T Minus 5, 4, 3, 2, 1, and We Have Pharmacogenetic Results in the EHR

For 4000 patients, we now have data and reminder tools to notify clinicians of important drug-gene interactions at the time of prescribing.

by GUEST BLOGGERS: Christina Aquilante PharmD and David Kao MD

The Go Live

The morning of Wednesday, December 1, 2021, members from the Colorado Center for Personalized Medicine (CCPM), UCHealth IT, and BC Platforms teams surrounded their home computers, fixated on a Microsoft Teams channel. It had all the feels of a space shuttle launch. The teams had been working for five months to upgrade the CCPM Biobank pharmacogenetic (PGx) return of results pipeline. Today was the big day – CYP2C19 and SLCO1B1 PGx results were about to be returned to the UCHealth Epic electronic health record (EHR) for Biobank participants.

8:22 am. “Good morning! Happy go-live! Kristy Crooks, Biobank Laboratory Director, will be signing off the first plate at 8:30 am.” typed UCHealth Project Leader, Emily Hearst.

8:30 am. “Please post in the Teams chat when you sign off on the first plate. We know there will be a delay as the plate is being processed,” typed Emily Hearst.

8:32am. “Plate signed off. Not seeing a result in Epic yet,” typed Kristy Crooks.

8:36 am. “PGX molecular was resulted!” typed Kristy Crooks. A flurry of emojis followed.

8:37 am. “Yesssss!!! Strong work all!” typed CCPM Medical Director, Dave Kao.

The teams worked for the next few hours troubleshooting minor technical glitches and testing more plates.

12:21 pm. “We have success!” typed UCHealth Systems Architect, Katie Hess.

The Biobank that returns Clinical Results

The success of December 1st’s go-live was a culmination of years of hard work from many different teams. In 2015, CCPM partnered with UCHealth to establish the Biobank Research Study. As part of the study, UCHealth patients are asked to provide a blood or saliva sample for genetic research. There is also the potential to have clinically actionable results (e.g., PGx) returned to them and their EHR. Prior to 2021, PGx results had been returned for some Biobank participants but the return process was put on hold to upgrade some of the IT infrastructure. After an incredible team effort, the revised IT pipeline launched on December 1, 2021 and

almost 4000 Biobank participants have now had CYP2C19 and SLCO1B1 results returned to their UCHealth EHR and patient portal.

Christina Aquilante, PharmD

CYP2C19 is an enzyme that metabolizes medications such as citalopram, escitalopram, clopidogrel, proton pump inhibitors, and voriconazole. Due to genetics, approximately 60% of patients are not CYP2C19 normal metabolizers, which can influence medication efficacy and safety. SLCO1B1 is a protein that transports statins into the liver. Approximately, 28% of patients have decreased or poor SLCO1B1 transporter function. This can lead to an increased risk for statin-associated musculoskeletal symptoms.

Given that > 30 million Americans take statins annually, this seemingly small risk [genetic variant] can ultimately affect a lot of people.

Christina Aquilante, PharmD

The “Last Mile” Problem

The questions that get asked most often by clinicians are – How will I know if my patient is a Biobank participant? How will I know if they have CYP2C19 or SLCO1B1 results? What do I do with this information clinically?  How often are these alerts going to interrupt what I’m doing?

The good news is that the CCPM and UCHealth teams have built clinical decision support tools to notify clinicians of important drug-gene interactions for Biobank participants at the time of prescribing. In other words – clinicians don’t need to look for it – the tools will tell them when it is important. Currently, PGx CDS tools are live across the UCHealth system for 17 medications affected by either CYP2C19 or SLCO1B1. These tools contain guidance for how to modify drug therapy based on the patient’s PGx results.

In the cable TV industry, this used to be called the “Last Mile” problem, where a cable company could build a terrific network of cable channels, underground cables and signal transmitters, and yet that “last mile” to the customer’s home, determines if the customer gets any benefit.

Importantly, the teams took great care when designing the CDS tools, and most of the tools are highly visible and yet non-interruptive in nature, i.e., they will not stop a clinician’s workflow. As of February 14, 2022,

301 drug-gene interaction alerts have fired in clinical practice for 268 Biobank participants.

David Kao MD

The most common alerts are for proton-pump inhibitors (PPIs), followed by es/citalopram, and then statins. The work to date is just the tip of the iceberg for the CCPM Biobank PGx return of results initiative at UCHealth. The team is in the process of preparing for another gene launch in early summer – this one for DPYD, which affects the chemotherapeutic agents 5-fluorouracil and capecitabine. Simultaneously, the teams are planning for the deployment of a Genomics Module in Epic and testing out new genotyping platforms with more extensive PGx variant coverage. When these pieces are in place, the sky’s the limit for PGx at UCHealth.

Christina Aquilante, PharmD, Professor
Director of Pharmacogenomics, Colorado Center for Personalized Medicine

David Kao, MD, Associate Professor
Medical Director, Colorado Center for Personalized Medicine

Thanksgiving #2 During Pandemic: giving thanks

Dear Reader. This is an email I sent to my Large PIG (physician Informatics Group) this week. I wish you all a restful holiday. CT

Dear Provider Informatics Group members: My General Medicine Division Chair sent this today, and it makes me reflect about Thanksgiving. I wanted to pass this along to you. It has been 20 months of chaos, emergency changes and emotionally draining life at work and outside work.

“The arc of the moral universe is long, but it bends toward justice.”

Martin Luther King

It is a reminder that in our day-to-day, all we see are boulders and rockslides in our path. In the long run we are bending the path to reduce burnout, improve connection and improve care. Our work affects 6000 providers, 15,000 nurses, and a couple million patients. 

I am thankful to be on this journey with you. I hope you can take some time this week with family and loved ones. CT

—–

From: Earnest, Mark
Subject: Giving thanks 

Dear GIM Colleagues,

Ms. Sutton, my third grade teacher, taught me to start letters that way – with the word “dear.”  

Since leaving her classroom, I’ve not really given the word much thought.  Aside from placing it at the start of letters, or employing it generically as a term of endearment for my wife, I haven’t used it much.  I use it even less now since “hi” or just a stand-alone first name have become de rigueur for email greetings.  Using it less, I think, is a mistake.   According to Google, “dear” means “regarded with deep affection; cherished by someone.”

Today, I want to use the word with intention. 

So, let me start again.

Dear GIM Colleagues,

We are approaching the one day in our calendar each year that we set aside for thanks.  I’ll confess that after 20 months of the pandemic and all the associated fire-drills, chaos, and public acrimony, I’m much more facile at bringing to mind the things I’m not thankful for.  That may be the most compelling reason to devote my attention this week to its intended purpose – focusing on the things in my life that I cherish and regard with deep affection. 

I’ll not bother you with my gratitude list in its entirety other than to say how much I look forward to a house that is again filled with its full complement of family.  I do want to reflect for a moment on work.

As a young man, choosing a career path, I was clear about one thing.  I didn’t want a job.  I wanted a purpose.  I was fortunate to find that calling in medicine and ultimately in GIM.  I chose well.  I have always loved caring for patients.  Along the way, I’ve found other, related opportunities for growth and points of purpose: teaching, mentoring, helping others find and actualize their purpose…  In all honesty, work for me has been a great source of joy and satisfaction.  A wonderful side effect to finding my purpose, has been the privilege of working alongside other purpose-driven people.  If I could start from scratch and hand-pick a group of people to take this journey with, I could do no better than you – my dear GIM colleagues.  It is a profound privilege to be part of such a caring, committed, selfless group of people. 

Now – after twenty long months and in the midst of a surge – is almost certainly not the easiest time for any of us to hold our work dear.  It has been hard.  Nevertheless, it is possible to be tired, even exhausted, and thankful at the same time (ask any marathoner at the finish line).   Unfortunately, we are not yet at the finish line.  We have a challenging winter ahead of us.  That in and of itself should be reason to pause and reflect. 

I hope this week that each of you can find a moment to consider our common purpose(s) and find the space to be thankful for it.  Doing so need not deny the challenges we’ve faced or the sacrifices made.  Each day, in ways big and small, you have all made our world a little better.   Because of your work, each day there is a little less suffering, a little more hope and a little more knowledge and understanding.  Surely that is worthy of thanks. 

I am not aware of much more we can do to turn the tide of the pandemic.   Somewhere ahead of us is a finish line.  We will face more challenges before we cross it.  We cannot control all of those difficulties, but in the months ahead, we will be focusing on the ones we can change.  We will be looking closely at the circumstances and structures that impede our purpose and make our work, particularly our clinical work, more difficult and less joyful.   We will be looking for meaningful, actionable ways of rethinking and restructuring our work to make it more joyful and sustainable.

In the meantime, I hope you all can find the space to feel thankful for what you’ve done through this great time of trouble.  I am thankful for each of you my dear colleagues, and hope that this week you will enjoy rest and gratitude among those you hold most dear. 

With gratitude and thanks,

Mark

Mark Earnest from History Colorado dot org website

Mark Earnest, MD, PhD, FACP|Professor (Pronouns: he, him, his)
Division Head –  General Internal Medicine
Meiklejohn Endowed Chair of Medicine

Transporting patients in the Covid Bag (guest post: Gary Breen MD)

Despite N95’s and protective gear, the entire Life Flight Crew came down with COVID the last time they transported your patient on a ventilator to a higher level of care. Now what?!

The Problem

How are intubated and ventilated Covid-19 patients transported?  As a hospitalist located at Yampa Valley Medical Center in Steamboat Springs, I have had to intubate and initial mechanical ventilation on a number of patients infected with Covid-19. 

Initially, following the onset of this pandemic, these critically ill patients were being transported via rotor or fixed wing aircraft to our larger UCHealth facilities on the Front Range for optimal care by flight crews donning PPE which included N95 masks, goggles or face shields, gowns and gloves. 

Despite this protective gear, many of the flight crews contracted Covid, which resulted in some emergency transport services becoming grounded until crews could recover.  A better, safer option for transporting these patients was needed.

The ISO-POD

Originally developed to transport patients infected with the Ebola virus, The ISO-POD is negative-pressure patient isolation and transport system which allows us to safely transport critically ill Covid-19 patients, while simultaneously providing protection to our emergency personnel.  The device has a port which allows for ventilator tubing, IV lines, and monitoring lines to pass, as well as 12 gloved iris openings to allow the flight crew staff access to the patient from head to toe. 

Packaging the patient

The patient is placed into the ISO-POD, and the bag is closed and sealed, then sterilized over the exterior surface to allow for transport.  Air movement into and out of the device passes through filters to remove viral pathogens, ensuring that flight crews remain safe during transport, which can only occur in a fixed-wing aircraft. 

Packaging patients up in the ISO-POD is a logistic challenge, often requiring 1-2 hours for crews to safely prepare patients for transfer.  The majority of our transfers from Steamboat are via Classic Air, who maintain three reusable ISO-POD devices, and a flight crew of over 300 people.  The ISO-POD has allowed Classic to transport numerous Covid patients without any crew infections.

Keeping our flight crews safe, and allowing hospitals to fight this thing together

The “Covid bag” has become an invaluable, and all too familiar tool, allowing us to transfer our critical Covid patients to larger UCHealth facilities in order to receive optimal care, while still keeping our flight crews safe.  As a physician caring for these patients, I am incredibly thankful to our dedicated flight crews for job they do, and appreciative of innovative technology such as the ISO-POD.

Gary Breen MD
Physician Informaticist
Hospitalist, Internal Medicine
Yampa Valley Medical Center, UCHealth

Social Distancing reduces more than just COVID-19: Guest Blog (Dr. Eric Glissmeyer)

Dr. Glissmeyer, informaticist, Utah, notes that emergency department visits plummeted in March and are much slower to rebound. Why?

During many winter seasons, pediatric hospitals are bursting at the seams. RSV, Human Metapneumovirus, and other respiratory viruses like non-SARS CoV-2 Coronavirus cause significant disease burden sending pediatric specialists scrambling to find space to admit children with bronchiolitis who need supplemental oxygen and other forms of respiratory support. Patients with the same viruses will “double bunk” in single rooms to receive life-saving care. 

2020 has been very different. COVID-19 was announced to have arrived in Utah March 6, 2020. March 13 2020 Utah schools announced that beginning March 16 online home learning would begin and Saturday March 14 the first case community spread of COVID-19 was confirmed. March 16 the Utah Department of Health issued a public health emergency limiting some services and businesses and Intermountain Healthcare and University of Utah Health announced elective and non-emergent surgeries and many non-urgent ambulatory services would be canceled. March 27 the Governor issued a “Stay Safe, Stay Home” directive. Social distancing during these months, via economic and public gathering restriction, was the only public directive. Mask wearing in Utah did not become widely encouraged until July 2020.

As a result of these social distancing measures, we have witnessed a dramatic decrease in infectious diseases. The following data are from germwatch.org and contain data of common infectious disease prevalence in Utah, as identified by testing performed at and sent to Intermountain Healthcare labs, clinics, and hospitals.

Utah disease prevalence, tests performed at Intermountain Healthcare labs
Group A Strep dropoff quicker in Spring 2020

We have seen a drop in Emergency Department census that is unprecedented. We attribute this change to the decrease in circulating viruses, commonly spread bacterial pathogens and different healthcare consumer choices. In over 15 years, we have not seen ED volumes in the low ranges we are consistently seeing them now. 

Even as many economic restrictions have lifted in recent months, ED census remains lower than previous. At this point, we are uncertain which of the following influencers are playing roles, if all, or others?

  • Health care consumer choices (avoiding health care)
  • Social distancing reducing disease transmission
  • Mask wearing reducing disease transmission as social distancing/economic restriction has begun to lift

Emergency departments are a clinical service entirely dependent upon what is referred or self-referred to them. Yet they are a critical part of the healthcare system for unexpected, emergent care and as a venue for coordinating complex care.

Unprecedented dip in ED visit volumes, Spring 2020

We are seeing an apparent, but slow, increase in ED census over the past 3 months. Much slower than the stock market rebound 😉

July 2020 Daily Census Range: 57-92 July 2019 Daily Census Range: 79-120

Our hospital and others around the country have been bursting at the seams with seasonally variable infectious diseases like RSV and influenza. We now know that social distancing behaviors that decrease disease transmission can have a significantly decrease disease transmission. Data from the Southern hemisphere indicate that influenza season may be better than previous years, perhaps because of societal behavioral changes.

-Eric Glissmeyer, MD
Associate Professor, Department of Pediatrics, University of Utah
Division of Pediatric Emergency Medicine, University of Utah
Medical Director, Care Transformation Information Services, Intermountain Healthcare

EHR v Covid-19. Leading Indicators and COVID-19 Hospitalizations by Region (Guest Blog: Brendan Drew, UCHealth data scientist)

The Covid-19 pandemic is still quite uncontrolled in the US.

In this post, we’re going to walk through an analysis that was conducted by the UCHealth data science team looking at “leading indicators” that could help us to plan for a coming spike in COVID-19 inpatient hospitalizations before we actually see an influx of bed demand.

Perhaps, if we start to see more patients reporting a cough, fever, chills, and other flu symptoms, we would expect that this may indicate a growing spread of COVID-19. However, can we actually use the prevalence of these symptoms to predict how many ICU beds will be needed for COVID-19? What about less common symptoms of COVID-19, such as loss of smell or taste, that have been shown to be more predictive of COVID-19 infection?

While this may sound like a relatively straightforward question, there are a number of confounding effects that make it difficult. The above graphic shows the number of patients making an outpatient or virtual office visit due to a fever. As expected, there is a general downward trend as the seasonal influenza season subsides. However, there also appears to be a “spike” in reports of fever in early March in our Northern Colorado geography (orange line). Could this spike be quantified for future predictions?

Defining a “symptom” in our Epic electronic health system is complex. For example, symptoms can be documented as the “reason for visit”, but a medical assistant may or may not choose to report all symptoms as the visit reason. Besides “reason for visit”, our Epic team has developed a COVID-19 symptoms checklist that screens patients at check-in (completed by front desk staff). This list was expanded substantially in the midst of the epidemic based on new evidence (for example, loss of smell). The consequence is that we saw an increase in reporting of these symptoms in April, due to the new data fields, while our actual number of COVID-19 inpatient cases was declining. In short, there is a significant amount of noise to parse through before arriving at a prediction we can trust.

How did we go about identifying the signal from the noise? Knowing that there was no “right” answer, we tested different approaches. I’m going to focus here on the most recent modeling attempt that we have found to be most insightful. We started with the premise that the correlations between our independent variables (reported reason for visit, reported COVID-19 symptoms, and documentation of ICD-10 billing codes indicative of confirmed or potential COVID-19 infection) and our dependent variable (number of COVID-19 inpatient hospitalizations) would change over time due to trends in seasonal influenza and introduction of new codes/data elements in our EMR system. We therefore constructed separate linear regression models for the months of March (when the epidemic hit and we did not yet have IT system capabilities for tracking many symptoms), April (when COVID-19 cases hit their peak and then declined, accompanying a ramp-up in new IT system capabilities), and May (something of a “steady state” when seasonal influenza had passed and no major IT updates were made regarding COVID-19 symptoms or billing codes).

We wanted to test a large number of independent variables, and therefore chose to use a linear regression method known as LASSO regression instead of the traditional OLS modeling technique. LASSO regression introduces a regularization parameter that penalizes large coefficients in the model. Instead of optimizing to minimize prediction error, the model minimizes the below cost function:

  • Y: Dependent variable
  • X: Independent variable
  • β: Regression coefficient
  • λ: Regularization parameter
  • n: Number of observations
  • p: Number of independent variables in the model

In plain English: we reduced the complexity of the model and thus reduced the chance of spurious correlation or the influence of random “noise” in the data.

Our independent variables were reported outpatient symptoms and diagnoses in the seven days prior to the index date, and our dependent variable was the number of COVID-19 hospitalizations in the seven days after the index date. For example, on May 1 we fit the numbers of reported symptoms and documented ICD-10 codes from the prior 7 days (4/24-4/30) to the number of hospitalizations in the next 7 days (5/1 – 5/7). An astute reader will note that our modeling approach violates one of the tenets of linear regression modeling in that the observations are not mutually independent, but rather a time series. To mitigate this issue, as well as the small number of observations in a given month, we used a procedure drawing bootstrapped samples from each month 100 times, and for each sample, using a 5-fold cross validation process to determine the optimal regularization parameter, fit a LASSO regression model. A bootstrap sample is a random sample of the same size as your original data drawn at random with replacement from the original data, so in some samples data points for 5/1, 5/2, and 5/3 will all be included, some may only include 5/1, and some may include none of those data points.

Once again giving a simple English translation for those less interested in the modeling approach: we introduced some randomness to our data to give ourselves better confidence in our estimates of the linear correlation between each variable and our outcome of number of future COVID-19 hospitalizations.

The below table summarizes, by month, the average correlation coefficient from all of the LASSO regression models fit to bootstrapped samples of data from that month, sorted in decreasing order by the value in May. Please interpret the nomenclature as follows:

  • reason_visit: Indicates the variable is the reported reason for visit in an outpatient or virtual encounter
  • symptom: Indicates the variable is one of the COVID-19 symptoms selected from a checklist by clinicians at the beginning of outpatient/virtual encounters
  • icd: Indicates the variable is documentation of an ICD-10 code referencing confirmed or suspected cases of COVID-19
Variable NameMarch CoefficientApril CoefficientMay Coefficient
reason_visit_COUGH-9.809771.9958827.786421
reason_visit_FEVER-0.738250.4876012.66054
reason_visit_CORONAVIRUS CONCERN1.167884-0.160122.399324
symptom_Fever-0.527060.5537180.626149
reason_visit_SHORTNESS OF BREATH0.71668500.599447
icd_B34.23.0065470.2977230.311514
symptom_Vomiting0-1E-150.22527
symptom_Diarrhea000.179083
symptom_Shortness of breath0.241053-0.013260.134918
symptom_Cough2.255370.1000870.042621
icd_R68.89-0.427230.7904270.020276
icd_Z20.8280.254416-0.101330.002899
symptom_Red eye000
symptom_Loss of smell000
symptom_Rash000
symptom_Joint pain000
symptom_Sore throat000
symptom_Bruising or bleeding000
symptom_Weakness000
symptom_Abdominal pain000
symptom_Loss of taste000
symptom_Muscle pain00-0.10438
symptom_Chills00-0.15124
symptom_Severe headache0-0.53023-0.16017
icd_U07.10.253596-3.47782-0.24094

The strongest positive correlation with future COVID-19 hospitalizations in the month of May was “cough” as the reason for visit. At first, the trend in this correlation over time seems counterintuitive. Why would we see such a strong negative correlation in the month of March but a strong positive correlation in the month of May? Well, a reasonable hypothesis has to do with the ramp-up in COVID-19 testing coinciding with the end of the 2019-2020 seasonal flu. In March, we saw an overall decline in patients seeking outpatient care for a cough, likely due to both the end of seasonal flu and social distancing keeping patients from seeking treatment at medical facilities, while we simultaneously initiated widespread COVID-19 testing at our inpatient facilities and saw a rapid rise in confirmed cases. In May, by comparison, there was no noise from the seasonal flu influenza and no significant backlog in testing to ramp up.

We can also look at the distribution of the regression coefficient for the cough variable in our bootstrapped samples to better establish our confidence in the value. The below histogram shows the distribution of the coefficient across all 100 bootstrapped samples for the months of March (blue), April (orange), and May (green). Notice that for a large number of samples from March and April, the coefficient is near 0, while for the month of May it ranges consistently between 5-10. What does this mean? It means that a few data points in March and April are likely having a disproportional impact on the estimate of the linear correlation, while the correlation in May is more consistent regardless of which dates are sampled.

Examining the scatterplot for the month of May, we see that this linear correlation does appear quite consistent across the time period.

After all of this analysis, what are our big takeaways? Can we take our regression model for the month of May and start using it to predict bed demand? Unfortunately, this would be unwise. One month of data is too limited a timeframe for us to be confident in our model. While we see a significant correlation between patients seeking treatment for a cough and inpatient COVID-19 hospitalizations in the month of May, both variables declined over the majority of the timeframe. We would feel significantly more confident in our model if we observed a spike in inpatient hospitalizations preceded by a large number of patients reporting in outpatient settings with a cough, as opposed to the continuous decline. Hopefully, this never happens, but we believe a second wave of COVID-19 infections is very probable by at least next Fall or Winter. Our plan is to continue to update our model with new data, potentially including new data sources such as patient engagement with our Patient Line call center resources or Livi chatbot feature, through the next wave of infections and observe performance before deploying to assist in the management of hospital resources.

–Brendan Drew, UCHealth data scientist

Dialing in to an Aging Parents Telehealth Visit… Why aren’t more of us Doing it? (Guest Blog: Glenn Sommerfeld)

I forgot about my father’s memory and neurology clinic visit even though I had promised to go down to Denver with both of my parents to help them navigate the complex world of healthcare four months before.  A lot changed in those four months, most notably COVID-19 swept across the world and made its way into the US.  The pandemic placed my aging parents at a greater risk if they contracted the virus while traveling from Fraser, Colorado to Denver and my work schedule was beyond capacity as I added Federal and State COVID-19 reporting coordination to an already full project portfolio.  How could a take a day and a half off work?  How could my parents stay safe?

Telehealth and Rural (Mountain) Living

I decided to move on from my first health care job in neurophysiological monitoring to acute care in 2011.  I also wanted to move to the mountains of Colorado.  My parents already moved from Colorado Springs to Fraser, just outside of Winter Park, Colorado.  Yampa Valley Medical Center brought me on as a quality analyst before they were part of the UCHealth system.  After moving to Steamboat, I realized how remote and isolated Steamboat Springs, Colorado was from Denver and the other “Front Range” cities in Colorado.  Here are some fun facts about driving from Steamboat for medical care:

  • Steamboat Springs to University of Colorado Hospital and the Anschutz Campus
    • 169 miles
    • 3 Hours and 10 minutes if traffic is good
    • One major mountain pass (or two if Eisenhower Tunnel is closed)
  • Steamboat to Poudre Valley Hospital
    • 159 Miles
    • 3 Hours and 21 minutes if traffic is good
    • Two major mountain passes or the choice to leave Colorado, go to Wyoming and drive back into Colorado so you only have to deal with one major mountain pass (adding on 30 more miles)

Many specialists come up to mountain communities on a rotational basis.  However, this may be once a month and possibly less frequent.  Telehealth is the obvious stop-gap for patients in rural and mountain communities that need specialized care.  A barrier to telehealth visits as Dr. Lin has mentioned in his blog has mostly been the providers.  However, with social distancing and with CMS lifting restrictions on reimbursement for telehealth, providers quickly adopted telehealth to keep revenue streams flowing for their practices.

Telehealth and Telemedicine Expansion and Deregulation

Telehealth and telemedicine rules and regulations relaxed at the start of the COVID-19 pandemic.  Now is the time to figure out how else to utilize technology to improve healthcare delivery.  Now is the time for innovation and policy reform.  So, how can telehealth help patient advocates and family members?  Could it be the answer for me and my dad’s visit?  Will it work for others in an urban setting or family members that are geographically separated?

Being a Patient Advocate Remotely

Before the pandemic, I had planned on taking a day off of work to drive down to Denver to accompany my father to an appointment at a neurology clinic.  This appointment transitioned to a telehealth visit following the outbreak.  I considered making the two-hour drive from Steamboat Springs to Fraser to be with him for the appointment.  After all, I would generate a net gain of two and a half hours from not having to drive all the way to Denver.  In a moment of clairvoyance, however, I decided to find out if I could join remotely.  After working with a few key stakeholders at UCHealth, we discovered that if my father gave me access to his My Health Connection account, I could join the same way he would for the remote visit.  This access also allowed me to review my father’s medications as the provider discussed them with my mom and dad and access the summary notes from the visit, so I could discuss treatment options with him and my mother at a later time.

The Visit (that’s me at the bottom, by the menu bar)

It was strange to know that I would be on a video call with my parents, but to be on the phone with them as well, ensuring that they could log on.  My wife and I have discussed the shift in caring for both sets of aging parents, but this was the first time I needed to support them on multiple fronts.  First working with them on technology and second being a health advocate.  The visits felt distant, yet at the same time normal.  The medical assistant greeted us virtually and started the intake process.  Dr. Zachary Macchi jumped onto the call about five minutes in and reviewed history and started the evaluation.  About twenty minutes into the call, Dr. Samantha Holden was able to join as well.  In the span of twenty minutes a total of six people (including my father) were working together.  Had we all gone down to Denver together, this may have been the same outcome.  However, Dr. Macchi joined the call first to help Dr. Holden.  He stated right away that she would be able to join us, but had other commitments.  My guess is that if we were in a traditional setting, we would have waited an extra 20 minutes but telehealth gave the flexibility for coverage.  Telehealth has its limitations.  My father had difficulty following the motor skills test.  We were unsure if it is his motor function or his ability to follow a two dimensional image in the three dimensional world.  For this and other reasons, everyone agreed on an in person visit three months following the virtual visit.

Just the first step… what are the next.

This visit made me realize the opportunity for telehealth in the patient advocacy realm.  While telehealth offers a convenience for the patient, it certainly helps with obstacles that patient advocates face.  I am lucky to live just a few hours drive from my parents.  If I lived outside of Colorado, I doubt I would be as involved in their care.  However, we now have the tools to improve care coordination between family members.  Our first step needs to be promoting the technology to allow for remote patient advocacy.  However, we could take it even further.  What if we could have an MA set up a camera during an in-clinic visit so the advocate (or family member) could join the visit if they lived too far away to join in person?  What are the other ways to utilize telehealth for family members and patient advocates?  Will CMS go back to restricting reimbursement for telehealth?  Time will tell for these questions, but we need the health care community to (dare I say) advocate for telehealth and the access it can bring for patient advocates.

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Guest Blogger Glenn Sommerfeld (thank you!)

EHR analyst v Covid. Making a difference with Ear Guards made with 3D printing (Guest post: Guy Ristoff)

Guy Ristoff, his sister-in-law Mollie, and brother Bill

My name is Guy Ristoff.  I work for the EPIC IT Team at UCHealth (Colorado) as an Analyst.  I also have a 3D printer.  A few weeks ago, I started seeing a bunch of people posting in 3D printer Facebook groups about ear guards to use with surgical masks.  I thought it was a great idea for me to explore here at UCHealth.

 I contacted a unit I have done some EPIC build for and asked if they would want some.  I created my first 10, delivered them to the hospital, and hoped they liked them.  I then contacted Gwen Martinez from the Clinical Informatics team and she sent an email blast to a group of people about the ear guards.  Within 20 minutes, we started to get responses.  It was amazing!  The first few “orders” were coming from the Northern Region.  My brother lives in Wellington and has 3D printer as well.  I called and asked him if he would be interested in donating ear guards to the Poudre Valley and MCR.  He was excited to help!  His kiddos even got in on the fun by making thank you cards for the staff.   

As for production, I can make 17 of them per batch, which takes about 4 hours.  It is not a super-fast process, but it is a lot of fun making something that helps people be more comfortable.  My brother has made and dropped off 80 of them.  I have created 122 of them for the AMC and MHC campus so far.   I am dropping those in the mail and at the hospital today!  I will keep up production, so keep the orders coming.  I am just happy to be able to help!

Here is my machine making a batch of them

Example of a clinician wearing a mask protected by the ear guard

CMIO’s take? Thanks to all our creative Epic/IT team members like Guy, to step up and help in every way that they can. –CT Lin MD

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

“What Matters to You?” instead of “What’s the Matter with You?” -guest post, Heather Coats, PhD, APRN-BC

Is the integration of an individual’s narrative into the Electronic Health Record FEASIBLE to Improve Person-Centered Care? (CT Lin: I’m excited to welcome Guest Blogger: Heather Coats PhD)

Person-Centered Care, a buzz word to refocus our Western (US) healthcare system on the user of the system, the person who has a health need.  We as clinicians, use the word “patient” but they are a human, just like us the clinician. We all have past, present and future stories that make up “who we are” However, this whole self sometimes is seen as parts in our western medicine culture…the cancer patient in room 202, instead of Jon, the person…who is a grandpa, a dad, and businessman whose illness is impacting his ability to be all of these things.

In recent years, the shift in Western Medicine to incorporate the person’s experience has been moving upstream. The IHI (Institute for Health Improvement) “Person- and Family-Centered Care” domain–Putting the patient and the family at the heart of every decision and empowering them to be genuine partners in their care, goal is to develop “partnerships between clinicians and individuals where the values, needs, and preferences of the individual are honored; the best evidence is applied; and the shared goal is optimal functional health and quality of life”  http://www.ihi.org/Topics/PFCC/Pages/default.aspx

Since 2015, the IHI helped share the practice of asking the individual receiving health care:  a simple question…“What matters to you?” in addition to “What’s the matter?” This reframing of the clinician-person interaction orients the care being provided more to the whole person, to give a much different light to a plan of care that opens the door for opportunities to involve the person’s whole self. http://www.ihi.org/about/Documents/IHI_Timeline_2018.pdf.

Now, I do not want to diminish the physiological as an important component in the delivery of care. As clinicians, our expertise (life experiences, training) are grounded in knowledge of the physiological, but I would dare to ask, we are not the experts in the whole person who is sitting across from us. Second, when a person is facing an illness…cure of the illness may not be a reality, but healing of the self is still possible.

A recent NPR Morning Edition aired on their Morning Edition program (June 8, 2019): “Storytelling Helps Hospital Staff Discover the person within the Patient aired on June 8, 2019 on Morning Edition on National Public Radio.

https://www.npr.org/sections/health-shots/2019/06/08/729351842/storytelling-helps-hospital-staff-discover-the-person-within-the-patient

Person-centered narratives are one proposed way to have dedicated tools to shift to more person-centered care.  

An exemplar of this narrative shift, is the MyLife/MyStory program at the William S. Middleton Memorial Veterans Hospital in Madison, WI. https://www.youtube.com/watch?v=_Wy1aMXQCTk. This program has included over 2,000 person centered co-created narratives into the electronic health record since 2013. Their program has trained an additional 50 sites to implement programs similar to theirs. 

This is where my “story” comes in,  I had the pleasure to attend MyLife/MyStory  training back in 2015, which allowed me to think about this type of program could be implemented outside the VA, and have a program of research that tested person centered narratives interventions to improve communication between clinician and persons receiving healthcare. My NIH/NINR funded research focuses on the implementation of a person centered narrative intervention that co-creates a first person narrative that is approved by the person, then uploaded into the person’s electronic health record for their healthcare team to learn more about “What matters to them?”  The first phase of the program did prove to be feasible and acceptable by the individual- the person hospitalized for serious illness, their family, and their clinicians. Through this work, perhaps, there is just one more way to help shift Western healthcare to “truly” be person and family centered.

Heather Coats, PhD, APRN-BC
Assistant Professor of Research
Office of Research and Scholarship
University of Colorado, College of Nursing
Nurse Practitioner, University of Colorado Hospital Palliative Care Consult Service (PCCS), Department of Medicine, Division of General Internal Medicine, University of Colorado, School of Medicine

“What is a Large PIG”? or, How to set up a Physician Champion for success during a hospital EHR go-live. Guest Post by Jonathan Pell MD

JonPell

UCHealth, like many other health systems, are extending their EHR network to affiliate hospitals and facilities. Whether a hospital is coming from a paper charting system or from a different EHR, there is dramatic culture change for independent physicians as they get ready to adopt the system-wide EHR. Here are some challenges presented by physicians working at these hospitals joining the system:

  • Independent physicians were loosely affiliated with the hospital previously. Some surgeons were used to handwriting their H&P or faxing in a preoperative H&P they dictated via their office chart. They did the same with paper preoperative orders. Will they be allowed to continue?
  • Independent hospitals have had paper-based or electronic order sets developed over decades of tradition which are often customized for each of the providers even though they address the same clinical condition. Will they be allowed to keep the many physician-specific versions of these local, non-standardized order sets in the system EHR? How about if they have no-longer-standard-of-care medications and care instructions?
  • Independent hospitals have medical staff committees, often with committee attendance paid by hospital. When assembling leadership committees, will the system pay for physician attendance at EHR committee meetings preparing for go-live?
  • Inevitably, some services and specialties are more engaged than others. In the worst case, physicians will ignore the calls to attend mandatory training and readiness evaluations. As a result, these same physicians and specialties will disproportionately think that “your EHR is a piece of #(&$.”  How will you work with these physicians?
  • Similarly, some services will need more support after go live than others. These are typically the least-engaged physicians in the hospital. How will you develop relationships with these physicians to help them be successful?

Our solution (after several trial-and-error experiences…) is to create ONE Physician Champion for that hospital, and to pay for 0.2 FTE (20% of a full time equivalent, or about 8 hours a week) to serve as THE Physician Champion for that hospital for 6 months prior, 2 weeks intensively during go live, and about 3-4 months after.

We anticipate this Champion would spend less than 8 hours a week in months leading up, and spend quite a bit MORE than 8 hours a week just before and during go live, as long as the total engagement over the 9 months, averages out.

Here are the relationships that will make this Champion successful (see graphic):

ChampionAndPhysicianReadinessLeads

  • Senior (system-level) Physician Informaticist with hospital go-live experience to be a partner and coach (model of “see one, do one, teach one” from residency training)
  • Project Manager who represents the IT analyst team that builds the EHR tools and infrastructure and tracks deliverables and deadlines, and Nurse Informaticist who represents clinical staff roles and shared workflows.
  • Physician Readiness Leaders working group to create consensus and disseminate knowledge back to front-line clinicians

To extend the reach and influence of the Champion, we establish a working group of pre-go-live Physician Readiness Leaders. The specialties represent a majority of patients admitted to that hospital. We emphasize the inclusion of particular specialties like surgery, obgyn, emergency medicine, hospitalists, AND infrequent consultants and primary care referring physicians.

This committee is co-chaired by the senior Physician Informaticist and the hospital Physician Champion, comprises about 6-9 Physician Readiness Leaders. The nurse informaticist and project manager also are crucial (see above). This whole group meets monthly in the 6 months prior to Go Live, then twice a month in 2 months after Go Live.

Physician Readiness Leads are required to: attend early EHR training, and attend extra EHR training sessions to reinforce collegial discussions and problem-solving during training, and make rounds in the hospital in the first couple weeks of go live to commiserate chat with colleagues. Depending on the hospital and local culture, these Leaders may continue to meet sporadically after go live for ongoing maintenance concerns and EHR updates. The hospital Physician Champion is contracted for about a year, and is expected to step down several months after the go live is completed. In some cases, that person or an alternate Physician Champion is selected for ongoing participation in the system-level Large PIG to help with ongoing EHR improvements and be the bi-directional relationship for that region/hospital with the larger informatics and physician community.

HERE IS OUR INTERNAL DOCUMENT FOR
Benefits and Responsibilities of Physician Champion

IMPORTANT: Strong Physician Relationships are directly proportional to effective clinical care and the successful implementation of electronic health records. It is even more important than the configuration of the actual EHR technology.

Benefits of the role:

  1. Develop a global perspective of the IT provider plan and how the unified integrated EHR system (Epic) can benefit your group.
  2. Hit the ground running in regards to workflow efficiency at go-live and staying ahead of the curve after go live
  3. Opportunity to be operational and clinical leaders in the hospital configuration decisions
  4. Decrease patient safety risk when providers’ groups are involved in order set build, training engagement and attendance at pre-flight sessions
  5. In the absence of provider participation in EHR meetings, nursing and administrator decisions may have unintended impact on provider workflow.
  6. Help to shape physician go-live support which can be focused for your providers that will have their first shifts and procedures after go-live
  7. Attend meetings where your feedback is highly valued and affects change rather than informational only meetings
  8. Start to develop partnerships, communication lines, and understanding of workflows that affect your day-to-day job
  9. Nurses want to know that the providers are on board with the change. Participating in the decisions of this committee allows you are to be seen as the leaders.
  10. Opportunities to visit and collaborate with same-specialty providers at other system Epic hospitals
  11. Develop relationships with colleagues to help improve the system prior to and after go-live

Responsibilities of the role:

  1. Attend 1 hour monthly physician readiness meetings for the 6 months prior to Epic go-live
  2. Review specialty-specific order sets to assure appropriate content is available for go-live
  3. Communicate with colleagues in your specialty at your hospital and inform the working group about your colleague’s readiness or participation in training, order set review, and pre-flight readiness.
  4. Bring specialty-specific concerns to the readiness group, particularly around multi-disciplinary workflows (e.g. is faxing/scanning of paper H/P’s allowed? Who will enter order set orders if/when verbal orders are permitted?)
  5. Communicate concerns to the Physician Champion
  6. Communicate information discussed during readiness meetings to your respective specialty colleagues
  7. Participate in early Epic training and at least one additional training session with specialty colleagues
  8. Participate in Clinical Informatics Journal Club as part of monthly physician readiness meetings

Some sample books included in our Journal Club:

  • Leading Change (Kotter)
  • Managing Transitions (Bridges)
  • Design of Everyday Things (Norman)
  • Nudge (Thaler)
  • Crucial Conversations (Grenny)
  • Getting To Yes (Ury)

Jonathan Pell MD

CMIO’s (and guest’s) take? Create a clear set of expectations and responsibilities and a small multi-disciplinary team with STRONG relationships. Success in informatics is about relationships. (Thanks, Jon!)