Grow humans, not IT employees (PIG-let series)

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.

Wide-Ranging Interview w This Week Health (CT Lin and Bill Russell)

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.

Dig Deeper: A Case Report of Finding (and Fixing) the Root Cause of Add-On Laboratory Failures

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.

Link to the paper in Pubmed:

https://pubmed.ncbi.nlm.nih.gov/35913087/

Help! Secure Chat in Epic, a ukulele EHR parody

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

291586658668_1

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

motorola2bpager

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).

Of course, there’s Pager Inversus, but that is a blog for another day.

Doc Halo, Vocera, Tiger Text

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.

Network Effects

(image from wikipedia.com)

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).

 

90 x 4, don’t bother me no more (ukulele)

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.

Tips on Mentorship (a conversation)

The PAC mentor program

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
  • Rowing downstream, not upstream
  • Advocacy, offering connections from your network
  • Peer mentorship
  • Blind spotting
  • Validation and encouragement
  • Lateral thinking
  • The Failure Resume

Here’s the audio-only interview (33 minutes).

CMIO’s take? Let us know what you think! From YOUR experience as a mentor or mentee, what have YOU learned?

Where do you keep the (informatics) pixie dust? (borrowed from NYTimes)

This is hilarious: angsty flowcharts to help guide readers. Must-read article.

Fawzy Taylor, social media and marketing manager of the bookstore: A Room of One’s Own, Madison, WI, via NYtimes “These Memes Make Books More Fun”

Thank you to Fawzy Taylor, whose brainchild this is. Fantastic in so many ways.

Why can’t we build our informatics and our internal education this way? For example, for newbie informaticists, how about my book-recs graphic above, based on the same idea?

CMIO’s take? What do you think of the graphic? of the style? of the content? Guess what? It doesn’t matter, if it gets us talking!

Door-dash ride along, a parent’s and informaticist’s view

Ever wonder what the gig economy is all about? What is the experience of drivers, interacting with restaurants, with traffic, with the AI-in-the-cloud, with customers?

My son recently turned to this service to make some cash prior to his upcoming trip. Wonder of wonders, he offered to let me come ride-along for a few hours on one of his outings.

Finally! a chance to see behind the velvet curtain! Is there a Wizard in Oz controlling things?

We spent about 4 hours together, including the dinner rush.

What did I learn, as a parent and an informaticist?

Gas is expensive

at $5 and eats (pun intended) into any profit margin. Food delivery is particularly hard right now, but I can’t imagine it is much easier or more lucrative even with less expensive gas.

This is hard work.

Even four hours is a lot of work, I can’t imagine doing this for more, and day after day. Even my son, after a couple weeks of doing this, notes that “this could be an occasional supplement to someone with an existing job, but I can’t see doing this full time for the few dollars it brings in.”

It is good to go online

and learn tricks from others. I haven’t done the surfing, but it sounds like there are youtube videos for strategies on how Dashers can make money. For example, “don’t take every offer that comes to you over the phone.” Some deliveries only offer a couple dollars for 2-3 miles of driving, working out to about a dollar a mile. From what we believe of the algorithm, if a driver turns down a delivery, the next driver gets a slightly higher offer. IF that is the case, it is the responsibility of drivers to look out for each other and decline overly cheap delivery offers! (see: Fight the Man!).

The informaticist likes end-users who educate themselves to improve their own workflow and experience.

Traffic is terrible

and some drivers have lost sight of their humanity. I occasionally see bad behavior on the streets when I’m driving, but spending 4 hours driving around the city, gives you a concentrated view of your neighbors. The pandemic has done something to our vehicular civility. People honking at folks driving the speed limit, people swerving and gunning their engines to get 1 or 2 spaces ahead in traffic, emotions running high while operating multi-ton vehicles. A dangerous workplace.

The informaticist understands strong emotion and unhappy end-users who act out at times.

Sometimes little physical tweaks

help provide better service. Having a shopping bag that is insulated keeps the food hot a little longer on your drive from the source to the delivery. Wearing comfortable clothing, having a phone with charger (a task-horse! Receive delivery offers, map your drive, text your delivery recipient that you are on your way, take a photo to prove you left it in the right place), and even better if you get good gas mileage.

The informaticist enjoys seeing work-flow tweaks that improve outcomes.

The smells are free, but it costs you

One bad side effect of driving food around, is that the food smells eventually get to you. Maybe not when you start, but a few hours in and inevitably you’ll get hungry. Uh-oh. Those fries … fast food places sure have dialed in the sensory experience. Other times the food is NOT to your preference, and you can’t get there soon enough to let it go. On the other hand, you get to learn where people like to order from, and you’re likely to find some new places to eat (we found bb.q, a relatively new Korean barbecue chicken place in Denver: cool)!

Don’t forget the drink(s)

The algorithm is smart enough to remind you to pick up drinks; having several moving parts to the order (not just the food bag, but also drink(s) and secondary items complicates the process and increases risk of error, so some reminders are built in. Also, some restaurants are on the app and can also call you back if you miss something.

Error-anticipating and error-correcting. The informaticist smiles.

Don’t be greedy. Or, maybe be greedy.

Apparently some gig economy workers run Door Dash and also Uber Eats and sometimes also Uber and Lyft AT THE SAME TIME, just to increase their chance of picking up more offers and staying busy. I can’t imagine the cognitive load (and increased danger) that entails whether stationary or while moving.

Separately, the app will sometimes try to package deliveries together (hey! if you drive another block, you can deliver a second request from a nearby restaurant, want to?) I can see the algorithm trying to lower costs and combine trips within a restricted time-block and geography-block. Kind of like the ‘traveling salesman‘ math problem. Except different.

The informaticist likes the math, hates the multi-tasking.

The attention economy

This usually refers to advertising, social media, how they are all now optimized to capture your attention and keep it. See: Made to Stick, The Shallows, Reality is Broken. Also see: every social media app on your amazing phone.

In this case, how does the algorithm capture you? It tells you “hey, you’re not accepting enough of these offers”. The little joyful “ping” of a new offer keeps us on the edge of our seats waiting to see what pops up next. It is HARD to quit driving at the time you set yourself. “I’ll just do one more, maybe the next one will be the big score!” Like Pavlov’s dogs, we could literally salivate when awaiting the next reward.

The informaticist likes “sticky” design, but only when used for the greater good.

Sometimes the little social tweaks can improve tips

My son learned to use the optional “send a message” tool. He would use it to tell the recipient that he had picked up the food and was on his way, with an ETA. “Hi Betty, Joe here. I’m on my way! ETA 10m” He even worked out exactly how few letters it would take to send a friendly note, with his name included, hoping for a better tip. And it would work, most of the time!

Informaticists like social engineering nudges when used for good.

Fight the man

Not all algorithms are looking out for the front line worker. “Fight the man!” becomes “Fight the code!” It is disappointing that gig economy algorithms have no allegiance to their drivers. No “company loyalty” engendered here: it seems that the algorithm is testing “how low will you go?” Here’s an offer to pickup from McDonalds for $2 to drive 2 miles to deliver. Want it? (no). or, Pickup from Applebee’s for $3 to drive 4 miles? (no). How about pickup from Korean fried chicken for $6 to drive 3 miles? (YES).

Sometimes it is not busy and you have to decide whether to take the lower paying deliveries because THERE IS NOTHING ELSE. But then, is that better or worse than just parking and having your engine off, saving gas, waiting for the next one?

Sure the algorithm has to make money for its Master-in-the-sky, but surely we can take care of our front-line workers and set some sort of regional minimum wage? Deliveries at $2/mile are helpful, but when it is $1/mile, it works out to less than minimum wage, and recipients do not often tip.

Hmm. Can the informaticist learn from game theory to improve user engagement in our common purpose? And are there principles of respect for front line workers in the design of artificial intelligence algorithms that make life better for all, not just the corporation?

Be grateful

when a son or daughter volunteers to let you come along to do something crazy like this. I’m aware these opportunities will not always be there.

The informaticist yields to the parent: YES, the parent says. I’m grateful.

Cutlery Illustrates Good Informatics Design (thanks @DirkMD)

from dirkstanley.com

https://www.dirkstanley.com/2022/05/a-tale-of-applied-clinical-informatics.html

This is brilliant. That is all.

City Scooters: an informatics viewpoint

A colleague and I were recently making fun of tourists and others riding the city scooters around Seattle and other large cities. Nearly no one was wearing helmets, they’re zipping in and out of traffic, going up against SUV’s and 16 wheelers. Just asking for it. Now, it is true that Seattle has some the best bike lanes around, with dedicated ‘green lights’ just for bike lanes, to improve safety. It IS a bike friendly town.

As an aside, my son and daughter, when they were 9 and 11, were riding their Razor scooters to the park, when I overheard them:

S: my scooter has a turbo boost to go fast.

D: oh yeah? My scooter has jets.

S: So, my scooter shoots out flames

D: Well, my scooter has apps, and I can download anything and plug it in to make mine better.

Wow, kids of the smartphone age.

I thought of my children, while I hopped on this scooter, downloaded an app to unlock and pay for a day of scooting, used Google maps to find the Art museum, used Yelp to find a good chinese noodle place, and Weather to see if I needed a rain jacket. All from one device. We are living in the future, folks.

So I’m humbled to report, dear reader, that I stooped to try one myself. I have returned from that ‘undiscovered country from whose bourn no traveler returns’. Hmm. Not exactly, but you get my meaning.

Seattle Chinatown gate

Here are some quick personal observations.

$ a city scooter is a nuisance – Some folks ride the scooter on the sidewalk, endangering pedestrians. Then they ride the scooter down wrong way streets against traffic endangering themselves. Often though, they ride in the many bike lanes, merging easily with bike traffic and other electric motor powered personal transport. It even looks harmonious!

$ a city scooter is a danger to the rider. There’s no way I would ride one. Okay maybe once. Okay, I’m pretty tired after my bike ride yesterday and maybe I could try it. At least it will be an interesting blog post. Hey this is scary. Hmm. Good design, my first ride is speed limited so as to protect the newbie. Wow, after a half mile of starts and stops I’m getting the hang of this and can’t wait to unlock a full speed ride. Zoom! Full speed second ride! This is a blast!

$ A city scooter is an app. The founders of this idea realized that their potential customer base is THE ENTIRE CITY of people who have a smartphone and need to get somewhere. With a QR code, snap a pic, set up an account, and in 3 minutes you’re on your first ride. Clever.

Museum of pop culture. Where are the ukuleles?

$ a city scooter is transportation disambiguated. I’m here in Seattle for an organized bike ride later, but don’t want to put my nice bike on the street with a lock. This is a great alternative: scooters on many street corners with an app-map to show you the nearest. Then, when you arrive, park (safely) and leave it.

$ a city scooter is micropayments. Even better with a day pass. $7 per ride or $21 per day, up to 6 rides. Cool. It’s like you own a fleet of scooters all over town.

$ a city scooter is a network which grows in value with more nodes. And Seattle supports several! not only are there Link scooters, but Lime scooters and bikes, and several other brands of mobility. Unlike the first generation of e bikes that required charging and locking stations, these can be left any where for convenience as long as they don’t obstruct.

$ a city scooter is an information highway. Interesting to think about what data is reported in real time, what adjustments leadership and management need to make to redeploy, fix, recharge, see where the scooters are needed and ‘rebalance’ their locations.

Seattle art museum

$ a city scooter is modular. The components of the network are easily swappable. Riders will report issues, the scooter will tell when the battery is low or needs repair. It is self-repairing as a network.

$ a city scooter has to gain popularity while promoting safety. After my second ride I received a mandatory quiz: which scooters are parked legally? What are the relevant city laws that apply to me? And yet there is the need to grow the business, so ‘helmets are required’ but a photo proof of a helmet is not required. ‘Photo proof of parking correctly’ is required. Hmm.

$ a city scooter has soooo many customers: the city government, employees, riders, the driving and waking public, shareholders. it is interesting also to think about how many city regulations had to be addressed and met, how the public perception must be managed, how the pricing and profit models have to continually be tweaked. Is there ‘surge pricing’ like with Uber? How do you balance all these demands and make a profit? What are the guiding principles?

Well, you recognize this one

$ a city scooter shrinks a city. This is perhaps my most profound observation. After the first nervous scoot, I had a face-splitting grin the entire time I was riding. Kick start, push the thumb lever and ZOOM I could see the city literally shrink in size as I rode. Blocks whizzed by, hills flattened, and I was master of the domain, blending into bike lane traffic with all my best friends. From Pike Place Market to the Space Needle and Museum of Pop Culture to the Seattle Art Museum to Biang Biang Noodles and back to the hotel. So easy.

CMIO’s take? Multi-dimensional thinking like this is common in healthcare informatics. I enjoy thinking, feeling, and working through hard problems like this. Do you? If so, come join our ranks! We and the larger healthcare industry need your brains and emotional intelligence.