enhancing features that minimized mundane clerical activities, streamlined charting time, and stimulated the cognitive clinical art of practicing medicine.
Brian Redig, MBA, SCPM
Lean Six Sigma Black Belt
Board Certified Nuclear Pharmacist
This is great, and timely, and something I want all my readers, my colleagues, my family to read. I need to read this again, too. This NYTimes article is about vulnerability, and the human condition, and ME not being embarrassed when (yet another) presentation or project, or idea that I have goes down the tubes.
It is particularly relevant now, as our team prepares to give a talk at the upcoming annual Epic UGM (User Group Meeting) for our Electronic Health Record. We’re going to be speaking on being “Terrified to Terrific” and our growth towards Physician Builders — physicians who are trained to develop custom content and templates for use in our EHR. It is a way for practicing docs to actually do significant customization to improve efficiency, effectiveness and teamwork in the care of patients. The RISK is: will we give a BORING presentation about establishing our team of physician builders, and then list all the BORING accomplishments over the past few years? Big deal. Instead, how do we share our vulnerabilities, our failures; the same fears that our audience will likely have about physician builders?
In short, our journey began about 5 years ago, when our IT (information technology) leaders were very hesitant to allow “those renegade doctors” into an IT shop and “hand them the keys to an expensive car” and “let them build stuff and potentially ruin everything.”
One great moment happened when our IT manager of ambulatory applications in our EHR realized that our physician builders were actually taking ownership of the EHR improvements during our “war room” day-long conference and helping to test each component of the software and ensure that things worked well. She said to me: “Who DOES that?!” meaning that she did NOT expect busy physicians to take the time and be part of the testing team and be full partners in improving the EHR software code.
CMIO’s take? It is “aha!” moments like this that make the journey worth it. We make assumptions, sometimes we’re wrong. It is vulnerable moments of letting others see when we’re wrong, when we fail, that we see each other as human, and we are more likely to help each other out. This sort of vulnerability builds our team. We are always stronger as a team.
Here we are at #ugm2018 Epic’s annual User Group Meeting. We’re at our first Directors’ Advisory Council session with over 600 attendees, and we discussed our governance approach to Physician Builders and how we overcame internal resistance to the idea that Physicians could do a good job creating new designs, templates, smart tools, and other content (and some actual programming) in the Electronic Health Record (they can!). In fact, our 19 Physicians who are now certified builders have made substantial improvements to our EHR environment on behalf of numerous medical and surgical specialties, as well as our physician users in general.
The point being, that although IT analysts are terrific for creating most of the content of the EHR, having physician builders with deep knowledge of the EHR technology leads to some interesting capabilities:
Physician informaticists, with clinical knowledge, strong communication skills, and now technical know-how, can help other physicians reduce the EHR burden by matching tools to the clinical scenario, and reduce cognitive burden. For example, it is difficult to order the right cardiac arrhythmia monitoring tool (Holter? Event Monitor? Zio? Some other device?). Instead of building what a cardiologist physician was requesting, our physician builder thought about it, and suggested some the creation of a cascading order panel that gently guides the ordering physician to the right order WITHOUT building an exhaustive long checklist with difficult-to-follow paragraphs of instructions. Having a foot in both worlds is beneficial in this case.
It is delicate and important do develop EXCELLENT relationships, CLEAR communication and strong guidelines so that the IT analyst team and the physician builders know what to expect from each other. When done poorly, turf battles erupt: “don’t touch those tools that I built!” But, done well, we become a synergistic team: “wow, thanks for taking on those Express Lanes; we would not have achieved our Honor Roll status (and helped all those urgent care centers) without your help.”
Really proud of our high functioning team.
And to ensure our audience got the point, we sang them our song. Lyrics below, YouTube link above.
We’re Physician Builders (Champions, Queen)
I’m a frustrated doc. Am Em
Passed my builder test
I wanna build
But she says: ‘You jest!’
And bad mistakes. C F
I’ve made a few
I’ve had my share of bad code kicked in my face C G Am
But I’ve come through! D7 G A
We’re physician builders, my friend D F#m Bm G A
And we’ll keep on buildin’ ’til the end D F#m G A
We’re physician builders, we are the builders Em A7 Gm A7
Those are happy users, cause we are the builders D C F G7
Of an Epic world. G7 D
I’ve set up smartlists. Am Em
And CER rules
You sent us Foundation and everything that GOES w it
I love those smart tools.
And maybe with time C F
Create a team goal,
We’ll share build in Text and Hyperspace
And make Honor Roll! C G Am D7 G A
We’re physician builders, my friend. D F#m Bm G A
And we’ll keep on buildin’ ’til the end. D F#m G A
We’re physician builders, we are the builders Em A7 Gm A7
Those are happy users, cause we are the builders
Of an Epic world. D C Bb G7 D
CMIO’s take? What are YOU doing to ensure that you don’t take yourself too seriously? Are you here at Epic #ugm2018? Let me know!
I just spent some time on the phone with an informatics colleague going through a particularly tough time with an EHR replacement and upgrade. Some bad things had happened at the organization: a major visionary physician leader had quit, a department chair had assumed control and was tightening the control on “physician productivity”. Furthermore, a major EHR upgrade had gone wrong, with a major multi-day outage and some glaring gaps in “down-time procedures.” Morale was very low.
This physician informaticist questioned “Am I still up for confronting all the challenges of this job?” This person pointed out that “decisions are made and I’m left holding the bag.” “Physicians are angry and I have no good news to tell them and no resources to do anything about it.”
AND YET.
I asked “Is it time for you to quit?” In response:
“Actually, even if they asked me to step down from this informatics position, I LOVE getting in there and solving complicated problems so much I would probably still do this work. Even for free.”
I don’t know of any more eloquent statement that explains the core of a physician informaticist more than this.
Friedman, in the NYtimes article above, talks about the triple acceleration: climate change, globalization, technology acceleration, that are upending our world, rewriting the rules, and causing us to re-evaluate everything we thought we knew.
Informatics work in healthcare is very similar. The rules change all the time, leaders change, visions change. Informaticists are the nexus between IT and clinicians, and are often blamed for anything that goes wrong. True story: when the WannaCry virus struck and took out the server farms at our Transcription vendor last year (for SEVERAL WEEKS, our physicians and surgeon could not dictate their notes), the rumor spread that
“You know, I heard that CT Lin shut that down because he just wants us to TYPE in his #*$&#$’ing EHR.”
Would that I were so powerful. We often deal with problems not of our own making, and with no resources. “What can I do?” “I don’t have anything new to say.” Here’s what I said:
Being a physician informaticist (PI) is often a thankless job. The quiet work we do: creating collaboration, understanding both IT and healthcare deeply, we translate and often avert disasters (avoiding bad design in templates, order sets, automated tools) that only we can see. When it works, the response is “Of course it was going to work. It is so simple.” When it doesn’t work, everyone knows it was you, even if it wasn’t.
Your value to the leadership of the organization can be incalculable. When the PI stands up and helps calm the masses, when the PI can send email broadcasts or go to meetings and explain WHAT happened, and more importantly WHY and what is going to be done about it, he/she is usually more clear than the technologists and can speak the medical language of clinicians and patients. Over time, his/her value grows from being clear, steadfast, and a calming influence. Maybe the executives start including him/her in higher level decisions because they remember that value.
Your value to the front line physicians and nurses is also incalculable. One time, a physician presumed that “Oh, the EHR project is going terribly… see how CT was walking with his head down and with that frown. Bad news.” On the other hand, being a clear explainer (even if you can’t fix it) and being transparent about what is happening now and why, allows the PI to be a beacon in a storm, and the go-to person for clarity. PI’s often become a valued representative for physician interests.
As we talked this week, I had flashbacks to my years on the front line doing this work. Over time, these memories are less like PTSD attacks and more like valued battle scars that one shows off proudly.
CMIO’s take? We don’t often talk about our histories in informatics. Our nascent field has grown from battle scars just like these, and we are all better for it. Although I did not feel like this at the time, I am grateful for everything I’ve learned and now apply for the benefit of our colleagues, our field, and importantly for my own sanity.
Tough thing, about being in on fads. Hate and love it at the same time. Our latest fad, is the idea of Physician, or Clinician, or Professional Burnout, and that maybe 60% of all US physicians are burned out. Terrible, right? Yes.
The great thing, though, is the global mental effort dedicated to thinking about this, writing about this, working on this. One of the most clever things I’ve seen in awhile on this topic is the opposite of FOMO, called JOMO: the Joy of Missing Out.
East Tennessee State University: Professor Hannah B Harvey
This is the first Great course that I have listened to. Yes, I’m like all of you. I’m proudest of those ‘important books’ on my bookshelf that I read during high school and college, and always aspire to buy and read more, but … there never seems to be enough time to CATCH UP ON THE LAST EPISODE OF BREAKING BAD or THE EXPANSE or THE MARVELOUS MRS. MAISEL (yes guilty as charged, your honor), much less break away to read a book (hello, audible.com for the commute) much less read the CLASSICS (unless of course your high school children start leaving their English lit or Russian lit or Holocaust books around and you pick them up an devour them, just to be annoying to the kids—try it, it’s fun).
So, it was with a mix of apprehension (will this be boring?) and pride (look at me! Taking another class for real! Kind of.) that I bought this and began listening. Thanks, ‘half-off audible.com sale.’ Turns out “on sale” Nudges do actually work (a future book review: I’m sitting here on the plane typing this review on my phone while the book Nudge presses against my knee in the seat-back pocket of this Economy seat).
Yes, yes I know. My wife often says: ‘it must be difficult to be you.’ Yes. Yes it is, honey. Thanks for noticing.
I’m listening to this first course. Professor Harvey has a bit of a southern accent, pleasant, well-spoken. A promising start. She’s explaining principles of good story telling, sure. Then she launches her first story, and I’M RIVETED. And then she dissects what just happened. AND I’M RIVETED. A big part of my job is: presentations, pitches for new ideas, new projects, talks to others about our successful work, speaking to laypersons, to programmers, doctors, students to convince them of something or another. I think I tell a pretty good story: some humor, some funny illustrative quotes, some quick lessons related to the story, and then a quick close.
But the professional storyteller? Watch this…
Wow.
Later in the course, the professor reveals that Little Red Riding Hood has hundreds of local culturally diverse versions. And many were not intended for children. In the version she tells, the wolf is a MAN. A handsome, vaguely dangerous, very attractive man. And darkness and blood and meat and ?string and ?white sheets in the river come into play. It only vaguely resembles the children’s story we all know. And the telling of the story is … transporting.
We learn about point of view, about developing characters and slight variations in voices, using head swivels, facial expressions, tone of voice, stepping around the stage to more clearly represent various characters.
We learn about accelerating time, expanding time to bring attention and create a short story from a longer narrative. We learn about the official role of the narrator, who, different from the heroine, or villain, or bystander, can be unreliable, or unlikeable, or have a complex and different point of view from you playing yourself. Hmm.
We learn about reading your audience, changing the story and presentation, engaging your audience in movements and shout-outs to bring them in.
And we learn about bringing it home. Remembering to tell a story THEY need and want to hear, not just a story YOU want to tell.
CMIO’s take? Give it a chance. I’m giving a thumbs up to Great Courses and to this Storytelling series in particular. I’m going to work on being a better storyteller in the service of improving patient lives. I’m also going to work on being a better storyteller to entertain friends and family and myself.
Our smart colleagues have published in JGIM (Journal of General Internal Medicine) and have updated the classic study: how long does it take for a doctor to interrupt the patient at the beginning of the interview, when patients begin their opening statement about “why I am here today.”
In years past, we found that the time it takes for a doctor to interrupt the patient used to be …
18 seconds! Then 23 seconds (hey! we’re getting better!) and now … 11 seconds?!?! That is, IF the doctor asked an open-ended question AT ALL. Yikes.
Seriously disappointing. But, are we surprised? The time pressures on doctors have increased over time. More regulation. More required elements in the documentation. Meaningful Use requirements of Electronic Health Records. Decreasing reimbursement. Not sufficient time or effort dedicated to redesigning the exam room, or to redesigning teamwork so that doctors can be doctors and not clerical workers.
Beyond that, we have an internal clinician retraining program at UCHealth to improve communication in healthcare encounters between patients and physicians, we call Excellence In Communication. Led by our inimitable Patrick Kneeland, executive for Patient and Provider Experience, and a team of a dozen physician coaches (myself included), we are teaching our docs highly effective communication strategies. In a four hour workshop, we can improve clinician experience, patient experience, and reduce physician burnout. Who doesn’t want that?
Of the many techniques and tips, here’s a trio that work particularly well:
Open ended inquiry “How can I help you today?”, and then WAITING UNTIL the patient is done with their opening statement. The published data on this indicated that the vast majority of patients complete their opening statement in far less than a minute, and the exception will go up to maybe 3 minutes, if uninterrupted. The trouble is that docs feel like they’re under so much pressure that every second of listening is excruciating, and the other parts of their brain are already; categorizing, creating a list of possible diagnoses, worrying about completing checklists, wondering about quality metrics, and are too “full” to be present in the moment. We train docs to practice listening for up to 2 full minutes to a colleague’s statement and committing to trying this in an exam room with a patient. Simple, but the behavior change is IMMENSELY challenging and yet IMMENSELY rewarding when done well.
The second technique is “What else?” That’s it. Just keep asking “what else” until the patient runs out of stuff. This, of course is the petrifying fear that docs have: “But that opens Pandora’s box and I’ll never get it shut ever again!” and “But then they’ll bring up stuff that I can’t help them with!” and “OMIGOD this will be 75 things and we’ll be here all day and night!” Yes well, we also know that the FIRST thing that patients bring up with their doctor is only 10% to 50% of the time, the most important thing they want to talk about. So, guess what, if we RUN with the first thing patients say, we’re going to be wrong 50 to 90% of the time. So there.
Finally, and this is the piece-de-resistance, say: “Well, we have discussed quite a few things so far. Which of these topics would you like to cover today in the time that we have? I would like to discuss A, and sounds like B is also important to you. How does that sound?” Negotiating the agenda is a critical skill, and makes items 1 and 2 really useful, creates a win-win agreement between patient and physician, and EVEN SAVES TIME. Imagine: a tool that increases patient and physician satisfaction, and saves time.
Notice that this has NOTHING to do with the EHR being for good or for evil. This works regardless of what you have in the exam room, as long as you have the presence of mind to remember to practice and use the tools.
In this, the winter of our discontent, when everything seems to be going in the wrong direction, when all of our institutions are under attack, and public courtesy and discourse seems to have gone awry, and everyone has a complaint, it seems that so few have ideas to help us climb out of this morass.
These tools could be a glimmer of hope.
CMIO’s take? Use these three tools in the exam room (or the meeting room, the board room, any professional or personal setting where important conversations occur), see what transpires. They are EASY TO understand, but require discipline and hard work to make them work for you. Persist, and they will pay off in large ways for you and for your patients.
This is perfectly aligned with what I’ve been thinking recently. This combines ideas from a couple of books we’ve been reading: Nudge by Richard Thaler (a future book review), and another book on my to-read shelf: Connected, by Nicholas Christakis.
Nudge talks about how small changes in our environment, often something we can design or control, can subtly shift our behavior in either desirable or unintended directions, eg: a public school cafeteria can dramatically influence student food choices by the positioning of the food (eye level? early in the line, or late?).
Connected discusses in more detail, the idea that not only direct relationships (immediate family members, close friends), but friends of friends, AND EVEN friends of friends of friends, have some influence over our own health, eg: the NEJM research study that showed that YOUR likelihood of obesity is related to the obesity of those who are THREE relationships away from you. Wow.
And now, positive friend relationships (described as MOAI in this article, from Okinawa, Japan, with the longest-lived women, expectancy of about 90) have everything to do with long term health. I’ll leave you to read.
CMIO’s take? There are SO MANY THINGS outside of direct-healthcare that influence our health, our lives, and we are just beginning to explore them. How are you thinking about this in your healthcare organization?
