What do 8000 patients think about the immediate release of test results since the 21st Century Cures Act Final Rule on information blocking? 96% preferred receiving immediately released results online even if their health care practitioner had not yet reviewed the result. (and more!)
Steitz et al article in JAMA Network Open: Perspectives of Patients about Immediate Access to Test Results
This collaboration between UT Southwestern, Vanderbilt, Beth Israel Deaconness and UCHealth surveyed over 43,000 patients, with 8139 respondents (18% response rate).
Thanks to Drs. Steitz, Turer, MacDonald, Rosenbloom, DesRoches for close collaboration, and to all team members, including the excellent Chief Patient Information Officer, Liz Salmi, for perspectives, insights and enthusiasm. This was a fun project to be part of.
It is the largest analysis of patient portal users’ attitudes about seeing test results immediately. Some key findings:
The survey findings suggest that patients and care partners who use the portal overwhelmingly prefer to have immediate access to test results, even if it means viewing them prior to discussing with their care team.
This holds true even among patients who reported that their tests were abnormal.
Despite the preference to continue immediately receiving test results, abnormal test results were associated with increased worry among respondents.
There was a non-significant protective association between whether a clinician discussed the reason for and implications of the test at the time of ordering and reduced patient worry.
CMIO’s take? Another push towards information transparency with patients. 96% of an 8000 patient survey indicate that they prefer having immediate access to test results, even if their physician/APP had not seen the result, and even if the result was abnormal. Some respondents did worry more with abnormal results, and there is an opportunity for us to improve our tools and workflow for those patients.
Do you have fun at work? Do you have committees named WONK, Large PIG, Small PIG, PIGlets, Daily JIG, SONG, PROM, SPOC, EMO? Perhaps GUANO? Maybe we did.
Thanks to our intrepid, good-humored team of informaticists at UCHealth. Led by myself and Alice Pekarek, our Director of Clinical Informatics, our team of nearly 40 physicians/APPs/nurses (not all pictured here), are the reason that our electronic health record works as well as it does for us. We are taking a well-deserved break at a local watering hole.
And, they’re fun to work with. A sample of how we’ve named our teams:
Large PIG: Physician/APP Informatics Group. We meet monthly to discuss ongoing high profile projects and debate system-level changes that affect all 4000 physicians/APPs, all 12 hospitals and affiliates.
Small PIG: my Senior Medical Directors of Informatics, my “kitchen cabinet” of advisors
PIGlets: our newest physician/APP informaticists, who participate in our book club, with Leading Change, Crucial Conversations, Good to Great, and our current book for next month, Wabi Sabi: the wisdom in imperfection (Suzuki).
Daily JIG: At the height of the pandemic in 2020, our Joint Informatics Group (nurse informaticists as well as physician informaticists) met daily to hash out rapidly changing protocols and build tools to support best practices.
WONK: Workgroup Orderset Nowledge Kommittee (ok, I had to torture the words to make this work; our system-wide orderset synchronization efforts)
SONG: System Operations Note Group (unifying progress note templates)
PROM: Provider Review and Operations Management. Ambulatory proposed tweaks to our EHR, discussion and approval
SPOC: System Protocol Operations Committee
EMO: Electronic Medication Optimization
GUANO (Ok, this was a failed attempt to get the Allscripts Touchworks Academic Advisory Group to agree to Group of Users at Academic-centers, the National Organization). This was not approved. 🙁
CMIO’s take? Where are YOU injecting fun / humor / moments of joy into your work? Let me know!
You’re kidding right? No one wants to start with a BLANK EHR screen when seeing patients. There HAS to be a way to automatically move data from ___ EHR (fill in name) to ___ EHR (fill in name), RIGHT? RIGHT?
It is a tale as old as time (or at least since the early 2000’s when clinics started installing Electronic Health Records). HEY, my EHR sucks! That other one over there MUST be better. Let’s rip out the current one and put in a new one. SURELY that will fix everything.
First of all, that is a fallacy. 20% of the success of an EHR project is due to the technology. 80% is due to the socio-political skills and workflow designs of those doing the installation.
Secondly, maybe we’re too late, and the NEW system is nearly fully installed. We’re just waiting on the data-load. How much data do you pull out of the current system and push into the new? Easy, right? ALL OF IT! Surely all that typing, mousing, clicking that our physicians and APPs and nurses and staff did entering data CAN’T BE WASTED.
In fact, I’ll make it easy:
Here’s a list of data to pull over
Problems (clinical diagnoses, billing diagnoses, problem list)
Medications (historical meds, active prescriptions)
Allergies
Immunizations
Past Medical History / Surgical History / Social History / Family History
Progress Notes, Hospital Notes, Emergency Department Notes
Done! W00t! Our new system is pre-loaded with lots of useful stuff!
Happy, nāive CMIO moving data around.
Not so fast, Sherlock.
Here are a sample of problems we encountered trying to make this happen in our organization:
PROBLEM LIST
We tried loading ICD10 codes from one EHR to another. Maybe 1/2 of the codes come across okay. Others start with “Adrenal Adenoma” and end up with “Adrenal Mass, Not Otherwise Specified”. In many charts, our physicians complained that “It would have been easier to enter NEW diagnoses rather than fix the details of the ones that imported incorrectly.”
Another issue: sometimes you end up merging EHR’s between two organizations. Then, you’ll get “Diabetes, type 2” and then a semi-duplicate “Diabetes, poorly controlled, type 2” and “Elevated Glucose” and “Diabetes, type 2, well controlled”. And then your physicians end up cleaning duplicates OR worse, just leaving the mess as is.
Medications
We transitioned EHR’s, years ago, from Allscripts Touchworks) to Epic. We pulled 2 million medications out of one EHR and ported it into the other. Unfortunately, data stored in Allscripts was, for example:
Lisinopril / 10mg / total dose: 20mg / once daily / quantity 180 / refills 3
As a result, the third field caused an error, and now the result of the import:
Lisinopril / 10mg / __ (defaulted to 1) / once daily / quantity 180 / refills 3
And the physician using the new system might prescribe the wrong dose. Thus, we hired a team of pharmacy technicians to go through each patient and FIX THE ERRORS. It turns out to be MUCH FASTER to enter an entirely brand new prescription than to correct an imported one. Booooo.
A Human Team for importing data
We ended up hiring a team of abstractors. How did we do this cost-effectively? As UCHealth grew as a system, we would add new clinics and hospitals, often with patients in common (eg, electronic data in 2 EHR’s, in health systems that were coming together). Automation and importing tools are still not up to the task of seamlessly merging data sets (eg: here is a lisinopril prescription from 9/2019, here is another one from 3/2020. Are they the same?). As a result, we thought about the most efficient way to fund a team to do this work. We ended up with:
Pharmacy Technicians, supervised by a Pharmacist.
Import Team work
We would send a team into a clinic, to look at the clinic schedule and import Problems, Meds, Allergies, Immunizations. We decided AGAINST importing Past Medical History, Past Surgical History, Social History, Family History. These last 4 were generally of poor quality. Garbage In, Garbage Out (and costly in person-hours).
Pharmacy Techs do well at meds, allergies and immunizations, and diagnosis selections were easily trained.
Sometimes clinics would pay overtime to MA’s, RN’s and some clinicians in advance of the EHR cut-over (bonus: increased time spent on the newer EHR grew their skills).
The team would abstract charts up to 3 to 6 months while using the new system, thinking that the most complex patients in a clinic would be seen more frequently, and then the bulk of the complex patients would be loaded.
Scanning?
We chose NOT to bring scanned images wholesale into the new EHR. We did a trial for a busy primary care clinic, and scanned 1 month of about 30,000 images. Usage / viewing of those images by clinicians and staff after a year was … ONE PERCENT. About 300 images were ever viewed, and most of the views were insurance cards!!! This is a very low utilization rate for a high cost, slow process for scanning, importing and indexing. Perhaps newer OCR (optical character recognition) and AI – self categorization tools might help in the future…
Instead, we asked clinicians to do EITHER: A) Incorporate data from old notes/EHR into the new one in their progress notes or problem list. We kept the old EHR live for one year, so that clinicians could cross reference without importing.
And/Or, B) Allow clinicians to “tag” individual scans from the OLD EHR to be individually moved to the NEW EHR. This resulted in a small, manageable list of scans to bring over that were most useful (discharge summaries, consultant notes, critical radiology reports).
Data transitions between EHRs? Hire a team. Maybe give them Red Shirts.
What do the books Good to Great (Collins) and How to Raise an Adult (Lythcott-Haims) have to do with Informatics? Don’t you wish you knew… (UPDATE! Link to Sinek’s Infinite game 2 minute summary)
Above: Using Craiyon to illustrate mentorship in the style of Picasso. (Thank you to Dr. V’s 33 charts blog for the innovation of harnessing AI to generate images for lazy bloggers like me)
I had a chat recently with a mentee that was enlightening, I think, to both of us. This new informatics leader was stressed about having a slate of recent failures:
Medical assistants in clinic their clinic tend to leave their small practice after a year or 2 of working with this person
Newly hired clinical informaticists (supporting physicians/APPs using the EHR under this person’s direction) were talking about leaving for a different job
However, what came out after further discussion was that:
These MA’s left to go to nursing school, to physician-assistant school, to physical therapy school
These informaticists were interested in growing their careers as well
Those who left often drop by to leave a to-go lunch, or leave gifts
So, which is it? Is this a failure or a success?
Of course, asked in this way, on my blog, in hindsight, the answer is obvious. On the other hand, faced with such situations in a busy, overworked clinic or informatics team, high-performing individuals leaving can be felt as a personal blow. “Oh, I spent so much time growing and mentoring this person over the past year, and THEY’RE LEAVING ME. WHAT AM I DOING WRONG THAT THEY WON’T STAY?”
Sure, it would be important to debrief these folks and make sure you’re not missing an obvious pay gap, or deficiency in the job responsibilities, or needed resources, or unhappy work environment. But in this case, these were all superstar performers leaving for positions that would allow them to grow.
In Good to Great, Jim Collins talks about Level 5 leaders who are humble enough to lead from below: to promote team work and team members and succession plans, and also to put the right people on the bus. Sometimes this means finding outstanding candidates who will outgrow their job and leave.
One could choose to look the employees leaving as a failure: all that expertise is walking out the door. Or, one could choose to see it as a success: we mentored this person, grew this human into their greater potential.
A thought experiment: Wouldn’t it be a tragedy for a superstar MA to spend a decade being a superstar MA, instead going on to become a Physician Assistant? a Nurse? a Physician? Of course, some will want to stay and BE that superstar MA… and that is okay too.
In How to Raise an Adult, Julie Lythcott-Haims notes: “Our children are not hot-house orchids, instead, they are wildflowers of an unknown genus and species.” And, there is nothing we, as teachers, mentors, supervisors can do that is as important as growing them, teaching them effective teamwork, giving them confidence, and letting them spread their wings.
In The Infinite Game, Simon Sinek states, that, unlike the Finite Game, in which the goal is TO WIN versus the other guy, the Infinite Game, the goal is to STAY IN THE GAME. What better way to stay in the game than to grow your future colleagues, where-ever they may go?
CMIO’s take? In being a Mentor, I contend, your goal is NOT ONLY to serve your organization with outstanding informatics work, BUT ALSO to GROW THE HUMANS under your care. Sometimes to grow, they will leave. And what they do after, may astound you.
Bill and I chat about Info Blocking, Anticipatory Guidance, Inbasket Redesign, a 350% increase in portal messages, a one-page pediatric medical record, and more!
I’ve made it to the big time! I enjoyed chatting with Bill about Burnout, documentation, inbasket, messaging online, and information blocking in a 15 minute chat in the hallways at CHIME 22 fall forum in San Antonio. See link above.
Excess venipunctures can be caused by Electronic Health Record-related factors. By doing a root cause analysis, we eliminated about 1000 unnecessary blood draws monthly. Cool informatics work by smart colleagues.
The latest ukulele song. Yet another illustration of how Culture Eats Technology for Lunch.
We’re working on a Unified Communications strategy at UCHealth. We have a history of implementing multiple communications channels over the years:
Bell-boys
Bell-boys (the precursors to pagers), with verbal alerts. You call a phone number, you record your 8 second message, and a minute later, someone, somewhere in the hospital hears this coming from the bell-boy at at their hip. Usually, you say: “This is East-8. Please come to bed 8217. Patient vomited blood.”
Worst case, you have excited nurses who don’t give you complete information. My favorite bell-boy utterance: “Doctor! Come Quick!”
Hmm. Which floor wing of the hospital? Which of the 12 floors?
Pagers
Then, there have been actual pagers, those infernal beeping machines that were the bane of residents and attendings worldwide (but the badge of honor for medical students offered one for the first time).
And then came the flowering of 100 new ideas. “Hey, I think my department could really use X. We don’t really like Y because, X is better. Everyone know that. And because our organization in years past did not have a well-centralized decisionmaking body, every department went and did as they liked. As a result …
Pandemonium
Why can’t the nurses and operators page me in time? They are SOOOO SLLOOOWWWW. We need to hire more.
Well, imagine this. The number of places a nurse has to look in the paper or electronic chart to find the contact information for any one physician or APP was in non-overlapping, non-cross-indexed dictionaries:
Handwritten pager number in the progress notes
Call my service and my staff will then reach me on my private cell. I don’t give that out
Look me up in Doc Halo’s website
Look me up in Tiger Text index
Look me up in Vocera
Fortunately, we finally have a tool in Secure Chat in Epic EHR that will replace all these technologies.
Over years, the building of telephone networks made owning a telephone increasingly valuable. The larger the network and more people you can reach, the more useful the tool.
The opposite is also true: the more different and non-connected communications tools you use in an organization, the worse it gets, and the harder it is to reach anyone.
I think we’ve finally learned this lesson: Secure Chat it is.
Culture Eats Technology for Lunch
Of course, the IDEA of unified communications and getting rid of older networks, like pagers, other secure chat tools in favor of one, seems simple. Don’t under-appreciate the need for LOTS of meetings and discussions.
In fact, it might be time to re-read Leading Change.Have to think about finding the Burning Platform, building Buy-In, building a Guiding Coalition, and so on. Informaticists would say, it is the classic 80:20 rule. Technology, as hard as it is to create, is only 20% of your success. The other 80% is the socio-political skill of those deploying the tech.
CMIO’s take? We are, after years of effort, growing our success. And to celebrate, this song (youtube link above).
Thanks to Chris Sinsky’s saying “90×4, don’t bother me no more”. Here’s a ukulele ditty go along with that. We’re making these changes to our inbasket for noncontrolled, maintenance meds.
We’ve been noodling on various ways to reduce the Electronic Health Record burden for our docs. One thing we’re going to change, across our system, is the way we set defaults for new prescriptions and for prescription renewals, for non-controlled, long term maintenance medications, like for diabetes (eg insulin, metformin), hypertension (lisinopril, hydrochlorothiazide), heart disease (metoprolol, spironolactone), and so on.
What does it mean? In the past, we have prescribers writing for 30 days, 60 days or 90 days supply of medication, and then some random number of refills, up to 1 year. As our practices get busier (and with the pandemic, as we have fewer clinical staff in our offices), the volume of prescription renewal requests are growing quickly. Why not, with these low-risk, unchanging medications, to reduce the burden for both prescriber and patient by writing for a 90 day (maximum allowed) supply and specifying 4 refills?
Our previous default, 3 (three) refills gets you to 360 days, for the patient who renews on time, so adding a 4th refill allows you to fill within 365 days (maximum allowed by federal law).
The countervailing federal law, for Medicare patients, is that annual visits will not be paid by insurance within 365 days, it must be AT LEAST 365 days since last annual visit. So… you can see how patients could routinely run out of their meds a week before their earliest annual appointment.
Hence, the song above: “King of the Code.”
CMIO’s take? The Solution: “90 by 4, don’t bother me no more.” Thanks to Christine Sinsky for the pithy rhyming couplet. This will take a chunk of unnecessary work out of our inbaskets and get us back to more important patient care.
I recently had the chance to sit down with David Bar-Shain MD, of MetroHealth, who single-handedly started the a mentorship program in the PAC (Physician Advisory Council), hosted at Epic in Verona Wisconsin.
The program has been running for 4 years now and has matched over 70 mentor-mentee pairs, over 170 people involved, supporting young physician and APP informaticists by matching them with mid- and late-career informaticists (and some who serve as both mentee and mentor!).
We recently had a chance at the Epic 2022 User Group Meeting to sit and chat about the fundamentals of mentorship, and what I find interesting and fun about being a mentor.
What did we talk about?
The importance of having more than one mentor
Mutual curiosity: telling our own journeys
Who sets the agenda for our meeting?
War stories and are they appropriate?
1-pagers
Storytelling
80:20 rule of informatics: socio-political vs technical skill
Book club and leadership
Learning from outside of healthcare
Mentorship is about asking open ended questions
3 psychological principles that apply to therapy as well as mentorship
