EHR v Covid-19. Pandemic mask history

I did NOT know that these beaked masks were full of theriac, a mixture of 55 herbs, intended to cleanse the air before the plague doctor breathed in.

AND that plague doctors carried long rods to maintain distance from others. I wonder where I can order MY “social distancing rod.” Can’t find one on Amazon, although this might do.

The article is fascinating. I’ll take a break from EHR pontification today.

EHR vs Covid-19. Antibody tests: Yikes.


If you’re here to understand some of the challenges of antibody testing with Covid-19, read on. Be warned: math ahead. What’s the TL;DR?

  • We don’t know whether having antibodies indicate that a person is IMMUNE to future re-infection now or later with Covid-19.
  • We don’t know whether having antibodies mean that a person is NO LONGER infectious to others with Covid-19.
  • We’re going to discuss Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value and say that MOST antibody tests out there may show Sensitivity and Specificity in the 80 or 90% range (seems good!)
  • BUT because the Prevalence of the disease is unknown and likely low (single digits or teens maybe), the Positive Predictive Value is likely to be TERRIBLE, meaning a positive result might just be … meaningless or WRONG MOST OF THE TIME (OMG).

Some of you know that my father is a statistician, so he is likely to read this uncomfortably and have lots of concerns about the accuracy of my statements. You may also know the quote popularized by Mark Twain:

There are three kinds of lies: Lies, Damn Lies, and … Statistics

But, here goes anyway; the point is important, it is bothering me, and I want people to know at least what little I understand.

Let’s say that an antibody test is 95% sensitive (meaning, for patients who really had COVID-19, it shows Positive for 95% of them), and 92% specific (meaning, for patients with NO Covid-19 prior infection, it shows Negative for 92% of them). Seems like a good test, if you look at it from an omniscient being’s point of view: you already KNOW who has and doesn’t have the disease, and you’re just waiting to snicker at how well the tests turn out.

The trouble is when you turn things around the other way, from a patient’s point of view. You SHOULD NOT CARE what sensitivity and specificity are. You SHOULD CARE what Positive Predictive Value and Negative Predictive Value are.

Okay, now some of you are having hot flashes, or shaking chills, or whatever your reaction was to taking Statistics in high school or college or medical school (or all 3). Imagine also, that your father also knows most of the people teaching your classes because of his professional network, and you’re worried that your grade on this test will reflect poorly not only on you, the son of a statistician, but on your father, your family, your entire lineage. Good, now you’re getting me.

Negative Predictive Value (NPV) is the likelihood that if your test is Negative, it is correct, and you don’t have antibodies.

Positive Predictive Value (PPV) is the likelihood that if your test is Positive, you DID have the disease and now have the antibodies.

Okay, here’s the setup, AND I AM NOT CLAIMING THESE ARE REAL STATS, this is just an exercise. Let’s hypothesize:

  • We will test 100,000 people
  • The prevalence of disease is 3% (3 of each 100 have the disease in our population)
  • Sensitivity of our antibody test is 95%
  • Specificity of our antibody test is 92%

See the table as we calculate this:

Test ResultCOVID past or presentNo CovidTotal
Antibody test Scenario 1

The NPV equals “true negative / (true negative + false negative)”, or 89,240/(150+89,240) or 99.8%. In a population with very few Covid-19 infected patients with antibodies, you’re going to be right MOST OF THE TIME, to find “no antibodies” in most patients. So far so good.

The PPV equals “true positive / (true positive + false positive)”, or 2,850/(2,850+7,760) or 26.8%. What?

This means that PPV, or chance that a POSITIVE antibody result is CORRECT is 26%. So, if you take an antibody test in this population and your result is POSITIVE, then there is a 74% chance THAT TEST IS INCORRECT. Can you imagine? “Here is your result, Sir, your antibody test is Positive, but 3/4 of the time that is wrong.”

So the test we’re describing above, with the above assumptions, is helpful when the result is NEGATIVE (right 99% of the time) but NO HELP AT ALL (wrong 74% of the time) if the test is POSITIVE. Got it?

Okay, lets try a second scenario. Let’s hypothesize:

  • We will test 100,000 people (same)
  • The prevalence of disease is 3% (3 of each 100 have the disease in our population) (same)
  • Sensitivity of our antibody test is 95% (same)
  • Specificity of our antibody test is 99.5% (DIFFERENT)

Here is our new table:

Test ResultCOVID past or presentNo COVIDTotal
Antibody test Scenario 2

NPV is the same: still 99.8% accurate. A negative is pretty good.

PPV is now: 2,850/(2,850+485) = 85.4%.

Therefore! Pushing this antibody test’s performance up to 99.5% specific makes a HUGE reduction in the number of False Positives, and makes it so that a Positive test for a patient is going to be right 85% of the time! Not perfect, but way better than 26%.

See what I mean? Moving from Sensitivity and Specificity to NPV and PPV make a really big difference when it comes to thinking “should I get this test” and “can I trust the result?” Maybe don’t rush right into getting your test until you chat with your doctor about how well it performs, what it might mean, and truly how useful these tests are.

Right now, for example, at UCHealth, we are only recommending testing patients who wish to donate plasma for our research study to infuse antibody-rich plasma into critically ill Covid-19 patients. Over time, as we learn more, we’ll expand testing to more patients (soon).

Thanks to Ed Ashwood, Medical Director, Clinical Lab, University of Colorado Hospital from whom I “borrowed” much of this example.

CMIO’s take? Whew! Statistics is hard. Who knew that Dad was right about how important Statistics is? Please look on your fellow statistics geek friends with kindness, they’re making our world a safer place. And, be careful what you ask from an antibody test.

Pandemic skills: Giving feedback successfully: I Like … I wish … What if … ?

Theater and acting: a life skill [icon from]

During this pandemic, many of us have been stuck in front of our screens, like talking heads (Max Headroom, anyone?). If “sitting is the new smoking” (or perhaps not), then I’ve been “smoking” a lot.

Virtual meetings are draining, and I’m on them up to 8 hours a day, even busier now with all the EHR modifications, keeping up with policy changes, what Covid-testing is available, how we admit, treat, discharge, follow, track patients.

At the ends of long hours, long days, long weeks, our nerves are frayed.

I’ve observed that interactions between people have everything to do with the interpersonal skills of the individuals. Sometimes the conversation does NOT go well. Whether it is by email (worst for crucial conversations), by phone (slightly less bad), by online video meeting (slightly less bad) or in person (best, when possible), it is certainly worsened by the pandemic situation.

I’ve been taking a Story Skills Workshop (by Seth Godin and Bernadette Jiwa) that recently concluded. I have to say that I’ve learned quite a lot, and not what I was expecting to learn. I highly, highly recommend it. Seth and Bernadette offer a series of online lessons, released over time. There are about 6 expert coaches, and the instruction is to sign up for an interest group or ‘accountability group’. You’re given a story structure (the 5 C’s: Context, Catalyst, Complication, Change, Consequence) and then specific lessons to write and polish specific elements of your own story in this framework. The cool part is the instruction to ‘first write your own story, and then go comment on at least 5 others.’

  • I learned that it is possible, in an online-only course, to develop a sense of community and collegiality in a short 30 days.
  • I learned that it is crucial to be gentle in first contact with others online. For example, when giving feedback on others’ stories, DO NOT start right in with ‘why don’t you add more Emotion to that moment in your story?’ You’ll learn (as did I) that conversation either stops or becomes defensive. Remember that online conversations carry ZERO nonverbal: no Kind tone of voice, no Friendly posture. All you see are the words, and it is automatic to imagine them coming from a frowning critic with crossed arms, shaking his brutish head. [Pause for self-reflection amongst my blog-readers, as well as from myself…]
  • Instead, try something my theater-trained son taught me:

‘I like… I wish… What if …’

My highly emotionally intelligent son
  • Framing any response this way allows your recipient to hear something positive, then a neutrally posed concern, followed by a tentative suggestion. Having been on both sides of such a well-formed critique, I can say: it is EASY to write, doesn’t take longer, and on the receiving end FEELS COMPLETELY DIFFERENT. It FEELS like a close friend, reaching a hand over to pull you up to a higher step.
  • FOR EXAMPLE: Take one of my story-critiques of a co-participant in the story workshop, not done well on my part: “Why don’t you add more emotion to your story? It reads like a timeline, but nothing about what you felt, or how that impacted you.” I thought I was clever, to point out one of the main points of that week’s lesson. What I received was… no response. Hmm.
  • Rephrasing the reply using this framework, when I replied to a different participant’s story, sounded like this: “Hi, Joe! I liked your story, especially the unexpected part about running away from home at 16. I wish I could be there at that moment when you made the decision, everything boiling-over, and then a crucial moment. What if you paused in your story and told us what you were thinking and feeling right then? I would be riveted.” Guess what? We had a great online conversation after that, and he re-wrote his story, and I WAS RIVETED. Win-win.

CMIO’s take? Story telling: cool. Gentle, effective feedback: cooler. Don’t we all need to get better at this?

Improving Communication with Video Visits: now with shorter video!

17 minute walkthrough
1 hour seminar version with intro and Q/A

Thanks to my excellent colleagues at UCHealth, Echo Vogel, Hillary Duffy and Duane Pearson, co-conspirators to spend an hour on a Zoom webinar to review Patient Experiences with online Video Visits. We are all on a rapid learning curve. Come spend some time with us as we review what we’ve learned.

Here is a link to my original post on Video Visits, and on Patient Experience with Video Visits.

And here is my one page PDF on best practices (including communication strategies) with Video Visits.

CMIO’s take: What are YOU learning with Video Visits?

EHR v Covid-19. Follow the data: Hemoglobin, Viral tests, ‘data humility’

For all the talk about Covid-19 testing, and testing for respiratory viruses, keeping mind, that the UCHealth (and most health system) labs do SO MUCH MORE than virus testing. Hemoglobin, for example. Hemoglobin is the measure of how much oxygen-carrying protein we carry in our blood, a way to detect anemia, blood loss. Look at the dip in the orange hemoglobin line in early March. Our testing volume throughout UCHealth fell in HALF. As we all reconfigured our hospitals to prepare for pandemic, we also stopped all surgeries except for emergencies. And the various colored lines at the bottom are all our previously described viral tests (see previous post). How puny and miniscule.

Okay, so wait a minute, lets look back at those virus tests: what’s this? Remember that purple was Influenza B, Green was Influenza A, yellow was RSV (respiratory syncytial virus). Then there are 3 viruses (including Rhinovirus) that SPIKE in March! OMG! None of those are Covid-19.

CT Lin is a GENIUS! He has discovered the TRUE CAUSE of the pandemic: out-of-control mutated winter viruses! AND, there are THREE of them, all spiking at once! Triple infections for everybody!

Well? What do you have to say for yourselves? You gonna buy it? Pause and think. Hmm.




Okay, you’re all smarter than me. Yes, you’re right. When we started Covid-19 testing, we also threw in RVP (Respiratory Virus Panel) testing on the same swab. This graph shows, not the “testing positive” results above, but TOTAL VOLUME OF TESTING, and RSV testing increased 700% in a month, due to co-testing on Covid-suspected patients. Aha!

So, layer in the Covid-19 positive results, and we see this, temporary bumps in 3 viruses (due to all the co-testing of Covid-suspect patients: blue, dark-blue, red), and a persistent and growing number of Covid-19 positive patients (purple). And then, we have cut back the co-testing since then. AND we near the end of the season for those other viruses anyway. Okay, this makes more sense.

Hooray! Let’s celebrate, we made some sense of the data!

But, wait.

Of course it is not a good sign that each week we detect more Covid-19 positive patients. It is either: more patients are showing up for testing, OR we have more test kits, OR we have relaxed the standards (all symptomatic patients can be tested now, instead of just health-care workers and critically ill patients), OR the exponential spread of the pandemic is not over, OR something else we haven’t thought of yet. Wouldn’t you like to know which one it is? Yes, so would I.

CMIO’s take? I hate living in the middle of the pandemic, when every night, we go to sleep in the middle of a cliff-hanger. I hated those season-ending episodes in those shows I loved so much. Here’s hoping our heroes solve the cliff-hanger in time for next season!

EHR v Covid-19. Follow the data: Visits, Testing, Symptoms, Codes?

It is time we looked back at the past month to update our data. Since we initiated social distancing in mid March, and then the Colorado Stay-at-Home order in late March and subsequent mask use, what has happened to Covid-19, and what about symptoms? other viruses, the geographic spread? Hold on to your hats. This is all UCHealth data from our Slicer de-identified data tool.

  1. Virtual visits are up, and stable at about 4000 visits a day. In person visits are way down from baseline in early March. Overall visit volume is way down, as it is for most health organizations right now. As Colorado starts to ease restrictions from “Stay at Home” to “Safer at Home”, we will see what comes next. Regardless, there will be repercussions from this some time to come.

2. Covid RNA testing is up (not enough), supplies for testing are short nationally, and unlikely to change quickly. The state is ramping up, and we all agree that widespread community testing is critical to safely opening up restrictions. Furthermore, antibody testing, although everyone’s working hard on this, is still not ready for prime time; the accuracy of the tests (false positive, false negative rates) are still too high to be trusted.

3. Cough, Fever, Shortness of Breath, Diarrhea is all decreasing as we reach the end of the worst virus seasons. What does this mean about Covid? Of course, mixed in, is the decrease in visits overall. This curve is worth watching over time as the state “opens up.”

4. Where is the spread across 12 hospitals. University of Colorado Hospital on the far right, Greeley Medical Center on the far left. The higher bumps in the middle are for Poudre Valley, Medical Center of the Rockies, Memorial North, Memorial Central. Some of our hospitals are seeing very little. Interesting regional variation. We are also intentionally protecting some of our hospitals to be Covid-free as much as possible, in case of future surge demand.

5. What about ICD10 diagnoses by docs? You may know that CMS published an new set of ICD10 codes (international classification of disease, version 10) that contain Covid-19: including: Confirmed Covid, Suspected Covid, Exposure to Covid, etc. Grouping them into Confirmed versus Suspected, here’s what you get in our visits since March (orange: suspected, blue: confirmed). This is a reflection of the scarcity of testing. Again, interesting to see where this goes. NOTE: The last down-tick on the orange may be due to counting a partial-week in the data.

So what do we learn?

A. We need more testing to figure out what the community prevalence is.

B. Virtual visits, even scalable at 20x previous volume, will not save the day.

C. Social distancing and stay-at-home are followed quickly by a dramatic reduction of Covid-like symptoms seen in clinics. BUT, be careful of conclusions: social distancing could also have affected the USUAL winter virus spread, OR patients are not choosing to be seen, OR the virus is mutating into a less severe form, OR distancing policies might really be working. Wouldn’t you like to know which it is?

D. ICD10 codes are being used in our clinics! But the trends don’t mean anything yet. It might be promising that “suspect Covid” codes are growing more slowly.

F. Covid is going strong into the late Spring (wasn’t it supposed to evaporate magically likes SARS CoV-1? That outbreak in 2003 largely evaporated by late May, early June). Covid-19 (more accurately, SARS CoV-2) is going strong and is likely to behave quite differently, not a good sign for us humans.

PREVIEW OF NEXT POST: How does testing for OTHER VIRUSES compare to COVID testing results in the late winter/spring? and what does Hemoglobin testing teach us about Covid-19?

CMIO’s take? The lessons from Pandemic are numerous and they just keep coming. Be sure to take a break, and take care of yourself. Don’t worry, I’ll be back soon.

Miso soup v COVID-19.

Miso soup. One of my late nite superpowers.

Here’s a Sunday post: Musing about miso soup and it’s role in my battle with the pandemic. If you’re here for data, clinical informatics, and health system thinking, you can leave now.

FLASHBACK, mid-1970’s.

When I was the age of my youngest niece (okay, my only niece), I remember telling my mother who had just served me a bowl of home-made soup, with a sprinkling of goldfish crackers:

THIS SOUP IS SO YUMMY. I think it must be the goldfish I put in there. Goldfish are the perfect food, and I think I’m going to make a soup just from goldfish crackers and hot water. Mom, can I have some hot water?

Of course I wasn’t watching my mother’s face at the time, I was so sure of my world-shattering upcoming invention: Delicious hot water-and-goldfish soup.

I stood by, as she boiled some hot water for me on the stove. I had carefully selected a big handful of goldfish, and was cautiously resisting eating them, KNOWING that the soup was going to be TOTALLY WORTH THE WAIT. I was bouncing with excitement.

At last, hot water, in a cup on the kitchen table. =Plt-phtl-tlthtpl-plthth-ppth!= I slid all my goldfish from my sweaty palm into the cup, gave it a big stir,

…paused for a drawn-out moment to let the flavors swirl…

And took a big sip.

What did I think? It gradually dawned on me, as my face twisted into a surprised grimace, that the soup was not good … AT ALL. Just a bunch of semi-soggy flavor-less crackers and hot water.

I tried to fix it: added salt and pepper. Even some “Accent” (packaged MSG salt; hey it was the 1970’s! anything goes). Nope. Nope. And Nope.

I finally looked at my mom, who was silently watching, smiling and shaking her head at me. It was a lesson, I suppose, that her son had to learn for himself. Good soup was just not going to be that easy.

FLASH-FORWARD, present day.

I have always been obsessed with soup. Almost every restaurant we go to (or, used to go to), I would scour the soup offerings for candidates. I did let go of my soup-inventing dreams, but have lately been punching out Instant Pot – powered soups like Rosemary Cauliflower and Ginger Carrot, to some pretty good family reviews. But of course, they realize it’s Dad cooking, so the critic-grading-scale is set pretty low and forgiving to start.

Night-times are for miso soup, though. I’m a night owl and do some of my best thinking and working at night, and give me 1 teaspoon of Marukame Boy brand Miso paste, a cup from the hot-water pot, a sprinkling of scallions (pre-sliced and saved in a container in the fridge), and maybe some … GOLDFISH CRACKERS from a huge Costco bag. Heaven.

And, what do you know? Miso soup, consumed daily is supposed to have ability to FIGHT INFECTIONS! Hey! Who needs vaccines or treatments? Daily miso soup for EVERYONE, that’s the ticket. Okay, whatever, no.

Turns out, if my pre-teen self had just known SOMETHING about miso paste, I might have been a chef instead. Happy Sunday, everyone. Hi, Natalie!

EHR v Covid-19. Nurses help families of ICU patients, from home

ICU rounds at PVH, photo credit: Lydia Baldwin

These are our healthcare heroes at work: From ICU rounds at Poudre Valley Hospital, part of UCHealth: Starting from the left standing we have Respiratory Therapy, Palliative Care PA, and Chaplain. Sitting from the left are RN, intensivist MD and Charge RN. In front of the intensivist (in green scrubs) is a telephone on the desk. The telephone is on ‘speaker’ and dialed in to a conference line. Also dialed in are: Pharmacist working remotely, Nurse Communication Liaison working remotely, Social Work.

So many great things going on here: Social distancing as much as practical (too much further and you can’t hear each other over the din of electronic alerts across the ICU), N95 masks (all day every day), reviewing data together from so many disciplines, discussing each patient in detail and taking immediate actions (placing orders, creating consensus on medical decisions, dividing tasks for rapid action).

In times of pandemic, the hospital follows infection prevention protocol and isolates very sick, very infectious patients. In this case, we have grouped and isolated all Covid-19 patients into a distinct unit, away from non-Covid patients. AND, in most cases, patients are not allowed to have visitors.

This is both good medical practice, and heartbreaking to families who cannot be present at a patient’s most desperate hour.

Out of this swirl of confusion, Julie Griffin, Nurse Manager of Care Management, thought: we have highly qualified nurses on-leave at home (orthopedic unit nurses with no post-op surgical patients; pregnant nurses for whom Covid infection would be particularly dangerous); how might they help share the burden of patient care with bedside nurses, and still minimize risk of contagion and exposure?

And so was born: Nurse Communication Liaison. Nurses from home, helping keep families connected, and reducing the burden on bedside nurses. We haven nurses helping with med/surg units as well as ICU’s. As described by ICU nurse Molly:

7AM: My day starts at 7: I review the Epic EHR chart from home for patients in the ICU. I read the notes from the nurses and the doctors overnight in our 12 bed unit. By the way, our unit has moved to double occupancy, and we’ve expanded to be a 23 bed unit. So much has changed, we’re so much busier.

8-10AM: I start receiving calls from family members and I give them updates on their loved ones, that I can, based on what I know. I am using Epic secure chat (a HIPAA-compliant text message service) to communicate with the ICU bedside nurses, social worker, respiratory therapy to get and give updates. I LOVE secure chat because it means the bedside nurse: who is gowned, gloved, doesn’t have to scrub out to answer another nuisance phone call interruption; they can catch up with chat-messages when there’s a break in the action.

10-11AM: Daily ICU rounds (picture above), where the team discusses every patient and I’m on the conference phone. It is a complete team with everyone pitching in.

11AM-430PM: We have designated ONE main contact family member for each ICU patient. We have found it can be overwhelming to have many family members calling each day for updates. I am so happy to be able to serve as the main contact for these family members and unburden our extremely busy bedside nurses to focus on their patients.

Some great unexpected moments:

Jamie: “Bedside nurses often spend 15 minutes on the phone with family. Multiply that by 5 patients and it becomes a big part of your day. We all wish we had more time to talk to families, but we’re often too busy caring for patients. I love helping connect with families and reassuring them.”

Jamie: “One gentleman was was not doing well. He was very quiet on the phone, and would never ask for anything. I spoke with his close friend at home, who noted that he was Jewish, and might appreciate a visit from a Rabbi or the Chaplain. I was able to arrange that.”

Jamie: “Being an ortho nurse on a medical unit, I was anxious at first. But communicating with the bedside nurses by secure chat and occasionally the phone, I found that even if I couldn’t answer families’ questions, I could always find out. Families are always so appreciative of the extra communication. I love this role. It is really awesome.”

Dawn: “The difference with this role is: There’s only the person on the phone. It is quiet at my home on my end. Normally when I’m at the bedside, I’m always trying to ‘wrap up the conversation’ with family: there are so many other things needing my attention. I can really feel good about being focused, connecting with family, and freeing up the bedside nurse to do their jobs.”

Dawn: “I was on the phone with the husband of a Covid patient. I noticed he would occasionally grunt, while we were talking about his wife. I had to ask him: ‘Are you okay?’ He told me he had had a fall, and had to pull on his pant-legs to go up the stairs. I recognized the signs of a major injury. It took some convincing, but I finally got him to call his doctor. Turns out the next day he was admitted and had emergency surgery himself.” As an ortho nurse, she was probably the perfect person to help.

Davida: “Sometimes you can remind the bedside nurse by secure chat: ‘his daughter would like to see his face today. Can you get the tablet in there for a Zoom visit?'”

Davida: “I feel really useful, being able to connect with PT, social work, bedside nurse all by non-interruptive but efficient Secure Chat, and then calling to make sure the family stays informed.”

Molly: “It is completely weird not to be an ICU bedside nurse right now. I think I will be better at charting in the future. Not being able to see the patient lets me understand what families want to know, that I rarely wrote down before: how do they look? are they following commands? can they squeeze? How scary this is for the family, and although it is a tricky role for us, it feels great to be helping.”

CMIO’s take? Thank you to our amazing UCHealth nurses: Lisa Claypool, Julie Griffin, Jamie Deschler, Davida Landgraf, Molly Carrell, Dawn Velandra for their experiences and stories.

UCHealth v Covid-19. The second surge (not what you think)

Mind the Brain Logo

I’m so proud to be part of a multi-disciplinary, talented group of clinicians. Our Department of Psychiatry is gearing up for what may become the second surge of our pandemic, as we relax the stay-at-home orders in Colorado:

Mental Illness. Depression. PTSD. Panic. Suicide.

These terms must no longer carry the stigma they do. There is no shame in reaching out for help. Appropriate and timely treatment can aid a person’s innate resilience and return him or her to health.

We have not experienced a pandemic of this scope for more than a century … We are psychologically inexperienced.

C. Neill Epperson MD

Read more of Dr. Epperson’s ideas and initiatives in this fight for mental health and the major investments UCHealth will be committing to improve the well-being of all residents of the State of Colorado. Welcome to the fight!

UCHealth v COVID-19. Patient success stories

Thanks to the hard work of our outstanding nurses, staff, and physicians, many patients with Covid-19 are pulling through. Here’s a particularly poignant story from UCHealth’s own reporter, Katie McCrimmon. Have your tissues ready.