Electronic Health Records and Clinical Informatics
Brilliant colleagues doing hilarious and important education work on Diagnosis Aware Notes for Epic EHR documentation.
https://youtu.be/uNGxPodJ4HA?si=rVF2KUqD_ggP25Rt
Brilliant colleagues doing hilarious and important education work on Diagnosis Aware Notes for Epic EHR documentation.
Time for XGM. Here are some pix.
Sorry, I don’t mean to create FOMO, but I kinda do.
Sat down for gourmet breakfast at Epic in Verona this morning and a few people wandered by and sat down.
Over the years our conversations have ranged from clinician adoption to EHR related burnout, to value headed care, and now the new shiny object is predictive AI and generative AI.
Can’t wait to hear why my colleagues have to say in the next few days. What a wonderful community of thoughtful, smart people.
The latest chapter in this evolving story is that state governments are passing regulations in reaction to the federal Info Blocking statute. Humans are such complex organisms. Meantime, our anticipatory guidance framework is also evolving. You can do this today with your patients!
We continue to evolve our Information Blocking / Sharing and Immediate Test Result Anticipatory Guidance (that’s a mouthful).
In case this is useful to other health systems working on similar projects, we believe that teaching our docs and providers about Anticipatory Guidance (shifting the counseling of patients about test results upstream to the time of ordering a test) is the best for everyone: less anxiety for patients, and fewer phone calls and messages for clinic staff.
See the screenshot above for staff and also provider guidance.
From a recent presentation about immediate release of results, some slides that might help.
And, here are the patient-facing and provider-facing 1-pagers in both PDF and WORD versions.
1-pager for doctors/providers (.PDF and .docx)
1-pager for patients (.PDF and .docx)
I hope these are helpful. Let me know if you develop something similar or better! A rising tide raises all boats.
Another news article about the reaction of artists, techologists to the rise of AI in art. While we ought to be cautious, we should also be at the table when such discussions occurr. AI and creativity and what it is good for and not good for; this is our next frontier.
Art from Harvard News. Illustration by Judy Blomquist/Harvard Staff
I celebrate you, my colleagues in the arena. For all of our failures, our setbacks, our licked wounds, we are making a difference.
Bringing my uke to another informatics conference.
A note of appreciation to my colleagues doing practical informatics work on the frontlines of healthcare
It may seem that everyone else out there has it easy: after all, JAMIA, JMIR and ACI informatics journals are filled with amazing colleagues who write about their amazing research, clinical innovations, successful project and implementations. Be careful not to let the FOMO get you down, as it does to me on occasion.
It is so easy to judge oneself: There must be something wrong with ME, why can’t I get anything done? Why can’t I be successful, why is it so hard for me?
Watching the finale of Ted Lasso recently, I was, as they say in French, ‘triste’. An emotion of sadness, tinged with joy. (I think that is right). On the one hand that the series is over, and on the other to recognize that there is such great art, such great writing in the world, about being a good person.
Ted talked about Theodore Roosevelt’s ‘the man in the arena.’ Or that the person doing the work gets dirty, suffers the slings and arrows, gets criticized. On the other hand, that same person is also truly living life, experiencing joy, making a difference. This contrasts with the person in the relative safety of the sidelines— the critic who points out flaws, denigrates.
CT deploys a pre-populated start date for schedule II controlled substance prescriptions to simplify prescriber workflow. Great, except terrible. The pre-populated dates cause unexpected havoc. CT removes the tool after a week and apologizes to 4000 physicians and APPs.
CT deployed radiology “indications of use” as checkboxes to improve ordering provider workflow. Great, except, terrible. Pages of scrolling checkboxes are unusable and are removed after 2 days. CT apologizes.
CT advocates for and then deploys messaging between patients and their clinics and providers to increase patient connection and engagement. Great, except terrible. CT apologizes for ruining healthcare.
These projects had a difficult birth, and yet, with persistence and great teams and supportive informatics colleagues, achieved success.
CMIO’s take? Keep in mind the long game. Let not the inevitable sarcastic shouting of the critic silence our efforts.
I celebrate you, my colleagues in the arena. For all of our failures, our setbacks, our licked wounds, we are making a difference.
A rock, a hard place and lateral thinking. Clear some space on your desk and in your head and come along!
Generative AI response to
“a physician informaticist caught between a rock and a hard place”
YOU are a physician informaticist. You are board certified in informatics, you are an effective physician builder, and enjoy an excellent relationship with your department chair and clinical colleagues. You have protected time to this work. You have excellent IT analyst colleagues who will collaborate and help get your projects over the finish line so that they’ll be used. You have built scoring tools, you have built smartforms to better capture clinical findings, you have built analytics reports that clearly demonstrate that you have improved the care of the patients in your clinics.
AND YET. Your organization is part of a large health system with byzantine socio-political dynamics. You have multiple bosses, and each boss has very different ideas on what you should and should not work on, and they don’t like each other. Projects that you initiate and introduce to your leaders disappear from view, only to resurface later as some one else’s idea.
A project that you were not initially involved with is now YOUR problem. Some project team built a Best Practice Alert that interrupts all the doctors, and no one is happy: it doesn’t have the right information to help with decision-making, the doctors are bypassing it, the intervention is not working, but HEY. YOU’RE the expert on workflow, so can you help us? Tonight? We need to fix this tonight.
Why don’t they keep you involved on projects you initiated? Why don’t they involve you earlier on projects where you have expertise? Despite your best efforts to describe your dilemma, it seems your bosses don’t really get you and aren’t listening.
And, you have made accommodations for quite a while. Maybe it’s okay, maybe it will be better next time. Maybe you’ll finally get be publicly recognized. Oh, not this year? Okay, maybe next year.
What if you heard this from a colleague? What would you do?
Multiple choice:
Reader, I have used all of these responses in my long and confusing career. What a disappointment I have been to my mentees and colleagues.
This time, though, in a recent conversation, I went a different way. This is something I vaguely learned during a leadership exercise, I’m not sure to whom to attribute this.
Given the scenario above, I said instead: Here is a task for next time we chat.
Take a time machine 2 years into the future. You have made some choices, advanced your career, and now you can’t WAIT to talk about the amazing things you’re working on.
How did you get here?
Set aside some time. Get a bunch of blank pieces of paper, some color pens, sticky notes, scissors, glue, whatever you have to be creative. TURN OFF your laptop, phone, notifications. No interruptions. No electronics. No one around to judge you.
Your mindset: Blue sky thinking. Post-cards from your future. Turn off your editor brain that says “You can’t do that.” Everything is possible.
Task 1: Quantity not quality. Fill an entire page with ideas of what you might be doing in 2 years. If you fill it, keep going.
* One column of ideas are “Redesigning my current role”.
* One column is “Stay in my current field but make a big leap”.
* One column says “NO limits. BUT, I cannot stay in my current field”
Fill the page. Most of the ideas will be terrible. Keep going. Dedicate at least 30 minutes to this. Your brain is not permitted to edit or cross out.
Task 2: Highlight the ideas that appeal to you in all 3 columns. Pick a few from each column and write a few sentences filling out the idea, just enough to develop some feelings around it. Does it excite you? Surprise you? Disgust you? Bore you? Scribble some notes. Spend at least 30 minutes on this.
Task 3: Get up. Go outside for a walk. Think purposefully about NOTHING. You have just prompted your brain to jump out of its rut and be open to completely new directions. Don’t listen to music or an audio-book or podcast. Be silent with your thoughts. Let your mind wander. At least 30 minutes. Some would even argue that you should sleep on it and conduct task 4 tomorrow. This is to allow system 2, your subconscious and non-directed brain to explore.
Task 4: Were there more ideas to scribble down? Pick your favorite idea from columns 1, 2 and 3 and write a page about each one. Scenarios you see yourself in. Things you are working on in each parallel universe. Projects you’ve accomplished. The joys of that work. Draw a picture. Use scissors and glue to build an artifact. Envision yourself in that role. Feel it. Close your eyes and look around in that world. Spend at least 30 minutes.
As you conclude your time, look at your 3 papers. One of them speaks more to you than the others. In one of them your inner child rejoices. In one of them, your energetic younger self cannot wait to get going. What is it?
At the least, it can be fun to see: a) how badly your handwriting has degenerated as we handwrite less, and express more thoughts by typing or speech-to-text, b) what it feels like to be in kindergarten again, scribbling, coloring, drawing, c) see how your right-brain creativity can take some time to come out of hiding.
Who knows? There might be something really useful or interesting there. Is it time to act? If not right now, should we remind ourselves to do this exercise again in a year?
This is an exercise in lateral thinking. This is a way of jumping your brain out of the usual well-worn cobblestone paths with deeply-grooved ruts from horse and oxen-drawn carts rumbling along them for millenia. Sometimes going “off-road” can spark an insight.
CMIO’s take? What did you come up with? Are there fragments of these dreams that you can put into action now? Where did this journey take you? Take a picture, send it to me! Let me see!
In 25 years, communication technologies have gone through several generations of change. Look back and see what I saw in 1997.
Throwing out old files from my office recently, I came across this blast from the past. In effect: “we should include an e-mail or electronic message function in the Electronic Health Record” or at least, “could you allow us to use our email program on the same computer as our electronic medical record? Then we could possibly cut and paste important questions and conversations between providers and cut down on full consults and referrals and improve coordination of care”
In 1997. At least 3 EHR implementations ago.
I hate to say “I told you so, but … I told you so.”
Here we are in 2020, and we have since studied patients having online portals and using online communication with providers and found these tools to be practical for providers and nurses and patients, and also shown to improve adherence to treatment and high satisfaction.
We have implemented Project CORE, a method for docs to request electronic consults from specialists on their patients; straightforward questions that come up regularly can be quickly and easily answered by colleagues WITHOUT having the patient physically go see the specialist. It is a win-win-win (speed of response for referring doc, no extra effort for patient, easy question/answer by specialist and decompressing packed schedules to make availability for more complex patients). Almost all our specialties now offer this to our primary care colleagues.
We have implemented Secure Chat within our EHR, an ability not only to send email-like messages (have had that since we implemented in 2011), but to send near-real-time text-like messages, securely within the mobile app (Haiku) associated with our EHR (Epic). Here’s an article from Providence Health System in Portland describing the features. Such interruptive alerting can be intrusive, but also when used well, can power highly-functioning teams.
Some observations:
This reminds me of something someone said to me when she was 5:
“That was back in the days of the dinosaurs, when you were alive, but I wasn’t.”
–baby daughter Lin, age 5
CMIO’s take? 1997 to 2023: electronic messaging in EHR’s? I told you so. I was just 25 years too early.
Immediate release of test results, discussed with a radiologist audience: a pro and con debate. What could go wrong? And, of course, the ukulele.
Thanks to Dr. Jennifer Kemp who designed and invited me to present a panel called: “Information Blocking Pro and Con: A Debate.”
I am at RSNA today. My first. Did you know the Radiological Society of North America is the largest medical conference in the world? I did not know this until yesterday. 40,000 attendees, over 4000 speakers. That works out to about 80 speakers PER HOUR. Geez.
I was one.
Disappointingly, not all 40,000 attendees came to see our panel presentation. 🙁
Nevertheless, of the 80 attendees, we had an excellent discussion in the context of releasing complex radiology images to patients, including MRI CT PET etc. and the resulting problems if/when patients find out about cancer or other devastating result by viewing their results online.
We had a question from a colleague from the United Kingdom, as they are just now about to formulate a similar law. ‘Would it be reasonable given US experience to establish a national standard for embargo: let’s say all providers uniformly delay a high risk result for 3 days?’
Our reply: probably not. Airline passengers are now aware of every moment of their luggage transport, and every moment of their arriving Uber driver. Why would radiology reports be any different? The consumerism movement is unidirectionally toward more transparency. Maybe 5 years ago, if the UK was considering a standard, that would have been standard of care in the US, but no longer.
indicate that among 8000 patients who had already received test results from a patient portal, 96% indicated they wished to continue to receive results immediately. Even among those receiving abnormal results, 95% still wished to receive results immediately.
It is also true, however, that 8% of patients receiving immediately released results did worry more. However, we believe this worry is based on getting “bad news” more than it is about getting “bad news immediately.” These are the patients we need to focus on, and more details we need to study.
Our suggested plan: that ordering physicians use anticipatory guidance: ordering physicians will eventually need to explain the result to the patient. Why not spend one more minute at the time of ordering to dramatically reduce the anxiety of the patient when they view the result later at home?
1. We are ordering a test. You may see the result before me. Best case, this is normal and I will contact you this way…
2. Worst case it could be … there is X% chance of this. If that is the case this is how I would reach you…
3. You have a choice: look immediately or wait to hear from me. What Q do you have?
In our experience this works very well and doesn’t take much time at all.
And for radiologists, publishing a contact number for patients to call if they have questions is very reassuring to patients and, guess what: they rarely use that number: in a busy multi-radiologist practice over the course of years reading hundreds of thousands of studies, their office has received 1-3 phone calls A YEAR from patients. And most of the time it is about factual errors in the report, and rarely is it to ask about the medical impact of the findings. It is quite minimal work.
CMIO’s take? The time for immediate release is here. There are great solutions to the anticipated problems. It also happens to be the law in the US.
If you’re still not convinced, or even if you are, here is a song for you, fresh from Chicago’s RSNA 2023:
Saving lives at UCHealth: a combination of predictive analytics (AI) and a dedicated team: the Virtual Health Center nurses. Come see how the sausage is made (kinda cool)
Can AI improve health care? Doctors at UCHealth are trying to find out.
Thanks to John Ingold and the Colorado Sun for highlighting our ongoing work to defeat sepsis at UCHealth using predictive algorithms and the Virtual Health Center (VHC). I appreciate my colleague Amy Hassell for the outstanding team she leads in this work.
Together we have reduced mortality, by the equivalent of 800+ lives saved per year from sepsis and other in-hospital deteriorations.
We have moved our internal process. We began in 2018 by showing everything to the bedside team. No change in outcomes.
Then we put the Virtual Health Team as a back-up service to the primary team. Slight improvement (200 more lives saved per year over baseline).
Now, we have the Virtual Health Team as primary service, both detecting deterioration and taking direct action, with the patient’s primary bedside team in the background. This dramatically improves speed and consistency of response to a complicated disease requiring a coordinated approach: now 800+ more lives saved per year from in-hospital deterioration.
We are happy with our internal improvements and are always hungry for more opportunities. Thanks to Amy and the amazing VHC.
Now, without further ado, we’re excited to share with you the next episode of the CIO Podcast by Healthcare IT Today.
For the 63rd episode of the CIO podcast hosted by Healthcare IT Today, we are joined by CT Lin, MD, CMIO at UCHealth-Colorado to talk about patient messaging. To kick off the episode we dive into his work in sharing patient results and the efforts to keep it private. Next, we talk about how the sudden increase in patient messaging has led to some practices charging for the service to get Lin’s experience and thoughts on the topic. Then we take a look into Lin’s past projects to get his insights on what project he felt was the most successful and what made it successful. Looking forward, we also discuss what projects Lin wants to work on but hasn’t had the time. We then talk about AI and where we think it’s heading. Finally, Lin shares the best career advice he’s been given and how playing the ukulele has impacted his career. Plus, he finishes off the episode with a health IT ukulele song.
Here’s a look at the questions and topics we discuss in this episode:
