Predictive Algorithms Save Lives Sepsis @uchealth: A 5-slide talk

This data dilettante (see previous posts: dilettante #1, dilettante #2) has enjoyed armchair theorizing with all of you, my best (online) friends. Today we explore how our super-smart team scrambled our way to improving sepsis care with a predictive algorithm we built.

The old saying goes: the success of any major project in a large organization follows the 80:20 rule. 20% of the work is getting the technology right, and 80% is the socio-political skill of the people doing the work.

We all underappreciate this fact.

It turns out that we spent months building a sepsis alert predictive tool, based on various deterioration metrics, and a deep analysis of years of our EHR data across multiple hospitals. We designed it to alert providers and nurses up to 12 hours BEFORE clinicians would spot deterioration.

We patted ourselves on the back, deployed the predictive score in a flowsheet row, and in the patient lists and monitoring boards, with color coding and filters, and stepped back to revel in our glory.

Right?

Nope.

Turns out that our doctors and nurses were ALREADY FULLY BUSY (even before the pandemic) taking are of critically ill patients. Adding YET ANOTHER alert, even with fancy colors, did NOT result in a major behavior shift to ordering IV fluids, blood cultures, or life-saving antibiotics any quicker.

Hmph.

See the fancy patient-wearable tech on the left (Visi from Sotera, in this case), and one of our hardworking nurses, with ALL of our current technology hanging off her jacket and stethoscope. She should be the visual encyclopedia entry for “alert fatigue.” 😦

(right: one of our overburdened hardworking nurses, image used with authorization)

Back to the drawing board

As result of our failure, we huddled to think about transforming the way we provided care. It was time to disrupt ourselves. We decided to implement a Virtual Health Center, mimicking what we had seen in a couple places around the country: we deployed 2 critical care physicians and about a half-dozen critical care nurses on rotation, off-site at an innovative, award-winning Virtual Health Center.

This second time around, we created a cockpit of EHR data and predictive alerts to the VHC clinicians, who were dedicated to watching for deterioration across ALL our hospitals, and responding quickly. This does several things:

  • Takes the load off busy front line clinicians
  • Creates a calm environment for focused, rapid response
  • Dramatically improves the signal-to-noise ratio coming from predictive alerts

This way, the VHC nurses view all the alerts, investigate the chart, and contact the bedside nurse when the suspicion is high for sepsis, and start the sepsis bundle immediately.

Soon, by tweaking the ways our teams worked together, we were able to reduce the burden on bedside nurses and physicians and simplify handoffs.

See chart above: Before the VHC, bedside nurses were responsible for detecting sepsis (infrequent, subtle signals during a busy shift with lots of loud alarms for other things), with many ‘grey box’ tasks, as well as ‘magenta box’ delays.

After implementing the VHC, the VHC nurses took over the majority of ‘green box’ tasks, reducing the bedside ‘grey box’ work and completely eliminating ‘magenta box’ delays.

As a result, we have dropped our “time to fluids” by over an hour, and “time to antibiotics” by 20 minutes, which we estimate has saved 77 more lives from sepsis each year.

CMIO’s take? Predictive analytics, data science, machine learning, call it what you like. This is a paradigm shift in thinking that requires disrupting “business as usual” and is hard, but rewarding work. I can’t wait to see what we all can achieve with these new tools.

What TikTok teaches us about effective communication

Those of us stuck in the “last century” take heed: TikTok and 15 to 60 second videos are IN.

My Tiktok channel: https://www.tiktok.com/@ctlin99

The TL;DR? 15 seconds should be the length of your educational videos. Wanna know why? and how? read on.

I was a Late adopter of Facebook

I’ve been thinking about the evolution of social media. In early days, I was a late adopter of Facebook, not getting why it was any better than email. Now, I get it: saying something once allows your network to see it, from close friends, to casual acquaintances. Medical residents explained to me that photos and memories were easier to share more broadly. AND, an existing large network made participation more valuable (hey! look at all the people I already know on here!).

Just like in the old days, getting a telephone was INCREASINGLY useful if there were MORE people and stores you could call. The network effect.

LinkedIn, Twitter

That led me over the years to LinkedIn (mostly for work contacts and posting my CV and work products publicly) and Twitter (still figuring it out, but a good way to keep up with news if you curate your network carefully, and also a way to post blog content). Also, Twitter allows you to curate for yourself an international community with similar interests, like #medtwitter.

And, my brilliant younger sister taught me that Twitter could also be good for lecture commentary and discussion (she will give a talk on 2 screens: one with her slides and another with a live pre-filtered Twitter feed: how brave! and give out a custom hashtag, like #postitpearls_lecture, and ask the audience to submit questions this way: wow).

YouTube

And, some of you know that I’ve dabbled in amateur song-parodies with EHR songs on my youtube channel.

IFTTT, blogging

Finally, I’ve figured out how to blog regularly and then use IFTTT to cross-post my content auto-magically to my other platforms (Facebook page, Twitter, LinkedIn) so that I can seem more connected and omni-present than I really am (Thanks for another great tip, Sis).

Tiktok?

BUT! TikTok is another thing altogether. My colleague and her daughter suggested that I take my latest Hamilton parody song (that I had gamely posted to YouTube and here I am shamelessly showing it to you again)

#notthrowinawaymyshot and now post it on TikTok, a post-millenial social media platform restricted to 60 second videos. Leaving aside the recent kerfuffle about Chinese ownership and control, this is qualitatively a different animal: getting your thoughts across in 15 seconds (preferred duration, and the time restriction being a result of the music industry’s maximum replay length of a copyrighted song). It has since been extended to 60 second maximum if you have an original soundtrack on your video.

So, I dove in. Unlike my “dozens” of views on my YouTube channel (with which I was satisfied; my broadcast domain is, admittedly to a relatively small physician informatics audience), my TikToks quickly blossomed to nearly 1000 views in 2 days.

Wow! I thought. I am AMAZING on TikTok.

What I did not appreciate is the 15 to 60 second format is much more attuned to the rapid “swipe” of post-millenials, and EVERYONE racks up lots of views. And, ultra-short videos are so easy to consume one after the other. AND, TikTok doesn’t need you to establish your network before your video gets out there; it shows your video to a random selection of viewers, and then those who LIKE it or SUBSCRIBE to you trigger the algorithm to show it to more viewers. So, an easy way to game the system is to use trending (but highly inaccurate) hashtags, like #superbowl, etc. Sadly, this user does not seem to have understood, or be willing to follow, some of these informal rules.

Furthermore, if you read online chatter about TikTok views “500 views total, is pretty sad; what you want is 500 views per hour.” For example, Nathan Evans, of Sea Shanty fame? He went viral at about 250,000 views, and now he’s at 12.9 million. Oh, well. Here’s my paltry Covid Sea Shanty, currently at 62 views (not 62,000) and SIX LIKES.

In contrast, our Informatics team at UCHealth just retired/deleted a 17-minute video I made a 10 years ago for a full “walkthrough” of how to use the Electronic Health Record for our ambulatory clinic physicians. Whew, how out of touch was THIS guy? Here’s a one minute snippet of the kind of video I posted back then, when we were on Allscripts Touchworks. So young, so naive.

Our more recent training videos are more like 1-2 minutes and focused on ONE technique or tool. Now, I’m thinking, maybe we need to shoot for 15-30 seconds. The cool thing about TikToks is that you can trim seconds, speed things up, because those viewers who “get it” can be done watching in 15 seconds, but the video can be paused and also it automatically replays so the viewer can catch subtle details. Hmm, is this a paradigm shift? Should we embed TikTok length education videos into our EHR?

Put Road Signs On the Roadway

As we say internally, shouldn’t we put the Road Signs and Driving Directions (our tips and tricks) on the Roadway (where our users are actually using the EHR) and not in the Garage (our online reference library and training webinars)? Aren’t our users more likely to click on tips WHEN they’re doing work, rather than when “oh, I have some time, let me see what I can go learn.” (which is never)

Austin Chang is my hero

There clearly is an entire evolution of thinking needed to succeed in this TikTok medium. And I don’t have the savvy (yet), the luck, or the persistence to grind out the many tries needed to break through. However, there are medical professionals who have. For example, Austin Chang.

Austin is … well, just go watch him. In 15 seconds, with hilarious music over-dubs, he uses captions and terrible dancing while in scrubs (ok not so terrible), to get his medical facts out there.

I both bemoan the general public’s deterioration of attention span (15 seconds now? Really?) and his ability to fit his tiny education bites (bytes?) into this format. It works. Some of his TikToks are over 2 million views. On MEDICAL TOPICS. Nice. Here’s the NYTimes writing about him.

This reminds me of reading The Shallows, a book about what the Internet is doing to our brains. Are we losing the ability to read a book? I don’t know. I, for one, did not finish reading the book. Ironic.

CMIO’s take: Beat ’em or Join ’em? What are YOU doing about TikTok in your field?

Cognitive load with the EHR and burnout:

why aren’t we measuring this more?

Dr. Elizabeth Harry, image from twitter

https://www.sciencedirect.com/science/article/abs/pii/S1553725020302464

Thank goodness for smart colleagues. Dr. Elizabeth Harry is first author on an important work that ties physician/provider task load to burnout. See link above. 

Using the NASA task load index, and the Maslach burnout inventory, she was able to demonstrate a substantial correlation with an increased task load (mental, physical, and temporal demands, and perception of effort) and burnout.

Far from pointing the finger at EHR’s alone, task load generalizes across many industries, with electronic tools such as the EHR being a major negative or positive influence.

I can see a fruitful future line of investigation and collaboration with this measurement tool.

CMIO’s take? How are YOU measuring and tackling provider burnout?

My Failure Resumé (a talk)

What lessons can we learn from CT Lin’s failures?

Thanks to the Colorado Chapter of HIMSS (Health Information Management Systems Society) and to Bonnie Roberts and Rich Morris for co-hosting my presentation.

Based on my recent Failure Resumé 1 pager. Here are some personal stories, life lessons, and 3 exercises to help you build a failure-tolerant future.

With, of course, a bonus ukulele song at the end.

CMIO’s take: Have you written a failure resumé? Are you building a failure tolerant future? Let me know in the comments.

The Eppendorf, CRISPR, Covid, and my medicine origin story

This post is THREE THINGS. A personal origin story, a (brief) book review, and a connection to recent stories on Pfizer and Moderna Covid vaccines. And, when we’re done, it might even tie together!

Image above: Dr. NoFronta Lobe, Mad Scientist. No this is not me in the research lab; this is me, a kindergarten parent at Halloween

My Origin Story (I was a budding molecular biologist in 1985)

I was alone in the brightly-lit sterile-white research lab; having spent 20 hours on a long, multi-day experiment. It was nearly midnight on Saturday in 1985. I was a college junior majoring in molecular biology, with aspirations of a scientific research career. I was studying P4 bacteriophage, a virus that attacks E coli bacteria.

The work sequence, I could now perform by heart: inoculate, incubate, centrifuge, enzyme reaction, pipette (fancy eyedropper tool) into an Eppendorf tube (a tiny plastic tapered tube. From a Q-tip-loaded with a single bacterial colony, I had carefully grown a quart of bacterial culture, then sequentially purified my sample down to 20 drops of a pearlescent white DNA solution.

So: 20 hours for 20 precious drops. 

Eppendorf tube, Fisher Scientific

Exhausted and looking forward to heading home, I was on my last steps before overnight refrigeration, so as I held the open Eppendorf in my left hand and my pipette in the right, I randomly thought: “What time is it? Am I going to miss the last Orange Line train going home?”

So, I moved to look at my watch…

And since my watch is on my left wrist, the Eppendorf tube in my left hand did a 180…

And I watched as all the liquid ran out … and onto the floor. 

I looked at the upside down Eppendorf, and then down at the floor and the drops of liquid there, uncomprehending. 

*How… what… nnnnnNNNNNOOOOOOOOOOO!!!*

My late-night-fogged brain finally registered SHOCK, DENIAL, ANGER, BARGAINING. The lab was deserted, I deemed it safe to express myself:

“F$*&@! S!#%! D&$%!” I said, eloquently.

Desperate, I dropped down and started using the pipette to suck up DIRTY droplets of DNA extract from the floor and replace it into the Eppendorf. After a few minutes I had about 1/3 of the liquid, now brown-tinged, back in the tube. Resigned, I put the tube in the fridge. 

NO time to fret, no time to start over. Nothing else to do. I got on my jacket and faced the Boston winter, and jogged for the Orange Line stop. 

Once on board that last train, I started to sob. There was no way that soiled sample would be any good. This COMPLETELY SUCKED. 

And, I realized, I really did not want to be here. I realized: I could do the scientific work, but, unlike some colleagues who revelled in long hours in pursuit of new knowledge, I was despondent, not very good at this, and missed being around people. 

That was the night I decided that bench research was not for me. I had thought my calling was in pure science, but this DNA catastrophe taught me where I didn’t want to be. I needed Humanism AND Science. So, medical school it was. I’ve never looked back. 

Molecular Biology after 1985 (CRISPR!)

Thirty-five years later after my profanity-laced change of career, Walter Isaacson chronicles the recent successes of genetic research, including the discovery of CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats) and CAS9 (CRISPR ASsociated protein #9).

Book review rating? 5/5 stars.

In a nutshell: Jennifer Doudna and Emmanuelle Charpentier, and many others raced to understand these strange “repeating sequences” in DNA and mRNA, realizing that they were bacterial defenses against “phage” viruses.

In this work, they discovered that CRISPR-Cas9, an mRNA plus protein complex could identify attacking virus mRNA and SLICE IT UP, deactivating it. They realized that this ancient protein complex could be taught to identify ANY RNA or DNA. Gene editing, invented by bacteria as a survival mechanism a millenia ago, co-opted by humans. Precise genetic scissors.

I enjoy Isaacson’s writing style. Not only does he clearly explain the adrenaline rush of scientific discovery (and the delicate dance between scientific sharing versus the race against other labs to publish and claim credit), but also the technical details of how CRISPR works.

Isaacson writes about Doudna and the response to Covid-19. What is even more astonishing about Dr. Doudna, the bench researcher and lab leader at Berkeley, is that she had the socio-political skills to bring together 40 leading geneticists across the Bay Area to successfully set up a brain trust to develop Covid-19 testing and vaccine development. This team lays much of the groundwork of the accomplishments of this past year.

Drs. Doudna and Charpentier were, deservedly, awarded the 2020 Nobel Prize in Biology “for the development of a method for genome editing.”

A personal note: my brief journey in molecular biology never quite crosses Dr. Doudna’s path, but I recognize the genetic tools mentioned, and studied the work of the luminaries in the field. I feel like a distant cousin to these scientists.

Highly recommended read, to understand the genetic foundation of our modern age.

Molecular Biology: the Covid fight

Here are 2 stories about Covid Vaccines, from the New York Times and WIRED.com, fascinating glimpses into the genomic-industrial complex. As of May 14th 2021, 36% of US adults are vaccinated against Covid-19. It is highly likely that these speedier and more effective mRNA-based detection tests and vaccines will forever be part of our lives. This could shorten development and improve accuracy of future vaccines.

WIRED.com story on Moderna’s Covid Vaccine trials

https://www.wired.com/story/moderna-covid-19-vaccine-trials/

CMIO’s take? Our modern world is built from advances in scientific method, computing and now genome editing. Despite my early failure in the lab, I feel fortunate, in the field of medical informatics, to be close to all 3.

INFORMATICS: Put the road signs on the road, not in the garage

Why make folks go to training or read a tip sheet if you could guide them just-in-time as they do their work?

Here’s a lovely example of our Physician Informatics Group (Large PIG) evolving as we improve the “intelligence” that our Electronic Health Record (EHR) supplies to our hardworking providers (physicians and advanced practice providers).

In the past

clinicians might have pulled up an app on their smartphone dedicated to the ASCVD: atherosclerotic cardiovascular disease RISK CALCULATOR, punch in some numbers and get a result to type back into the EHR.

Later on, some well known national websites would do the calculation for you. Still requires finding the website and typing in numbers.

Even later, we would put hyperlinks within the EHR to link you automatically, but the typing was still required to get an answer.

NOW

we have built a smartphrase (while using the EHR, in any text field, type “.ASCVDRISK”, hit the RETURN key, and Voila, the answer above:

Risk calculated based on what the EHR knows about your patient: age, sex, diabetes, smoking, blood pressure, cholesterol. AND THE ANSWER: 9.1%. FURTHERMORE, disappearing help text guides you to use this information appropriately, and only saves the relevant info to keep in your progress note.

My colleague’s wonderful metaphor for Clinical Decision Support like this?

Put the road signs on the road, not in the garage.

It is already hard enough to use an EHR with patients. Don’t make me go looking for that training document from weeks or months ago, don’t make me think. Make it easy to do the right thing. It is a small celebration every time we can do this right.

CMIO’s take? Thanks to Rich Altman MD for a beautiful new tool in our system. What road signs can YOU take out of the garage and put on the road?

Info Blocking Rule is coming 4/5/2021. Here is some last-minute help for health systems

Break down those barriers!

Well, it is finally here.

The 21st Century Cures Act has an Information Blocking Rule that goes into effect as of April 5, 2021. It was originally supposed to launch in November of 2020, but the federal government told us “JUST KIDDING” 3 days before and delayed until 4/5.

Because we laid all the groundwork and also felt it to be the RIGHT THING FOR PATIENTS, we went ahead and launched our changes in November, and SURPRISE: I still have a job, wasn’t fired. Thanks to our MMOLC sharing community.

A brief reminder

The rule stipulates that patients should be able to receive a copy of

  • Test Results (laboratory, pathology, radiology) and
  • Their Provider’s (physicians and advanced practice providers) Progress Notes

upon request. The interpretation was that if a patient had a Patient Portal account in the EHR (electronic health record) of the clinic or health system, this meant immediate release of this information. This is a major change for many health systems who had not yet adopted Open Notes (release of progress notes) or delayed the release of test results by several days.

Since our adoption of Immediate Release

of Progress Notes and Test Results since November of 2020, I have had exactly 2 complaints reach my desk, both from oncologists representing unhappy patients who read their CT imaging study on Friday evening and had difficulty reaching their doc until Monday. This is in the setting of about 1 million clinic visits, 800,000 radiology studies, 30,000 hospital stays, millions of lab and pathology results in these last 4 months.

So, not perfect, but not nearly the “sky is falling” result, as anticipated by many colleagues.

In case you’re still working through this, here are some documents (some updated) that we used. Some are actually named Information SHARING instead of BLOCKING, just a more hopeful attitude. I hope these might help you. Images here, links to full PDFs further down.

Even better, our colleagues at OpenNotes.org are doing some terrific office hours with experts online where you can hear the real-life experience of leaders ALREADY doing this work in various fields, successfully.

CMIO’s take? Are you ready? Do you have documents YOU can share? Lets do this!

COVID Vaccines at Colorado’s Epicenter from March 2020: JBS Greeley Beef meat packing plant.

Changing minds with Stories, not Data.

NEWS ARTICLE: https://www.greeleytribune.com/2021/03/05/jbs-workers-having-seen-the-largest-outbreaks-in-weld-county-receive-first-doses-of-covid-19-vaccine/

This was a remarkable event, and I’m glad I was there to see it.

For those who may not know or remember; Greeley’s JBS meatpacking plant was the center of Colorado’s first major outbreak of COVID illness, resulting in numerous deaths and hundreds of workers getting sick and hospitalized. Meatpacking requires close quarters, and one infection spread rapidly to many.

I watched on the news with horror as the disease spread, and Greeley, a small town in rural Colorado became national news. Greeley also led the state in COVID illness early in the pandemic.

Public Health Effort

The great news NOW, is that Colorado’s Public Health coordinated a multi-health-system effort to vaccinate the nearly 5000 employees there. When I heard of the opportunity, I dropped everything and headed up there last Friday to be part of the effort.

It would seem an insurmountable task: How do you coordinate nearly 100 volunteers who don’t know each other, in a noisy, unfamiliar plant? How do you incent workers who may have questions about the vaccine, to come discuss and be vaccinated? Will you have enough translators (at least 8 languages are spoken by employees)?

7 health systems coordinated

Soon, however, we got organized into 14 tables of 3 vaccinators, taught how to load vaccine syringes from defrosting Pfizer -70 degree vials, supplies distributed, and employees started rolling in, paper consents in hand.

Doctors, nurses, medical assistants, technicians, healthcare workers speak the same language. Despite the cold hallway, we buckled down and got to work.
Dr. Hoffenberg instructing each table on standard vaccine process.
Patients arriving by the hundreds

2500+ vaccinated

We vaccinated over 2500 employees on Friday, a great day and smooth operation. See above for the write-up by the Greeley Tribune, among many news organizations on site.

The “Education Room”: Stories NOT Data

Here is where it gets interesting. I found out that I was assigned to the “Education Room” upstairs. Management at JBS was serious about maximizing employee engagement with this big push for vaccination.

  • The plant was closed for 2 days.
  • All workers would be paid for 4 hours of shift work JUST TO SHOW UP.
  • All workers who got vaccinated would receive an additional $100.
  • All workers who declined vaccine could sign a paper … AFTER they went to the EDUCATION ROOM where Dr. Lin and other physicians and nurses were waiting
Image blurred intentionally

Hmm. I thought I had signed up to vaccinate today …

When I heard this, my life flashed before my eyes. Not really, but I had a rapid sequence of thoughts:

  • I hoped they had enough translators (turns out, yes: Somali, Spanish, Amharic/Ethiopian, many more)
  • I hoped I had heard most of the rumors and misinformation about the vaccine before and be ready to respond
  • I hoped that I could avoid STATISTICS and DATA, since most vaccine-decliners have (mostly misinformed) STORIES. Data never beat a compelling Story. Only Stories have a chance to fight Stories in the battle for feelings and changing minds.
  • I thought back to a book I read recently, The Righteous Mind, about values, moral thinking, and how those with liberal values, and those with conservative values see morality with very different lenses. Would I be able to speak a common language to connect with those who saw the world differently?

Reasons why NOT?!?

Yes, it turns out, we only had about 100 people come through for the 6 hours I spend there. Of the 100 we spoke with, I heard a dramatic range of reasons why people were declining the vaccine:

  • “Well, it’s not a real disease anyway.”
  • “I heard the vaccine kills people.”
  • “The vaccine is only 95% effective. So what is the point? Like, it doesn’t even work.”
  • “I heard it is made from dead babies.”
  • “Only old people have a problem with COVID.”
  • “I am healthy. I don’t live with old people. I don’t need it.”
  • “My roommates will make fun of me. We are not getting it.”
  • “My parents told me not to get it.”
  • “Why are WE the guinea pigs, before everyone else?”
  • “I’m going to wait and see.”
  • “I’m pregnant. I heard it is dangerous for my baby.”
  • “I already had COVID. So, I’m immune.”
  • “I never get ANY shots, flu, nothing. I don’t need it.” (and more)

This was a daunting task. However, we had a room full of translators for all languages, 3 tables set up with information sheets and 3 cultural ambassadors to explain the importance of the vaccine and WHY JBS managers and leaders thought this was important, and even Union Leaders who would show videos of themselves getting the shot themselves (thank you JBS; very organized!). THEN, if the participant was adamant about their decision, fine, go sign the paper and get paid.

Less Helpful Conversations?

IF they had a question, one of us would get called over, and we could chat. I heard a few discussions in the room. Some less effective approaches:

Employee: “I don’t want the shot. I already got COVID. I’m immune.”
JBS Supervisor: “I haven’t got COVID. I’m not immune. You don’t care about me?”
Employee: “Nah man, stop talking. Where do I sign the paper.”
(Confrontational)

Employee: “I don’t want the shot. I’m healthy.”
Medical advisor: “You know, the shot is 95% effective. Even though it doesn’t protect everybody, the data shows that almost everyone gets immunity. Even if you DO get the infection, it is likely milder and you won’t have symptoms.”
(Data-heavy, confusing, and not addressing the issue)

Employee: “It is not a real disease.”
Medical advisor: “Yes it is. People die all the time. Here are 5 reasons the shot is safe and the evidence that it works…”
(Not enough reflective listening, eliciting thoughts, trying to find common ground, and too much talking)

Whew. I could see myself falling into each one of these traps. I set myself a goal to find STORIES to match and counter their STORIES and to suppress temptation to exhibit my command of the DATA (sooo hard).

Better Conversations?

Here are some of the better ones we came up with. Importantly, ALWAYS begin with “What questions do you have?” and “Tell me more about what you understand.” and “Anything else?” and “I like that you are trying to get good information before making a decision. This can be very confusing and scary. I would like to help.”

Employee: “I’m pregnant. I’m afraid for my baby.”
Me: “Yes, there is less information from the vaccine tests about pregnant women. HOWEVER, MOST of the women doctors and nurses at University Hospital who are pregnant have gotten the shot. And we are confident it is safe for the mom and baby.” (result: agreed to shot)

Employee: “I heard the shot makes you sick.”
Me: “Well, most people do not get sick. If they do, some get a sore arm, or a headache or fever, like getting the flu. Tylenol helps. For me, I had a fever for about 3 hours overnight.” (result: agreed to consider it later)

Employee: “Why are we the guinea pigs and getting it early?”
Medical advisor: “Actually, the doctors and nurses were the guinea pigs; they got the shot back in December and January. We are all healthy and staying safe, with no major side effects. We want YOU to be protected too.”

Employee: “I just don’t want to do it.” (unable to state a clearer reason)
Me: “I hope you see all the doctors and nurses in this room. We are all volunteers, took a day off to come here, because we WORRY about you and your community. You are Essential workers. Last year, many of your co-workers got sick and died, and we did not protect you. We don’t want this to happen again.” (result: thanked us for volunteering, and promised to consider vaccination)

Motivational Interviewing?

Of 100 people, about 20 agreed to the shot during our session, about a 20% conversion rate. Is this normal? I have no idea. One of my colleagues noted:

“Compared to vaccinating, this is soul-crushing. To do your best explaining why a crucial vaccine would save lives IN THIS PLANT, and not to connect. So hard.”

Nurse Practitioner in the Education Room at JBS

At the same time, we all agreed that many of the decliners also said they would think about it some more, and would consider getting it later. In motivational interviewing lingo, perhaps they were moving from “pre-contemplative” to “contemplative.” Even a mild attitude shift like that, is a win.

Some of the more effective strategies:

  • Listening more than talking
  • Finding common values: “The Broncos!” or “Protecting elderly parents”
  • Telling a personal story of COVID or getting vaccinated and how it felt
  • Talking about “looking out for each other” “protecting our community” “making Colorado safe” “keeping Covid out of your family”
  • Using metaphors: “Which vaccine? Its like, Dodge, Ford, Chevy. Just get in the car. We will all get there.”

Dr. Steve Hoffenberg, Emergency Medicine Physician, coordinated the vaccine efforts at JBS. Thank you, Steve.

FINALLY: Will you look over this document with me? I wrote a ONE PAGE summary of what I thought were the BEST STORIES to fight misinformation about COVID Vaccine. What do you think?

Download the document here: https://www.dropbox.com/s/k94xra38b4tmmst/2021-0309%20Why%20Should%20I%20Get%20the%20COVID%20Vaccine%20CTL.pdf?dl=0

CMIO’s take? Wow, there is a lot more to vaccine work than “give shot, call next patient.” Coordinating a public health effort: massive. Focusing on high risk populations: important. Listening, connecting and changing minds: some of the hardest work of all. In the coming months, THIS will be the conversation.

SNAFU tent: Optimizing a Covid-19 Mass Vaccine effort at Many Levels

Dancin’ away troubles at UCHealth’s SNAFU tent for Covid Mass Vaccination

Optimizing the Mass Vaccine Event

This will be a fun exploration from a CMIO’s perspective. Let’s think about individuals and work our way up to national optimization, from a personal perspective. And, don’t miss the SNAFU Tent Vaccine Dance at the end…

Seven Levels of thinking

  • Level 1: Make myself efficient
  • Level 2: Make my pit-crew efficient
  • Level 3: Make all pit-crews efficient
  • Level 4: Make the entire Mass Vaccine efficient
  • Level 5: Optimize Mass Vaccine for volume or cost
  • Level 6: Optimize Health System Vaccination plan
  • Level 7: Optimize National Vaccination

1. Make myself efficient

Readers may remember recent writeups where I incrementally overcome my lack of skill as a physician at vaccinating. I’m a quick study, and when great nurses and medical assistants are around to teach, I got better quickly. See above, with the pre-peeled bandaid/ vaccine/ alcohol swab grip, and second hand to manage the smartphone electronic documentation. I’m MOB-ILE.

Here’s the set up: have an assistant play “keep ahead” by peeling bandaids. The hardest part of the job is peeling bandaids with gloves on.

The next hard part is that vinyl gloves stiffen in cold weather. So, use the sani-wipe jug to elevate your glove box closer to the propane heater. Smart! Actually even that wasn’t really warm enough, so I took to doing this:

I call this “praying to the propane gods.” Or, holding the gloves up for 5 seconds of warmth: makes a huge difference in the ease of putting them on (150 times that day).

Handwarmers: Even better idea

Of course, Bernice comes to me near the end of the day and tells me “Dr. Lin, put 2 handwarmers in your coat pockets and put your next pair of gloves in them, so you always have warm gloves to swap.

“D’oh!” as Homer Simpson would say. Why didn’t I think of that?! Thanks, Bernice.

Colorado Rockies’ Dinger drops by

2: Make my pit-crew efficient

This section is actually mis-labelled. My pit crew made ME efficient. Unlike previous days, where I built up such an efficient process that I was able to stay ahead of my pit-crew colleagues in our 4-car pit-stop, today I was teamed up with 3 outstanding medical assistants from Lowry Internal Medicine, my own UCHealth clinic in Denver: Marina, Yanira and Bernice. The tables were turned: now, every time I looked up from my completed vaccination, the other cars in my pit had already gone! Too fast, gals! You’re too fast for me. 😦

Team Lowry, with my BFF’s.

View of the Mega tent with 4 of the 8 rows, and the pharmacy (vaccine reconstitution tent to the right). The other 4 rows are out of sight to the right of the pharmacy tent. We can vaccinate 32 cars in 8 rows at a time this way. Furthermore, we would huddle and learn from each other “How are you going so fast? What is your set up? How do you ask the screening questions? Where do you put the sharps container?” etc. Thank you, smart colleagues, for teaching me.

3: Make all pit-crews efficient

To further smooth the process, given what we had learned on previous weeks, we posted 4 SNAFU tents after the Mega-tent that we would refer to for any slow-downs or technical concerns. For example, one car pulled up with 3 people to be vaccinated. I would perform one vaccination, and since my row was ready to roll by then, I would place a red card on the windshield, indicating SNAFU and the flaggers would direct the car to receive the remaining 2 shots about 100 yards away. This simple workflow adjustment (4 SNAFU tents for all 8 pit-crews) kept ALL 8 lines moving. This was a difference (for me) between vaccinating 124 people one day and 158 the next. Super smooth.

Another example: a patient drove up and their Electronic Record account showed “second vaccine already administered.” I couldn’t solve it with my smartphone Rover app, so I referred him to the SNAFU tent.

After some investigation, we found out later that day, it turns out that another organization in town had incorrectly registered that patient (a common first and last name and somehow erroneously documented date of birth) so that the mistaken vaccine APPEARED in OUR system on this patient (our separate Epic EHR’s share vaccine records now) that he had already had his second shot (incorrectly). We presume this was because some institutions are still using a paper-vaccination process with “document later” staff (as we did last month, in favor of speedy vaccinations). This re-introduces errors that the EHR was supposed to eliminate (bad handwriting and transcription errors). Hmm.

We are glad we are now using the Rover smartphone app. We’ve tinkered with it so that it is now possible to be as fast with Rover as with paper (AND eliminating the transcription step). 50 seconds with paper, and 50 seconds with Rover. Ha!

4: Make the entire Mass Vaccine efficient

We had lots of competing concerns to keep in mind, when thinking about the entire effort. Police were concerned about backing up waiting cars into nearby streets. (whew, we avoided this). How many total staff were needed to register patients? (too many in version 1) How many tents to rent for these events? (originally 1 mega and 18 cabana-style tents, now 1 mega and 2 cabanas) How would we deal with inclement weather? (snow, rain, black ice, wind: the mega-tent is superior to cabanas for keeping staff out of the weather and minimizing wifi and cell-booster mesh network issues; FYI, my new 5G iPhone 12 pro max was awesome in our pilot testing for speedy smartphone documentation)

Our diligent road crew out there dodging and managing tent-avalanches.

We have been pleased to constantly drive down out patient-throughput times, down to 22 minutes (including the 15 minute observation period)! And this past week on Sunday, we drove our total time down to 16 minutes in some cases: 1.5 minutes for registration, vaccination, a couple minute driving time, and then a 10-minute observation period. Wow. We believe we are the fastest Mass Vaccine service in the country at this rate. Even better, we are making observation OPTIONAL going forward, because of our non-existent severe reaction rate.

We believe we can expand beyond 10,000 per weekend, and believe we can do 20,000 or possibly 26,000 per weekend, if the State has vaccine supply and would like us to.

5: Optimize Mass Vaccine for volume or cost

So, what is the goal of a Mass Vaccine event? Publicity for vaccination? Sure, we had news helicopters circling, lots of press, lots of people commenting on how easy it was, and how much they’re looking forward to hugging grandkids.

We can optimize for convenience for frail elderly. Sure, stay in your car from home, back to home, no walking. Can we help people avoid healthcare settings? Sure.

We can optimize for speed: in which case, bring more vaccinators, and rent a second mega-tent. There is room in this massive parking lot for more staff, we can create more lanes and instead of 32 at a time, we could do 48 cars or more. 20,000 per weekend is entirely conceivable, if vaccine supply were up to it (not yet).

Or, we can optimize for lower cost. With our original full teams in the early weeks, we overstaffed and calculated a per-vaccine operating cost in the mid $20’s. Of course, the vaccine itself, is free to us and patients, paid for by the feds. But, tents, staff, project managers, coordinators with police, state, county and city government, vaccinators, training team, pharmacy team, coolers and vaccine supply chain management, traffic tents, snow removal, medical observation team, volunteer-coordinating managers, paramedics, command center coordinators, walkie-talkies, workstations on wheels, smartphone devices, wifi repeaters, cellular repeaters, scheduling of appointments, design of vaccine clinics… pretty soon it is a big operation. After a couple days, and constant re-design, we were able to trim operations down into the $17 range.

6: Optimize Health System Vaccination plan

First Covid Mass Vaccine design, last month, at Coors Field, Denver

Vaccinating patients on-site at University of Colorado Hospital, Bruce Schroeffel Auditorium

Outdoor vaccine guy vs Indoor vaccine guy

AND THEN. We compare our Mass Vaccine efforts to our ongoing (but less splashy) vaccine clinics in 10 facilities across UCHealth, spread across the entire state of Colorado, at even lower per-vaccine cost, with the capability of 5,000 to 10,000 per day. We are hiring permanent staff to run these vaccine clinics and stop borrowing from clinical teams across our system, as we think we will be doing this for quite some time.

Volunteers?

It is gratifying that we have lots of folks (many retired) willing to volunteer their time. The challenge with accepting this help is: it can be more expensive to run a scheduling calendar and training for hundreds (?thousands) of part-time (or one-time) volunteers than it is to have a reliable, skilled steady crew to take care of business. For the rare volunteer who COULD come regularly (for 8 or 10 hour shifts!) (for months!), that would be a blessing. And, as this vaccine saga goes on, we may indeed need more help.

Pop-up Outreach Clinics for the medically Under-served

Another effort I’m grateful for, are our Pop-Up vaccine clinics. We are taking our show on the road to multiple community centers and churches in medically under-served neighborhoods, where leaders are helping us schedule thousands of vaccination appointments among their neighbors. I’m heading to several in the coming weeks. (stand by for more posts from the front lines!)

UCHealth has given 270,000 vaccines, about 20% of Colorado’s total to date.

Yup, you read that right.

From this graph, you see our green Mass Vaccination events occurring on 2 weekends. Dark blue is University Hospital with over 13,000 vaccines given per week, and our other regions similarly. Light blue is South region, Purple is North region. Red includes our small hospital and outreach clinics at about 10,000 a week. Again, limited by supply.

7: Optimize National Vaccination

A rising tide lifts all boats.

For those interested, UCHealth has published a playbook for other organizations: https://www.uchealth.org/covid-19-mass-vaccination-planning/ with lots more details.

And Finally: a SNAFU Tent Vaccine Dance?

Is this real? Apparently, yes. Dr. Jonathan Pell and our elite crew of SNAFU tent staffers put together a dance invitation for upcoming cars.

I was surprised to find out how many younger colleagues had never heard of the term SNAFU.

The good news? Our process worked so well, the SNAFU team did not have much to do, a few cars here and there during the day. So much time, in fact, that they came up with their own DANCE.

I have no words.

CMIO’s take? How to get better in Seven Different Ways. Let’s go!