EHR v Covid-19. Video Visits: How to Improve the Patient Experience

The new normal? No white coat during Video Visits! (c) CT Lin

Executive Summary: We have a global pandemic, daily policy changes, we work from home, have new video tech, and we are learning to communicate and build relationships in new ways. It is easy to forget that there may be a scared patient on the other end, counting on us. How might we improve the patient experience? Some ideas:

IDEA                                                    DETAILS

Secure Chat with your MAScrub your schedule together, days ahead for patients more appropriate for telehealth vs in-person visits, med rec, troubleshooting, visit focus
Arrange your room, selfSee tipsheet in Epic “Demonstrate Professionalism.“ How is: your room, your light, your clothing?
Eye Contactand, put a sticky note on PC cam to “LOOK HERE!”Arrange the camera at eye level if possible. For some, looking down = frowning? Eye contact on video visits is EVEN MORE important. “If I look away it is because I’m looking at information in your chart”. 
Avoid running lateIf you DO, inform your MA by Epic secure chat & they can inform patient
Greet the patientI like to raise my arms in surprise when we connect: every human connection now, is amazing. Maybe thank them for connecting with you. Ask if they’re in a safe private spot (eg: advise patient NOT to be driving!)
Talk, human to humanAsk: how are you coping (aside from medical concern)? Scared? Worried?  
Reflective ListeningEven more important now in this time of anxiety. You can reflect or say back Data, Ideas, Feelings, Values. It strengthens connection: for example  DATA: “It has been 5 days of worse symptoms?”  IDEAS: “so you think it might be gout?”  FEELINGS: “you’re worried about work? Hmm.”  VALUES: “so, what’s important to you is your family.”
PEARLSSome clinicians may have taken the Excellence in Communication course. The PEARLS acronym can also be helpful. Some examples:   Partnership: “We’ll get through this together.”  Empathy: (reflective listening, as above)  Apology: “I’m really sorry that happened.” “I’m sorry for my part in it.”  Respect: “You have worked really hard on this.”  Legitimization: “Anyone in your situation would feel that way.”  Support: “My team and I are here for you. We aren’t going anywhere.”
Physical Exam creativityTeach them to take a pulse “say beep when you feel it” and YOU can count. Patients may have a BP cuff, Pulse ox, flashlight, thermometer. 
Ask for help from familyOthers may help add to history or exam findings
They may ask about YOU as a human“How are YOU doctor? Are you staying safe?” So many surprising comments from patients worried about their doc. Thank them! 
Brief LIFE adviceDuring pandemic, consider: A) Limit news/social media to 30 min/day. B) Exercise daily. C) THREE GOOD THINGS exercise: proven to reduce depression, anxiety if done consistently “What 3 things are you grateful for today?” Can become a great family habit at dinner. 
AVS,
Open Notes
From My Health Connection, they can see your AVS (after visit summary) and your Progress note (called Clinical Note) to remind them of details of your visit. Maybe at end of visit, ask: “Sometimes I don’t explain myself well. Can you tell me what you’ve heard, so we’re on the same page?”
Reassurance and Hope“We’re going to get through this!” “Stay in touch with your loved ones.”
Ending the visitConsider: a handwave OR palms together, nod OR thumbs up OR “You Got This!” Forecast next steps or if your MA will call them after.
Secure chat with your MAHandoff any items after visit for continuity (referral, next visit, lab, etc)

Link to PDF of this document.

And, here is how our Medical Office looks now, deconstructed. One part is in my basement …

The deconstructed doctor’s office (c) CT Lin

And here’s Medical Assistant Becky, hard at work keeping both the patient and the doctor on track at her home. That virus has got no chance against us.

CMIO’s take? Hang in there! You Got This!

Thanks to all my colleagues for letting me “borrow” their ideas for this post.

EHR v Covid-19. Cough, fever, shortness of breath in the data

Okay, I acknowledge that I’m a data dilettante. Hmm. Interesting concept. I guess that is one step up from me being a data ignoramus. Having an anonymized population graphing tool in the EHR leads to amateur data exploration. Come along, won’t you?

DATA SET 1: 3 Years of CHIEF COMPLAINTS

The above graph shows 3 winters of data from our records, chief complaints of patients across our healthcare enterprise (4000+ doctors, several million patients) and number of patients each month with complaints of Cough (purple), Fever (blue), Shortness of Breath (yellow), and Diarrhea (red). Keep in mind: UCHealth grew in size over the past 3 years, with a growing number of hospitals and clinics, so the denominator number of patients is not the same from left to right. It also does not account for individual medical assistant or physician behavior who may or may not enter similar chief complaints across different patients, across different practices.

Nevertheless, I think you’d agree there is an interesting pattern here, including a higher peak of cough and fever this year! Wow: Covid19! But wait, that peak started in January. Unlikely the Covid-19 arrived IN SUCH VOLUME in January. But our old friends, other cold and flu viruses are plentiful. Hmm. So: Rhinovirus? RSV? Flu? See last post.

Look carefully, though, there is an interesting uptick in Shortness of breath in March 2020, out of proportion to the last 3 years … hmm. Interesting, but inconclusive.

And interestingly, diarrhea does not spike in winters, and doesn’t spike this winter either, despite (some) reports of Covid-related GI symptoms. Notably abdominal pain did not spike either (data not shown).

CONCLUSION 1: Fever, Cough, Shortness of breath are prevalent in our region BEFORE major Covid-19 activity, but some peaks seem higher.

DATA SET 2: REGIONAL CHIEF COMPLAINTS

Okay, lets take another step. What if we track SYMPTOMS (chief complaints), group them together and then see if we can find a Hot Spot where ONE region (UCHealth has 5-ish distinct geographic regions) has symptoms going up, disproportionate to other regions?

SURELY this means something!

See the yellow line shooting up at the beginning of March! This is the Denver region, compared to northern Colorado, southern Colorado, and a couple of other regions. These are percentages, not actual volume.

So, what does ACTUAL visit volume look like?

Slightly different view, by county and by actual volume of visits, and now you see a consistent plummeting of patients with “chief complaint” of fever, cough, shortness of breath. What is going on here?

The larger phenomenon is the Social Distancing order 3/21 and then the Stay at Home order on 3/26 by the governor of Colorado. So the sharp drop begins on the week of 3/21 and continues to plummet. At the same time UCHealth ramps up its Virtual Urgent Care and Primary Care service (allowing patients to see healthcare providers by video visits from home), which grows by hundreds and thousands of visits in late March. And who are likely the folks driving up Virtual visit volume at end of March? Yes, probably patients with Covid-19 symptoms.

Furthermore, Denver Metro is (I believe) more likely to have heard of UCHealth’s virtual urgent care and virtual visit service, more so than people in other Colorado communities.

Finally, looking at the newly Covid+ patients in each of our hospitals during that same time frame (not a cumulative hospital census number), you DO see an increase in admissions the week of 3/20, and yes, more cases in the more densely populated metro Denver (blue line) but the peaks are synchronous and NOT trending differently from the other regions. If the divergent yellow Denver line (above) represented a real increase in spread, the below blue line should spike and continue to grow off the chart.

CONCLUSION 2: Be careful what you conclude! Knowing some of the underlying story, I conclude the divergent yellow line is NOT a disease spike, but a change in behavior and a new service starting AND some increased rate of spread in Denver.

DATA SET 3: COMPARE ONE REGION’S SYMPTOMS VS HOSPITALIZATIONS

One more exploration: could chief complaints (Cough, Fever, Shortness of Breath) of patients presenting to clinics BY REGION possibly explain an increase in Covid+ patients a few weeks later BY REGION? Perhaps use the data as an early-warning signal for hospitals that a Surge is coming, that the curve is about to go exponential? A leading indicator and not a trailing indicator?

Here’s Chief Complaint in Denver Metro (percent of visits):

Here’s Chief Complaint in Denver Metro (actual visits):

Here’s hospital admissions for Covid+, Denver Metro:

What is your analysis? Make up your mind … then scroll on.

CONCLUSION 3: I see the “percentage” of complaints start growing steeply on Feb 21. I see the hospitalizations start to rise Mar 13, about 4 weeks later. I see “actual count” of complaints peak and decline after Mar 13. I see hospitalizations peak and decline Mar 27, about 2 weeks later. We Found a Signal!

Danger, Will Robinson!

This is post-hoc data analysis at its best, looking back at the data in hindsight and saying “Of course I was right all along.” It fits a good story, infection rising in the community and the sickest showing up about 4 weeks later, infection falling in the community, and Covid-19 admission cases falling a couple weeks later. Maybe there is some truth here.

However, looking at data and graphs from another region, the Fever/Cough/Shortness of breath curve stays mostly flat, and yet the Covid-19 hospitalization bumps same time as Denver.

Go figure.

I hope this jaunt through the data gets you interested in thinking about data, in seeking patterns, in questioning your findings, in considering viral behavior, disease behavior, human behavior, health system behavior, government behavior.

And, we are thankful that our infection rate, our hospital capacity, our leaders in Colorado, our government/business/public health/health system/community leader relationships are strong and can work well together.

CMIO’s take? Data analysis is hard. Sometimes you find signal. Sometimes you find noise. Sometimes you mistake the one for the other. Armchair theorists and even amateur data dilettantes (including some enthusiastic CMIO’s) should be careful.

EHR v Covid-19. Other Confounding Viruses! and graphing data

The Epic EHR has a tool called Slicer/Dicer that allows clinician-users to set up qualitative analyses of our populations in sophisticated ways. Of course this doesn’t replace the need for report-writers and more sophisticated analyses. But it is amazing what an informaticist can come up with, sitting in an Incident Command Center on an Easter Sunday with unusually few escalation phone calls to deal with.

For example, the curve above shows Influenza Positive test at UCHealth (12 hospitals, 600 clinics) over that past 3 winters: 2018-2020. Be cautious about interpreting the data: UCHealth has grown in number of clinicians and in patient volume, behavior of testing for “flu” may have changed. But it does look like the annual peak of flu positive patients is Jan or Feb each year.

Taking this further, our lab distinguishes Influenza A from B, and looks like “B” positive peaked in December vs “A” peaking in February.

Respiratory Syncitial Virus (RSV) peaked in February.

Rhinovirus peaked in September.

The “other” coronaviruses peaked between December and March.

Human Metapneumovirus peaked in March.

Finally, Our Coronavirus RNA test shows an ongoing increase (that last column showing Zero is an artifact of delayed reporting during my report run).

These are of course Lagging Indicators: trend lines that occur AFTER the fact: patients are in our hospitals, or are positive healthcare workers with symptoms. The constraint of insufficient testing kits to test everyone who has symptoms and indeed everyone who was exposed or has concern, gives us very little surveillance data to look forward for future outbreaks. More on surveillance ideas in an upcoming post.

It does occur to me, that in the coming months and years, that Medical Education could be turned on its head. In the past, I was clever enough to show our medical school leaders that this same Slicer tool could “make the textbook come alive.” For example, a student could create a graph, from existing UCHealth patient de-identified data, that the percent of patients with hypertension increased if you compared those with a BMI of up to 20, then 21-25, 26-30, 31-35, 35-40, and then greater than 40. You could see the that the percentage increased from 5% into the 32% range. Voila: possible relationship between Body Mass Index and prevalence of hypertension!

Repeat with diabetes, high cholesterol, asthma. See what blood pressures are typical for patients on a particular BP medication.

And for our current topic, have students figure out when respiratory viruses peak over the year, instead of reading a book chapter on ‘Pathophysiology of viruses.’ That would be a med school class I’d like to take. Maybe have students help with our CURRENT problem of trying to use our EHR to detect signal for patients about to deteriorate for Covid-19.

CMIO’s take? The EHR is becoming an integral part of how a modern doc takes the deluge of health data and uses that power for good.

EHR v Covid-19. Prepping for the Surge: Inpatient Guide for Outpatient Doctors – Guest Blog

Inpatient Guide for Outpatient Docs: Table of Contents

Covid-19 threatens to hospitalize an exponentially increasing number of patients in the coming weeks. In addition to building more physical space and finding more equipment, what happens when we run out of hospitalists to manage their care? What if, instead of our usual 10 teams of hospitalists, we need 20 teams? Thirty simultaneous teams?

Thanks to CT for the guest-blogging spot.  I’m a physician / programmer working at the University of Colorado and UCHealth, helping our system prepare for the Covid-19 crisis. 

Seeing the the massive surges in patient volume related to the Covid-19 pandemic that befell our colleagues in China, Europe and New York, we knew that we would have to find “surge capacity” among providers in our area.

We guessed that outpatient docs (like CT and me) would be needed to support the inpatient service, where neither of us have been for a long time.

I for one, was relatively panicked by the thought of serving on the inpatient service.  Not only is it a different branch of medicine at this point, more than a decade from my training years, but from an informatics perspective, the workflow is completely different.  I figured that if someone with my (relatively high-level) of comfort with the Epic EHR was feeling stress, others would be as well.

So roughly four weeks ago, I reached out to my informatics colleague on the inpatient service and suggested that we leverage our existing training videos to quickly produce a comprehensive written and video guide to the inpatient service, targeted at these likely recruits.

He and I, together with three other hospitalists, another outpatient internist and an informatics neurologist, quickly compiled a comprehensive document of workflow and tips.

We were gratified to find that a large number of internists practicing outpatient (clinic) medicine were willing to serve as part of the Surge teams and were interested in this just-in-time training.

There was so much interest in our training tools (document plus embedded videos) that the University of Colorado General Medicine division re-arranged the Grand Rounds schedule, and we presented this material to 150 interested outpatient internists at this week’s Grand Rounds, held by Zoom meeting.

We are so grateful that our cross-specialty relationships and shared technical expertise that are unique to informatics allowed us to create and present this material in a matter of days. Our wish:

  • That our surge of hospital patients is manageable
  • That our hospitalists stay safe and healthy
  • That any outpatient providers who are called to duty stay safe and healthy
  • We are grateful for the role we’ve played, and will continue to play
Rich Altman, MD, University of Colorado

I hope that you can benefit from these documents. However, the longer view and greater message is the value of a strong informatics team which is uniquely positioned to rapidly mobilize and meet unforeseen needs.

Richard Altman, MD

EHR v Covid-19. Pandemic Drives Patient Portal Signup (and helicopters and dinosaurs)?

More CMIO armchair theorizing

Amidst the furor of the health industry struggling to battle a microscopic foe, there are some interesting tidbits. And a data update, thanks to a question by @TheLizArmy on Twitter.

Here’s the TL;DR: Pandemic concerns, relaxation of Federal rules and Stay-at-home orders have resulted in explosive growth in our patient-portal sign ups at UCHealth. We went from 66% to 72% of patients seen between February and April 2020 with an active Patient Portal account. Look at the sharp up-tick. We are now at 700,000 online patients from 650,000 last month! AND, as of yesterday, our Video Visit count exceeded 4000 PER DAY.

All because of a tiny micro-capsid of proteins and a short strand of RNA.

Evil RNA-based life form? Can’t we just get along?

==INSERT SHORT AUTOBIOGRAPHIC ASIDE HERE==

In 1984, I spent a summer studying under Richard Goldstein PhD at the Harvard Medical School Genetics and Microbiology Department, and writing my thesis on the genetic makeup of the P4 bacteriophage, cutting and splicing DNA to figure out how the darn thing worked.

I stayed for the summer with a friend in an apartment on Massachusetts Avenue, and would ride my bike through Cambridge, over the Charles River and into Boston and the Lab. It was a good summer; I even decorated my bike helmet and called it my Bike Capsid:

Actual photo I printed and glued on my bike helmet in 1984

I celebrate my nerdiness.

A capsid is what the virus packages it’s DNA into to travel between bacteria. The tiny feet are what stick-it to a bacterial cell wall, and the tube is what the DNA is injected through, into the innards of the cell, like pirates commandeering a hapless merchant ship.

It so happened, that one late morning, the traffic was backed up for a half mile at the bridge over the Charles; a traffic cop guarded the crossing. I rode up on my commuter bike: “Hey Officer, what’s going on? Why is the bridge closed?”

He looked at me with disgust? boredom? and replied:
“Dinah-soah comin’ up the ri-vah” and walked away.

Dinah … WHAT?!

I turned to a nearby passenger on a public transit bus with an open window: “Did he just say: “Dinosaur coming up the river?” The guy just shrugged.

And sure enough, about 15 minutes later, the sounds of a helicopter, with a museum-quality dinosaur underneath, coming up the river to its new home at the Museum of Science. My summer was never the same after that.

Seriously? (from Arthur Pollack, https://www.boston.com/culture/lifestyle/2015/08/31/this-is-the-story-behind-my-favorite-photo-of-boston)

==END OF AUTOBIOGRAPHIC ASIDE==

Which is all to say: me and viruses, we go way back. And Dino’s are sometimes the hero of the story.

And while I’m meandering, it is fascinating that humans, in their slow, inevitable, dino-like lurch toward progress, sometimes put up such barriers (Federal Medicare prohibition of paying for telehealth, HIPAA Privacy concerns stopping the use of commercial 2-way video, cross-state prohibition on the practice of medicine) that we get in our own way. And then it takes a tiny little single RNA strand and a couple of proteins, to change the globe, and our lives.

The uptick on the curve above proves that humans crave connection. The uptick looks kinda like … the neck of a dinosaur? Anyway, here’s proof that dinosaurs are still ready to battle viruses on behalf of humans, growling in the Command Center at UCHealth.

CMIO’s take? What is your interesting back-story? Lately, we only have one channel in our brains: survive and defeat Covid-19. But we are so much more interesting to each other than that.

EHR v Covid-19. From the front lines: Virtual Visits take off at UCHealth. The Covid-19 burning platform

In-person clinic visits by week (red) and virtual visits (blue) at UCHealth, part of 2019-2020: UNVALIDATED DATA (red blips are likely Thanksgiving and December Holidays)

As recently as 2 months ago, we, the virtual visit leadership team, sat in a conference room bemoaning our fates: HOW will we get our 4000 providers (doctors and advanced practice providers) to start conducting Telehealth or Virtual Visits with patients? In all of 2019, our organization conducted about 2700 visits between providers and patients. This was a disappointing number, having spent a year integrating a 2-way video system (Vidyo) inside our Electronic Health Record (Epic). This was also disappointing because the state of Colorado passed the Parity law requiring insurers to reimburse healthcare providers the same rate for video visits as with in-person visits. What else could one want? Video visits for everybody!

Not so fast.

Turns out, doctors are humans too: you figure out a way to do something well (in-person visits with all your equipment for vital signs, sensors, gee-gaws, tests, fine-tuned teamwork honed over decades of practice), you don’t wanna change.

“If it ain’t broke, don’t fix it.”

CT’s inscrutable high school coach, to an uncomprehending student

We came up with all sorts of leadership plans to increase video visits: more education to front-line physicians (not helpful); sending experts to clinic to tout the benefits (nope); introducing video visits to clinicians already on bundled payments, such as surgeons whose post-op visits were no-fee (slight adoption). Video visit adoption was a local phenomenon: a few docs found it useful and did several hundred visits that way over the course of a year, and most others did not try it. Finally, we did get some traction by dedicating some urgent care docs to Virtual Urgent Care, for either a flat $49 fee or co-pay with participating insurers. For the most part though, bupkis.

In the graph above, the blue line indicates fewer than 100 video visits a week leading up to … March 2020.

And then, we know what happens next: PANDEMIC. Social Distancing. Stay-at-Home order from the governor. Suddenly clinic in-person visits plummet. And all across our 600 clinics: “Hey, wasn’t there someone here last year talking about some kind of video-thingy that we could use to see patients? Anybody have their phone number?”

We are luckier (or perhaps more prepared) than most other healthcare organizations:

  • We already integrated video into our EHR
  • We have a high-functioning IT infrastructure on a single EHR
  • We have a strong informatics group (physicians, APP’s, nurses)
  • Our clinical and administrative leaders collaborate well, and nimbly

And, okay the Feds helped:

  • CMS relaxed the rule prohibiting Medicare from paying for video visits
  • HHS relaxed the rule for HIPAA-regulation on providers of video (allowing for Skype, Zoom, even FaceTime), not that our organization needed this.

As a result, within a week of that first pandemic-related request from our providers, we scaled from 2700 visits in ALL of 2019, about a dozen per day, to 3000+ visits PER DAY. Lets say that again:

Video visits went from a dozen per day to 3000+ per day within a week

That’s just crazy talk. And also proof that John Kotter is STILL right, from his book Leading Change: Your first step is a creating a sense of urgency: a Burning Platform. And boy do we have one now, thanks to a microscopic life form .

And now? Now, I sit here in my home office, with my laptop and my smartphone connected, waiting for my next patient, who is visiting me from their home, arranged by my medical assistant, sitting at her home. Our bricks-and-mortar medical office is 2/3 empty, with a reduced crew seeing in-person visits for those without video visit tools, or needing physical exam or other services.

When we connect, every interaction feels like a victory. Every “return visit” feels like re-connecting with an old friend. In fact, I reflexively raise both arms like our team scored a goal:

“You made it!”

“Yes, I did!”

“It is GREAT to see you!”

“Yes! And how are YOU, doctor? Are you doing okay?”

The empathy of patients toward ME and my colleagues, is touching, and genuine, and so much appreciated. Unbiased opinion: longitudinal primary care internal medicine has the BEST patients in the world. Truth.

CMIO’s take? We are creating a new healthcare world, by necessity. Will we ever go back?

COVID Incident Command: a day-in-the-life

The author, defended by his creature creations.

A recapitulation of a series of tweets about my recent experience at the UCHealth’s command center. I rotate the responsibility for the physician support position with about a half-dozen other docs. The command center has been up for almost 3 weeks now.

1/ A day @uchealth Incident Command Center. Constant stream of calls. Room is full of experts (infectious diseases, pulmonary, disaster) with a dozen other directors. Like being the frontal cortex of a massive organism…

2/ If you’ve never served in a Command Center, it is scary as heck, and also exhilarating. Things happen and decisions are made in minutes and hours, not weeks and months, as is more usual in a large organization… is that

3/ Sample incoming call: ‘ICU wants to know whether to send a second COVID test nasal swab on a patient whose test was negative yesterday but the team has high suspicion they have COVID.’ (Yes, not via nasal swab, but by tracheal aspirate for better sampling)

4/ Sample call: ‘Community organization purchased 10 COVID tests somewhere; would we send a medical assistant to perform swabs on their employees.’ (No, test performs poorly for patients with no symptoms.’ and, how do you choose who to swab? And, what would you do differently if you have a result? negative: stay home. Positive: stay home(!)

5/ Sample call: ‘Hey, if ventilators are scarce, we could build Iron Lungs faster: want some?’ (After internal discussion, no: COVID is associated with ARDS (adult respiratory distress syndrome). ARDS causes stiff lungs, unlike polio, and even then they didn’t work well), AND, how to manage IVs and catheters?

6/ Our converted conference room now is 24/7 staffed with executives, directors, nurses, doctors, staff who connect to every part of our 12-hospital, 600 clinic, 4000 provider system. Kinda like a neocortex…

7/ We sit and take calls from all over the system, clarifying the daily-changing policy, delivering nimble responses to moment-to-moment events in our EDs, our clinics, our hospital wards …

8/ We huddle in purposeful groups through the day: medical officers, informaticists, nurse leadership, respiratory therapists, ICU teams, hospitalists, data analysts, facility managers, tent-building teams(!) …

9/ We ‘run the board’ twice a day to ensure our top issues are addressed, re-prioritized, to keep our eye on the ball: racing ahead of the coming tsunami of COVID-infected patients collapsing on our doorstep…

10/ We marshal our supplies, build negative pressure rooms, re-allocate staff, negotiate new partnerships, create and dissolve projects to solve immediate problems…

11/ Dramatically expand our Virtual Health Center for Virtual Urgent Care, expand our nurse call line to handle COVID concern calls, go from 2700 virtual visits last year to 3000 virtual visits per DAY this week…

12/ Discover new trends: hypoxic COVID patients who are surprisingly not short of breath, patients who oxygenate better laying on their stomachs, how poorly bleach wipes interact with electronics(!) …

13/ We tearfully celebrate improvement: today a cluster of patients successfully extubated from the vent, a few patients de-cannulated from ECMO, a hallway of nurses applauding an ECMO survivor…

14/ And yet we have fun… Jurassic organisms battle for supremacy while modern organisms do the same.

15/ Our loyal administrative intern asked our Incident Commander at the end of her day shift: ‘How do you feel? How do you think we’re doing?’ …

16/ Her reply: ‘For the world, terrible. For our country, very worried. Here, we have prepped well, we have a great team, we forecast constantly, and we are going to meet this challenge.’ So proud of her, and us.

Is this our Midway moment with COVID?

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.

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.