Solve your problems, with a Ladder at work (what?)!

He’s at it again.

There is a risk, in a large and growing IT organization in a large and growing health system (we’re up to 9 hospitals, 400 clinics) is getting disconnected among the hundreds of employees and colleagues within this unit. We certainly don’t have all of it figured out, but there are proud moments when we do something good…

(like untalented folks playing ukulele – see (as an aside, did you know that YouTube now AUTOMATICALLY generates closed caption content?) (although bad singing apparently still stumps it!) (and, there is a tool for humans to correct the computer-generated text) (hey, everybody, just like transcriptionists everywhere, who are employed by companies applying Speech Recognition to incoming physician dictations BEFORE having a human correct the computer generated text, I’m now also officially a Correctionist! the new title, apparently, for transcriptionists doing this new work).

Whew! I’ve always wanted to create a parenthetical aside that took on a life of its own (see my previous review of the book Mezzanine for the most artful and entertaining example of massively meandering asides).

Nevertheless, after some initial hesitance, gradual persuasion, and some non-standard funding, we’ve had a ping-pong table ensconced in the midst of our IT building for several years.

IMG_3589Okay, so we haven’t always been as quiet as we should be, to avoid disturbing those unfortunate enough to have a cubicle near the Ping Pong room. And, yes there is always the persistent business pressure of converting that conference room back into more offices, but we have held on (so far).

Use of the table is sporadic, and I feel, insufficient to deliver the quantity and quality of potential joy and human connection that comes with such an unexpected resource. In other words: HEY PEOPLE WHERE IS EVERYBODY.

I know, West Coast start-up companies all have ping pong tables and foosball, and the perks to attract millennials and them younger folks who, I’m told, are constantly joining the workforce. Sure. I’m just an aging boomer trying to keep up.

WHICH brings me finally to my point. After years of inertia, I put the finishing touches on my Ping Pong Ladder last night, and mounted it with some help (and, an IT colleague’s pen that has a built-in Level!)

This is a flashback to my heady days, in college, of being the Athletic Director in my dorm, and trying to convince my classmates that playing an intramural sport actually helps reduce stress and improve academic performance. In those days, I built and posted a ping-pong ladder in the basement of our dorm and had an active cadre of about a dozen classmates with more enthusiasm than skill, and had a grand time.

Heady days of college
OK, actually, heady days of college. The “athletic director.” Uh-huh.


However, the contrast here, is (okay, you can stop laughing now).

The contrast here is, nobody knows what a ping pong ladder is! Really?! “Hey,  when is the tournament?” “How does this thing work?” There’s a bigger social commentary here, too much FaceTime and not enough face time. Too much texting and not enough bowling. If you haven’t heard about or read Putnam’s amazing critique of the modern age, Bowling Alone, (TL;DR) at least read the synopsis, like I did.

I had to explain the underpinnings of the Ladder to several colleagues; that you challenge up to 3 spots up the ladder, and if you win, you take their spot and everyone else moves down, and that fundamentally, it is about social connections, finding someone to play ping-pong with, and having a social construct, an excuse to blow off some steam, have a chat, get some blood flowing, and then get back to work. No need to even break a sweat if you don’t want to. The good news is, everyone has either played ping pong or is willing to try. At least that is my hope.

Did you know, by the way, that official ping pong rules changed decades ago? Seriously? I learned that a game was first to 21, that you served 5 times in a row then switched, etc. Now, games are to 11, and you switch EVERY 2 SERVES. Apparently, nobody has time anymore. But, games do move more quickly, and more folks do get to play. So there’s that.

And of course, thanks to the first followers; it would be a sad day if my tile was the only one on the ladder. We had 19 colleagues put up a tile on our first day. Hooray!

CMIO’s take? Do you have a ping-pong ladder? or have you had to explain some ancient social norm recently to a younger colleague? Do we even think Ping Pong Ladders can survive in this modern age? Or is it time for the Boomer and his sad Ladder to walk into the sunset? Let me know.

Muse: an ironic but helpful? App for mediation

My smarter and hipper younger sister is loaning me her Muse brain sensing headband, knowing that I have developed a recent interest in meditation.

I have to say, I went through some rapid-cycle opinion changes on this device:

  1. Hey, cool a new technology of some sort.
  2. Wait, this is for meditation?
  3. Neat, it has galvanic skin sensors to detect brainwaves maybe.
  4. Why do I need a technology to help me disconnect from technology?
  5. I’m already pretty good at meditation; now I can have an objective measure of how good I am.
  6. Hold on, isn’t meditation about not judging oneself and accepting ourselves for who we are? How is this helping?
  7. Oooh, neat, this fits my big head pretty well. And hey the app plays ‘rain’ sounds that calm down and get quiet as my brain waves relax. Actual biofeedback without a neuropsychology appointment and a $1000 rig?
  8. Hey, I’m not very good at this. I’m getting thunderstorm sounds from my iPhone speakers. Ironic on several levels.
  9. I’m pretty sure that I’m good at meditation but the app is just a lousy, poorly written piece of code that can’t appreciate my type of calmness. That’s it.
  10. I got the rain to calm down! and heard my first chirping bird, indicating a few seconds of continuous calm! Way cool! These designers are geniuses.
  11. Uh oh, my excitement triggered more rain.
  12. This is pretty cool.

Despite my schizophrenic waffling on this, I convinced my generous sister to offer the headband to me on a long-term, no-collateral loan. Best middle sister ever.

CMIO’s take? Sometimes it is fun to use technology to disconnect from technology and look inside yourself. Yes, I know that I am a collection of clashing contradictions. That’s my thing.

Book review: All The Pretty Horses

Rating: 5 stars.

Another book pilfered from my daughter’s bookshelf, reading for her seniors English course. Published in 1992, and a National Book Club winner.

The first paragraph is astounding, a panoply of senses, wistfulness, loneliness and a tremendous sense of loss. Read that first paragraph here:

Polysyndeton is one of many words my daughter can now use to show that my command of the English language diminishes daily. Apparently McCarthy uses repeated ‘ands’ to create flowing, breathless descriptions to overwhelming effect on the reader.

This is the story of John Grady Cole, a man who crosses the border into Mexico after his father dies and his adventures there and the bubbling emotions under the surface and the wide open spaces and the horses, so many horses, and falling in love, and prison, and fighting for his life, and escape and, maybe redemption.

Whew. Read the original. Waaay better.

CMIO’s take? People had real adventures before smartphones and GPS and Uber. Put down your electronics and read something simple and powerful. Of course, you’ll have to log in again to blog about it …

Re-envisioning Electronic Health Records

Okay, so this “forward looking” image is somewhat self-serving.

Recently I was asked by a colleague, how would I size up current EHR’s: what are the major wins and major needed improvements? In about an hour, and off the top of my head, I wrote this list. It is neither comprehensive nor deeply reasoned. However, it IS a compilation of frustrations and grateful moments that come from having help design, implement and USE an EHR over the past 2 decades.

  1. See Youtube, from a Boston EHR interest group, CRICO: Provocative; I don’t agree with all of it, but it provokes a lot of discussion, see below.
  2. MAJOR win: engaging the patient using the portal: online communication, access to records, Open Notes, Open Results, is just the beginning of a needed improvement in information transparency. Anything that eliminates the telephone tag circus is good.
  3. MAJOR win: having the chart accessible ANYWHERE ANYTIME avoids missing data (medical errors from handoffs of care) and paper filing and paper shuffling costs. As one colleague wrote: PAPER KILLS. In the late 1990’s between 1/3 and 2/3 of patient appointments did NOT have the relevant paper chart pulled in time for me to see the patient. How embarrassing. This no longer happens. Also, our paper filing, despite a team of 50 in medical records, was always 2-3 weeks BEHIND. Even if you DID receive the paper chart, chances were good you did not see the recent report you needed.
  4. MAJOR win: improvements in legibility (sometimes at the cost of unreadability due to note bloat). How many times per day did used to I take a paper chart to a colleague or nurse and ask “what you think this says?”
  5. MAJOR win: easy narrative documentation using Speech Recognition, and increasingly, Natural Language Processing (detecting codified concepts using machine learning). We only just starting to see the fruits of these technologies. A typical physician’s cost for human transcription, per year is about $15,000. And the turnaround time can be days, resulting in missing data during that time. Speech rec is instant. AND NLP has the potential to create instant alerting and reminders.
  6. MAJOR win: reminders and alerts improve the frequency of doing the right thing at the right time more often (when well designed). This is the FLIP SIDE of of Alert Fatigue (see below). I love when my system reminds me to vaccinate, or screen for colon cancer, or screen for depression, particularly when I catch and prevent an illness that I would otherwise have missed.
  7. NEEDED IMPROVEMENT: alert fatigue: poorly designed, terrible signal-to-noise ratio of alerts. Enough has been written about this. Our Physician Informatics Group (PIG: yes, we don’t take ourselves seriously), constantly struggles to improve the SIGNAL to NOISE ratio of these alerts, and to reduce alerting. I consider it a personal failure if we have implement at “Best Practice Alert” that stops a doctor’s work, instead of designing a smarter EHR that “guides” and “nudges” a doctor’s behavior, so that we make the RIGHT THING EASY.
  8. NEEDED IMPROVEMENT: Better ways of capturing physician-patient interaction (see #1), maybe full video recording instead of typing out a history, and having the machine collate into a timeline, concise narrative.
  9. NEEDED IMPROVEMENT: user interface design: (see #1), why can’t the electronics disappear into the wall until it is needed and then pop in with reminders and context-sensitive help just-in-time?
  10. NEEDED IMPROVEMENT: how to eliminate communication barriers and snafu’s based on nurse-physician-patient ping-pong messages.
  11. NEEDED IMPROVEMENT: an appreciation from clinical leaders that an EHR is NOT THE SOLUTION: instead, need to focus on a clinical re-invention that uses an EHR as tool to create better teamwork and communication. How to get that across? Our biggest successes come from clinics that realize this one fact. See previous posts on SPRINT  EHR Sprint team: work hard, persevere, sometimes you get to build a dream team and TRANSFORMATION Politico (and HuffPo): The Doctor of the Future (with stuff about us, and Care Redesign at UCHealth!)

CMIO’s take? Send me a message! What’s missing? What would you take issue with? Let’s craft a message to our EHR vendors and demand innovation and something better. I’m convinced we’re in version 20 of something that will need 50 versions to get right.

Book review: Aurora by Kim Stanley Robinson


This is a fascinating speculation into the future of human space travel to the Stars. What would happen if you were born, the sixth generation to live on a starship? What if your planet destination was questionably habitable? What if your cohort decided to return to star travel? What if things progressively went wrong? What would star traveling humans had never seen planet-side sunrise?

Robinson does a nice job setting up the scientific premise of a multi-generation ship heading out to the stars. Ho would the 6th generation feel about being brought into a world not of their choosing?

How would the travelers deal with the inevitable technology and mechanical breakdowns over hundreds of years? How can any small society have the resilience to self-repair long enough to reach their goal?

And what if there were major decisions to be made upon arrival? What is the leadership and cultural environment of a ship of 2000, and could it withstand a life or death decision without degenerating into anarchy?

Sure, the storytelling at the individual level is perhaps less compelling, but the grand scale of Robinson’s vision, sweeping across centuries and across vast reaches of interstellar space, is a great journey.

CMIO’s take? The human psyche is fascinating, at the levels of society, community, organization, family, and ultimately individual. Stepping outside our own familiar environs lets us see ourselves more clearly. Sci fi helps me do that. How do you do it?

EPCS: Morphine (ukulele video)

This guy thinks he can sing. How unfortunate.

Has your organization adopted technology to electronically prescribe controlled substances (EPCS)? If so, good for you! If not, what are you waiting for? UCHealth is kicking off this project on April 9, 2018, a “big bang” for all providers who have a DEA number to be able to e-prescribe and avoid that horrible, bifurcated workflow of “electronically transmit all the regular prescriptions directly to pharmacy, but remember 1) keep your tamper-proof prescription paper stocked in the correct drawer of the printer, 2) to go get that narcotic prescription off the printer, 3) sign it with pen-and-ink, 4) then tell your staff to track down the patient to come pick it up or remember to put it in certified mail to the patient, especially if the patient called to request, or worse, you forgot to get it off the printer before the patient left clinic.

After the DEA ruling to permit EPCS a few years ago, our EHR vendor developed the 2-factor authentication tool to meet the regulation, and now we have finally contracted with a company to provide that service, link our physician identities to their smartphones via an encrypted app, and now a smartphone alert and a password (something you have and something you know) are our two factors that permit EPCS.

Here’s a little something I wrote to commemorate our EPCS go live:

CT on ukulele singing “Morphine” inspired by Eric Clapton’s classic song “Cocaine.”
(Part of my YouTube channel)

I also created an internal-only training video for Duo Mobile as second factor for EPCS.

I learned the structure of a well-told instruction video from the original “Apple Business” video tips back in the early zips (2000’s). You’ll see a human, then a quick screen video, then close with a human. Perfect format:

CMIO’s take? Sometimes a video tip (or video musical tribute) is what gets an audience’s attention.

Amy Cuddy and the coming wave of scientific recriminations

I have seen Amy Cuddy’s presentation; she speaks well, has a compelling argument, and a research study that she published in 2010 that backed up her assertions. It made sense, and “power posing” became something I thought about at times.

Since then, there has been this backlash; the article speaks about it in detail, that is a personal attack on Dr. Cuddy, which is mostly unfounded, and is tragic for her career, and I am hopeful for her resilience and rebound.

However, much more concerning is the implication for all social science research and indeed all research; the critique about replication of findings and the over-reliance on the p-value in research. Most studies rely on a p-value of “0.05” indicating that the likelihood that a finding in a study represents a real effect in the entire population that was not studied (for example, studying 100 patients where there are 10,000 patients who were not studied, and it would be unrealistic to study all 10,000), should show that it is highly unlikely that the results would occur as a result of sampling error.

The critique is that, before publishing, researchers should REPLICATE their findings, or better yet, have others replicate their findings. The challenge here is that research is already slow, plodding (it can take years to write and submit a grant, suffer the indignity of a very small chance of getting funded months or years later, conduct the study over a year or 3, then spend time writing up the results, submit the paper, hope that some journal somewhere accepts it), and with long delays before results are accepted and published. Now consider the requested addition of replication: do this AGAIN in a different setting, a different population of patients and then combine or compare the results.

Shall we double the grant funding of all results so that we can do this? Is research funding not scant enough as it is (some colleagues have a 1:500 chance of funding their research at current funding levels)?

CMIO’s take? Not an easy question to answer. I think there is a lose-lose proposition coming out of this discussion, with no clear path forward.

Amazon’s AI Flywheel, and what we can learn from it

from amazon dot com

A fascinating look inside Jeff Bezo’s strategy at Amazon, pivoting the entire company on Artificial Intelligence, and how it is driving Echo.

More interestingly for me, how does AI connect throughout that massive company, how has one person brought that single technology under one roof, one connected integrated team, and make the results of that knowledge available to all the other teams previously developing such tech independently?

Finally, how does the AI group create the virtuous flywheel, described in Good to Great. 

Somehow, Amazon has cracked one of the great business puzzles; how to create a small innovative team within a much larger bureaucratic business, that is nimble, learns fast, develops expertise in many related areas (surrounding AI), and then serves up that knowledge to the rest of the organization in useful, coherent, collaborative ways, driving up the value of the entire organization?

Whatever it is, Amazon is bottling it, and Amazon is selling it.

CMIO’s take? The cycle of the virtuous flywheel is our aspirational goal.

Book Review: Between the World and Me


Five stars.

This is thin ice for me, a well-assimilated Asian, reading and commenting on the African-American experience of disenfranchisement.

I’m currently immersed in the world of West Baltimore: ‘powerdisking’ seasons of The Wire, amazed at the lingo, the culture, the down-and-out police and detectives who get up every morning to face the jungle, in a world where the jungle is clearly winning.

And in the middle, the black man. A powerful, yet powerless figure. The games, the chess moves, the subtle alliances, the backstabbing, the occasional yet vicious executive liaisons of violence. (I originally wrote ‘explosions of violence’ but maybe autocorrect understands something I don’t).

And now, Mr. Coates writes this book: a letter to his young son. One letter, one book. It is a quick, searing read. Indirectly, it addresses ‘the men who believe themselves to be white.’ And with this phrase he lays bare the bias underlying so many assumptions of American culture.

Coates is an educated African-American man with command of the language, a deep understanding of the powerful forces shaping American history, an unflinching eye toward the shameful treatment of blacks in America, in past centuries and including now.

And he sadly has to pass on his cautions and his learnings to his son, who even today, is not safe, for all the same reasons.

As an Asian-American, this is not my fight. I carry neither the inherited guilt of the Southern plantation owner (but did enjoy watching the Dukes of Hazzard when I was growing up: sorry), nor the chromatic guilt of appearing ‘white’ (although it is true that I was labeled ‘white’ at high school graduation*).

This book amazes me: that a black man in America spends his entire life knowing that, fundamentally, he, and his body, are never safe: he could be detained, arrested, or killed at any time.

Trevor Noah, host of the Daily Show on Comedy Central, recently said that since moving to the U.S. that he has been pulled over while driving, more than 50 times.

Although such systematic bias and discrimination against Asians existed in my father’s time, and more in decades and centuries past (Chinatowns built to house and segregate workers for the railroad, epithets that spoke of ‘a Chinaman’s chance,’ meaning that the Chinese worker who was lowered down in the basket with explosives to carve the railroad tunnels out of rock would likely die), I have fortunately not often been subject to those pressures, those glass ceilings, those verbal taunts and those mortal risks.

America does have a checkered past. Indeed the present is also checkered. We are by no means out of the dark tunnel of our chromatic biases. But it is the conversation and powerfully articulated voices, like those of Mr. Coates and the empathy and compassion of our melting pot society that might move us forward.

*True story: I was getting ready to graduate high school in Tallahassee, Florida, part of a senior class of about 600, about 1/3 black and 2/3 white, and one Asian. Honestly, having spent more than a decade growing up among these same friends, I did not feel isolated or apart.

I was approached during the week prior to graduation, by the registrar of Amos P. Godby High School, who informed me:

‘I hope you don’t mind: I made you white, otherwise I would have had to put two more columns into my report for the numbers of white boys and girls, and black boys and girls. I would have had to type up Asian boys and girls. Just because of you. So I made you white.’

What did she want me to say? Perhaps ‘thank you?’ Or maybe ‘no thanks, I prefer to be black?’ It puzzles me to this day.

CMIO’s take? This CMIO has no take.

Remember that you will die. (WIRED)

from wired dot com

Wired magazine is starting to re-invent itself again; now as a paid-subscription service with interesting articles on a website called Backchannel. The first few articles are doozies: incredible thought pieces on the near-future of technology. I’m inhaling these; love the thoughtfulness behind the reporting.

This article speaks about the stranglehold our devices have on us; something that is prevalent in the news. The upshot, and most relevant recommendation to reduce your smartphone use?

Remember that you will die.

Wow, that’s a show-stopper. Makes you think, doesn’t it? I believe this is exactly what the victorious Roman generals, when they returned from their military conquests, would have whispered in their ear, during the celebratory parade back in Rome: “Memento mori.” (or, perhaps it is merely a cool meme).

Anyway, a good read. I’m trying various things to reduce my smartphone distraction. This memory is helping. I’m also trying out turning my smartphone screen to grayscale. I’m also turning off all my ‘bing’ notifications and red number badges for “unread messages” on LinkedIn, Twitter, Outlook on my desktop and on my phone. I’ve deleted my Facebook app (which is power-hog anyway) and only check it using a browser, and on MY TERMS, no longer drawn in by that siren-song red circle.

I’m trying to hack my own brain chemistry and reward circuits by removing visual triggers and cues. This is also described in the book Deep Work.

CMIO’s take? Time to start hacking your own motivations and actions.