Category: Informatics/EHR

Electronic Health Records and Clinical Informatics

“E in EHR does not stand for Fax” — Steve Hess, CIO

I constantly enjoy the creativity of my colleagues. In this case, Steve Hess, our CIO at UCHealth, made this statement during a discussion about our fax-server software linked to our EHR. As our organization has grown, we have added hundreds of clinics, and now we’re approaching a dozen hospitals in our network, all on a single instance of an EHR.

Consequently, our communication and IT architecture is primarily based on within-EHR communications, the so-called Inbasket. However, we often communicate with healthcare entities (insurance companies, out-of-network clinics and hospitals, skilled nursing and rehab facilities, etc). To force others to use our EHR’s inbasket is unrealistic.

So, even in this 21st century, the lowest common denominator for communication between healthcare entities is … FAX. Our organization faxes millions (yes, MILLIONS) of virtual sheets of paper each month, a veritable blizzard of paper. Furthermore, our faxing volume now is bumping against our licensing limit, and Steve, very rightly, is pushing back against any increase in our faxing capability, and this is where he notes:

“The E in EHR does NOT stand for Fax.”

Which is hilarious. And sad at the same time. Where is our national interoperability? Haven’t we been working toward electronic seamless communication for over a decade as we furiously install EHR’s in every clinic, every ER, every hospital? Yes, and nothing is ever that easy.

So, thinking through our fax problem, several things became clear:

  1. Faxing STILL is the lowest common denominator. If our clinic notes and other messages to other clinicians MUST go through, fax is still the best most reliable method. Who wants to go back to stamps and envelopes? (let’s not talk about mailing test results to patients, as we still do that for some patients: don’t get me started)
  2. For all clinics and hospitals willing to use our web-based secure portal, what we call “Provider Connection”, we can set our communication strategy to send e-messages through that portal. Independent clinics and hospitals who are closely affiliated with use, do use this, and this works well.
  3. For all clinics and hospitals (independent of us) who use their own licensed version of the Epic EHR, we are gradually learning to turn on between-organization messaging, and these e-messages will gradually replace fax. This is getting going.
  4. For all clinics and hospitals on our instance of our EHR, we should be sending ALL notes and messages electronically through EHR e-messaging to our respective inbaskets.
  5. For all clinics that have connected to CORHIO (the Colorado Regional Health Information Organization and other Health Information Exchanges cannot get up to speed fast enough for us) we should be able to turn off our point-to-point communications like Fax because we deliver all notes and results from our EHR to CORHIO’s exchange, which then can deliver results to ANY EHR in the state.
  6. There are still hundreds of organizations out there who use a non-Epic EHR with no capacity for electronic interconnection to CORHIO, or who still use NO EHR. Then, these clinics only have ONE method to send or receive all these incoming messages: FAX. Sad.

Here is where we run into some surprises. Turns out, not ALL of our clinicians in our OWN ORGANIZATION have agreed to use e-messaging and still rely on Fax. What? Old habits die hard. It turns out, while our attention was elsewhere, some of our clinicians and clinic managers were able to convince someone in the IT organization to alter the setting for delivery of test results and referral letters from e-messages BACK TO FAX. On the one hand, I can see a reason why. Some clinicians are used to having the sound of the fax and the presence of paper in the fax-received tray as their TO DO task list, and never “got into email” (really?!). Some clinicians work at multiple healthcare organizations and do not want to check the inbasket of their general email, and the inbasket of the EHR for hospital 1, and the inbasket of the EHR for hospital 2, etc. I could see this being a huge hassle, where ONE fax machine could be the single TO DO list. SO, THIS PROMPTS SOME ACTIONS on our part:

  • All employed clinicians at UCHealth MUST use e-messaging. We will embark on a clean-up of our internal process. Why install an EHR and then let people continue to fax within our organization? It is like buying a Porsche and then cutting out the floorboards and pushing with our feet like Fred Flintstone.
  • Re-examine every affiliate clinic and hospital and figure out how to switch as many communications from fax to e-messaging with Provider Connection. In some cases, like the clinician with multiple hospitals, such a switch might dramatically worsen their clinical work, and we would make exceptions there.
  • Push on CORHIO and other HIE’s to improve between-organization messaging and link our EHR to their systems to make such messaging seamless.
  • Accelerate our investigation of Epic EHR interconnect messaging so that we can send/receive messages from other organizations that also use Epic.
  • Consider a drop-dead date (like “killer app”, this is a terrible term in healthcare) when we might say: “Fax is dead. In order to receive clinical messages from us, you must use Epic EHR or Provider Connection.” I think we’re not quite there yet.

CMIO’s take? Quotable quips are easy to say, and make us feel ridiculous sometimes. But then you have to take a hard look at yourself, and your organization, and the state of healthcare technology, and decide what to do. Do you have a similar story? Let me know.

Letting patients file their Advance Care Planning (Advance Directives) online via Patient Portal (Hillary Lum et al)

Dr. Hillary Lum

https://www.sciencedirect.com/science/article/pii/S0885392418310479

Thanks to Dr. Lum for her persistence and clarity of purpose. She led a team of physician leaders and IT staffers through a complex process, resulting in a first-of-its-kind online tool:

The ability for patients to complete their Advance Care Planning and upload the results using an EHR (electronic health record) patient portal. 

Why is this so important 

  • Very few patients, much less US adults, have an Advance Care Planning document (including Advance Directive, Living Will, 5 Wishes, No CPR, or any other document that records the wishes of the patient in regards end-of-life care)
  • It is difficult for patients to find the form, to understand the form, complete the form, return the form, AND THEN to have clinical staff file or record the form and its wishes in a way that is easily accessible by both healthcare providers as well as patients themselves.
  • Patients without any advance care planning documents risk the possibility of receiving unwanted care at the end of their lives; since patients are so often non-communicative as their health deteriorates, unless the doctors and nurses have a clear statement from the patient, we must assume that the patient wants CPR and other aggressive measures, even if it borders on inappropriate. This tragedy can easily be avoided with easily available documents expressing the patient’s wishes.

And now, at UCHealth, patients can avoid this risk! From the privacy of home, patients can now log in, launch the Advance Care Planning module, complete the questions, and even upload any signed documents in regards to their wishes, into their online Patient Portal, in a permanent storage location easily accessible by the patient (or their permitted proxy) or any of their healthcare providers at UCHealth.

This is pretty cool, and a big leap forward. In fact, even without any publicity to patients (the module just appeared in the portal), over 1000 patients recorded a NEW advance care plan in the first month after this module went live. And, patients continue to sign up at a constant rate.

We hope this continues at UCHealth, and more importantly, that other organizations start doing this as well. Only 36% of US adults (studied in 2017) have an advance directive; meaning that about 2/3 do NOT!

CMIO’s take? We have a lot of work to do, people. Let’s get the rate of advance care planning much closer to 100% of US adults; we never know when we’re going to need one, and by then it is often too late.

Open notes in a Resident clinic: research study results

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Research study paper is here:    http://ow.ly/6eY530jYZJy

We’re published! Thanks to co-authors Bradley Crotty MD, Corey Lyons MD, and Matthew Moles MD, we helped a multi-health system collaborative to study the idea of Open Notes in primary care residencies (family medicine and internal medicine at University of Colorado Health system), with research findings above.

Ultimately there is some anxiety from both faculty and residents about patients reading their written progress notes online, after the physicians have signed off on those visit notes. We are happy to claim that our program, of all the training programs was least optimistic that this would turn out well for our physicians and patients.

Overall, though, since we gathered this survey data, we have gone on to turn on Open Notes throughout our health system (UCHealth) and now uniformly offer Open Notes to all patients in our 700 clinics, 11 hospitals, and 21 emergency departments. The fear that the “world would come to an end” has not yet come to pass, and we are hearing positive things from our patients about their ability to read notes and benefit from them, including:

  • I often forget much of what we discussed in the visit, now I can go back and refresh my memory
  • Sometimes my wife asks me “what did the doctor say?” and now we can go review it together
  • Sometimes my other doctors don’t receive the consultation letter from my specialist, and now I can show him/her that letter/note from my patient portal. I can be in charge of my own information
  • I can use my doctors note to look up words I don’t understand and get more background information so that I can ask more intelligent questions at my next visit; I feel like a part of my own healthcare team

CMIO’s take: it is good to study what we do. As Robert Anderson MD, one of my mentors told me: “We should use the laboratory of our direct patient care to study and learn. Everything we do with patients should be evaluated and can be improved.” Thanks, Bob!

Happy holidays from the Large PIGs, JIG, and CMIO

Dave Corry arriving late to our group photo, to the CMIO’s amusement and dismay

I hope that you are making plans to celebrate the season, to connect with friends, colleagues, family, and take time for yourself.

I consider myself so fortunate to work with such a great group of informaticists or informaticians (inforMAGICIANs?!), or informatics people, whatever we call ourselves. The work we do, sometimes seems like a grind, but keep in mind, fellow informagicians, that we strive to improve the lives of patients, colleagues and staff by improving the information systems we use for the greater good. 

We try to keep it light in our naming of projects and committees. For example, our Joint Informatics Group (including clinical informatics nurses as well as physician informatics) is JIG. Our physician informatics group are the PIGs. This leads to the New PIG book club, the Small PIG leadership group, and the meeting, which encompasses all physician informaticists: Large PIG. 

And, be sure to throw up your hands and have a good laugh once in awhile. By the way, here’s an updated picture with Dave raising a glass. 

CMIO’s take? Here’s to you and the good work we all do. Cheers!

The Glass Cage by Nicholas Carr (book review)

The Glass Cage pbk mech.indd

One of our book club books, for the ‘clinical decision support’ team for the electronic health record at our institution. We have now read it in our Large PIG book club meeting (the Physician Informatics Group: we try hard not to take ourselves too seriously). Some of us were depressed after reading. The initial optimism of the ‘glass cockpit’, the fancy new computerized design of the complex Airbus aircraft, are instead proving to be a ‘glass cage’, which isolates us and anesthetizes us from the real world. The author provides riveting examples of glass cages: the Inuit who lose their cultural skills of navigating brutally inhospitable landscapes because of GPS and snowmobiles, also, the pilots who make error because of automation, leading to automation bias and automation complacency: thinking the computer must be right, and the computer will know, so I don’t have to. Further, our attention wanders as we cede responsibility for moment to moment control of the task. How do we fight such a trend and temptation, as designers?

Yet the author speaks about ‘adaptive automation’ where a computer could detect the cognitive load or stress in a human partner, and share the cognitive work appropriately. He speaks of Charles Lindbergh, describing his plane as an extension of himself, as a ‘we.’ Can we aspire to improving the design of our current electronic systems to such a partnership that avoids the anesthetic effect and instead becomes more than the sum of the partners? Chess is now played best by human-computer partners; could health care and other industries be the same? And what could that look like? The Glass Cage gives us an evidence-based view into that future (and hopeful) world.

UPDATE: We had a great discussion during our recent book club. As an indicator, several of my colleagues told me: “I don’t like this book.” Perfect! It made for a juicy, spirited conversation about the benefits and risks of automation and how the stories in the book did or did not apply to healthcare and what we were building. Maybe we can consider “adaptive automation” so that the computer scales up and down its assistance as the clinician comes under crisis so that the human can focus on problem solving and the computer can increasingly assist with routine tasks. And then, we need to take care that “automation complacency” does not increase. We already have heard of clinicians saying “Well, EHR did not pop up an alert for a drug interaction, so that means it must be safe to prescribe this new med for this patient.” Whoa, are we giving away the primacy of our own training and experience to an algorithm already?

CMIO’s take: keep reading, keep learning. It is only through extensive experience from reading and books that we can learn from others in healthcare, and from others in other industries divergent from our own. There are more smart people who DON’T work for you, than who do.

 

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

JonPell

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

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

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

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

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

ChampionAndPhysicianReadinessLeads

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

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

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

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

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

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

Benefits of the role:

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

Responsibilities of the role:

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

Some sample books included in our Journal Club:

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

Jonathan Pell MD

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

CT Lin MD, CMIO and his views on world domination (news, Becker)

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Kidding. Not kidding.

https://www.beckershospitalreview.com/healthcare-information-technology/crucial-skills-for-aspiring-cmios-q-a-with-uchealth-s-cmio-dr-c-t-lin.html

Further thoughts about Becker’s Hospital review for interviewing me and talking about my role as CMIO.  I have enjoyed their series on CMIO’s, and our collective vision:

  • Clinicians, in the care of patients in an increasingly complex world
  • Technologists, who whisper to the Ghost in the Machine
  • Leaders, who learn (some via the school of Hard Knocks) how to establish a vision, drum up consensus, listen to the cacophany of feedback, hold true to important principles, compromise when needed, and slowly, slowly drag your organization toward a more perfect future. For me, this includes:
    • Creating a “Sprint optimization team” to health system leadership and getting it funded long term
    • Creating “APSO notes“, convincing a dubious physician audience and implementing it as the default progress note in our EHR
    • Creating Open Results (sharing test results with patients) over 15 years ago, convincing a dubious physician audience, and implementing it as the system-standard across the entire enterprise
    • Open Notes (sharing clinician progress notes with patients), same…
    • Open Images (sharing radiology images with patients, live as of August 2018, FUTURE BLOG POST!), same…

And, sometimes a ukulele makes it better.

CMIO’s take? For all the difficult conversations and troublesome daily fire-putting-out crises, this is an amazing job, and I get to do this with an amazing team. Thanks to ALL my colleagues.

Dept of Medicine Innovation talk (video) on EHR Sprints

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I play a doctor in this blog, and sometimes in real life. 

http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/Pages/RIC-09-20-2018-Lin.aspx

Recently I gave a talk for the Department of Medicine Innovation and Research seminars at the Anschutz Medical Campus for University of Colorado’s School of Medicine. I spoke about one of my favorite topics, some of which I have discussed in these blog pages: Reducing the EHR burden and improving physician burnout with EHR Sprints.

CMIO’s take: what is YOUR organization doing to address physician burnout? Something similar? Let me know!

White paper: the Future of EHRs (National Symposium at Stanford)

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I had the privilege recently of being invited to a national symposium hosted by Stanford Medicine and Dean Lloyd Minor, sporting numerous EHR clinical experts, informaticists, vendors and other thought leaders. See the resulting white paper (caution, in addition to expert opinions, there are quotes from me):

http://med.stanford.edu/content/dam/sm/ehr/documents/SM-EHR-White-Papers_v12.pdf

CMIO’s take? I found it an invigorating, forward thinking symposium with lots of great ideas for where we are and where we are going. Most importantly, we tackled WHY solving the EHR conundrum (so important, but so far from where we need to be) is crucial to the future of healthcare.

Reducing Physician Burnout using an Agile team (EHR 2.0 Sprints), Guest Post by Brian Redig

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A little over a year ago, CT Lin, CMIO at UCHealth asked “How might we reduce physician burnout associated with the use of the electronic health record?” as part of an initiative he coined EHR2.0.  Through collaboration with Physician Informatics, Epic Certified Analysts, and Trainers, the optimization sprint pilot was quickly out of the starting blocks. Would the experience be the 100 meter sprint or the 110 meter hurdles?

The team accelerated quickly generating ideas.  They sent out surveys, evaluated provider efficiency profiles, created checklists, investigated prior optimization requests, and observed providers interacting with the system.  The team included Ambulatory Analysts, Trainers, a Scrum Master, a Nurse Informaticist, and a Physician Informaticist.  They had two weeks to accomplish as much as possible through interaction in the provider’s clinic establishing a medium for collaboration in real time.

The hurdles could be anticipated; “everything is critical!”, governance, change control, communication, capacity constraints, time, trust, and differing opinions.  Next, too much work in progress could create a residue effect as the analysts bounce between ideas instead of focusing on immediate next steps towards completion.  Finally, how do we identify and address assumptions, inferences, and facts?

The team leveraged agile methodologies in running the sprint to help address some of these obstacles. They used a Kanban board (Backlog, To Do, Doing, Done) as a way to visualize their work and agree to the work in progress, a Burn Up chart to show their accomplishments, and a Daily Scrum (Huddle) to discuss challenges, priorities, next steps, and context for the upcoming work.

The key to the sprint became the stakeholder participation in prioritizing what was important to them and assisting with trade-offs.  Instead of ideas having a static prioritization of critical, they float relative to other ideas.  There was also simultaneous exploration of the problem and solution domains as the immersion provided immediate feedback loops.  The focus quickly shifted from linear/more is better to high value deliverables.

The team was thinking through doing expressed best by the Chinese proverb,

“What I hear, I forget;
What I see, I remember;
What I do, I understand.”
–Confucius

Early results across the finish line demonstrate high impact to Epic flow sheets, SmartLinks, note templates, In Basket efficiency, Synopsis, and Med Rec along with positive net promotor scores.

The experience was neither a 100 meter sprint nor a 110 meter hurdle, it was a Tough Mudder!

The fastest way to the finish line was to lower hurdles through collaboration and provide performance enhancing features that minimized mundane clerical activities, streamlined charting time, and stimulated the cognitive clinical art of practicing medicine.

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Brian Redig, MBA, SCPM
Lean Six Sigma Black Belt
Board Certified Nuclear Pharmacist