Electronic Health Records and Clinical Informatics
Caution: humor and high quality research facts ahead! What percent of patients worry? What percent of patients prefer immediate release even if result is abnormal? There are research findings?
Listen in! This was a great conversation, with Drs. Steitz of Vanderbilt University and Liz Salmi, citizen scientist, patient researcher, punk rock star. I’m there too. Interviewed by Jerome Pagani and Craig Joseph MD. Will there be ukulele?
Here’s the paper:
Come join us! Dr. Bryan Steiz, first author, Liz Salmi, Chief Patient Informaticist, and I discuss our recent publication on the subject of patients accessing their test results online BEFORE their doctor can inform them. This poses a host of gnarly questions that had no data, no answers … UNTIL NOW.
It is hard to express the excitement I have for this tiny little (yet disproportionately huge) development in our Unified Communications strategy
To those NOT on the Epic EHR journey, or those who have NOT been implementing “secure chat” tools in their organization, this may not seem like a big deal.
It is.
The challenge? Secure chat is terrific when you’re the sender, you can reach a LOT of colleagues by texting on your smartphone. HOWEVER, there is such a thing as “TOO MUCH OF A GOOD THING.” Some of our residents are receiving upwards of 400 secure chat interruptions PER DAY.
How can one even think, much less be effective as a physician / APP / resident caring for patients?
One of the unwanted interruptions is the expression of “Thank you!” when grateful for a rapid and effective response from a colleague. And YES, we do want to increase our mutual expression of gratitude to build trust and a sense of teamwork and human connection.
HOWEVER! This “Thank you” can come when the physician is scrubbed in to a surgical case, and we can’t tell when something is an new message or a “Thank you.”
One tool we have been begging our Epic Wisconsin developers for, is a NON-interruptive EMOJI that allows the reply with a THUMBS UP or SMILE or SURPRISE or CRY or HEART, that is NOT interruptive but shows up the next time that person checks their phone.
As a result? WIN-WIN! We give gratitude, feel a sense of connection AND the recipient does NOT receive another interruption, but can digest that reply at their leisure.
WELL, your wait is over, UCHealth colleagues, we have installed this Epic version update and now: HOVER OVER (on computer) or TAP AND HOLD (on phone) the message and you too, can send non-interruptive THANK YOU emoji’s.
Now, I’m going to go send our Epic Wisconsin colleagues an nice THUMBS UP.
Where Bobby Zarr and I discuss the future of learning in health systems, with AI embedded in tools like the ones in our Learning Assistant, what we internally brand our education from uPerform.
Aren’t you frustrated with EHR usability? Don’t you wish you could see just-in-time guidance in the EHR? If the US Highway system can put signs on the highway, why can’t we?
From Dall-E image creation via Bing.AI browser
AMIA Panel: Signs on the roadway with Dr. CT Lin and Dr. Ryan Walsh
I enjoyed our panel discussion, encompassing two related topics:
From Dall-E via Bing.AI
CMIO’s take? We have found success with our technology innovation partners, uPerform and Amplifire. Click the link to learn!
The classic case of the Uber self driving car, in-person monitor, and the fatal pedestrian accident, is now legally concluded. A sober reminder of ALL OUR complacencies. Or paraphrasing Shakespeare: “But, soft ye now, the fair Ophelia, nymph in thy orisons, be all my complacencies remembered.”
https://www.wired.com/story/ubers-fatal-self-driving-car-crash-saga-over-operator-avoids-prison/
This made news a few years ago: a self driving Uber, under testing with a monitoring person in the driver seat, hit and killed a pedestrian (who was not as a crosswalk).
The monitoring driver plead guilty to reckless endangerment and will avoid prison time.
This reminds us of the constant and growing influence of AI and automation on our daily lives. We are all less vigilant when an assistant gets really good. Maybe 99% effective, maybe 99.9, 99.999, like with self-driving vehicles. What happens to the 0.001%?
Recently I was criticized by a medical colleague because “I wrote a prescription for a muscle relaxer, and it caused a drug interaction with the patient’s birth control medication. Epic did NOT stop me, and it should have.” The implication was, that it was Epic’s fault, and thus, those who configure Epic (CT Lin and his henchmen).
CMIO’s take? Classic automation complacency. We give the automation power over our daily lives and we stop watching carefully. Have you seen this in your work? Let me know.
Any health systems still struggling with decisions about sharing Open Notes and Open Test Results, and how to build a win-win-win relationship between physicians/APP’s, patients and hospital leadership? Here you go, the result of years of building together at UCHealth
The general idea of information sharing between a clinic / hospital / physician/APP and their patients seems like “Mom and Apple Pie”. However, the devil is in the details. How do we approach this at UCHealth?
We do have over 2 decades of discussion on these topics, and these are now distilled for you. I’ve published earlier versions of this document (search info blocking on my blog and you’ll get them).
I was prompted by hospital leadership, as we rebuilt our “physician/APP onboarding” education plan, on how to explain Open Notes and Open Results to our newest providers. I thought of including our latest document from 2020 (wow, that is 6 internet generations ago!), but there were lots of outdated statements.
CMIO’s take? Here you go! My up-to-date version of Information Blocking / Sharing / Open Notes, Open Results introductory document for our newest colleagues at UCHealth; feel free to share amongst yourselves. If you make improvements, please let me know! We’re always looking to improve.
Here’s a sneak peak at my newest talk. Did someone’s story defeat your data-driven brilliant proposal? Do you understand why? Like me, did you go crawl under a rock and wonder “wtf”? With luck, I’ll share this talk in November.
This is my proposal for CHIME fall forum. Storytelling for Leaders.
And recently given as a talk for UCSF’s Rehab Informatics Group.
If all the stars align, maybe I’ll see you in November?!
Do you struggle with EHR workflow and optimization? Do you have an optimization team where you work? Can you tell us about it? We’re gathering a national feedback sample. Come help make things better!
Survey link: https://redcap.link/Keeping_up_with_the_EHR_survey
Thank you for your time and attention.
Rachel and Amber
Rachel K. McEntee, MD | she, her, hers
Assistant Professor, Hospital Medicine
Associate Chief Medical Information OfficerThe University of Vermont Health Network
https://www.linkedin.com/in/rachel-mcentee-md-9328729/
Amber Sieja, MD | she, her, hers
Professor of Medicine | University of Colorado School of Medicine
Director, UCHealth Sprint EHR Optimization and Training Program
Senior Medical Director of Informatics, UCHealth and Ambulatory Services
https://www.linkedin.com/in/amber-sieja-4058b777/
Want to see how the sausage is made? Here are some tidbits from our recent EMO discussion. Yes, our committee is named Electronic Medication (warning) Optimization. Who doesn’t want the “EMO notes”?
from Bing / Dall-E image generator
We have a new tool from our EHR vendor to allow physicians/APP’s to “opt out” of future similar interruptive alerts about medications.
For example: “Magnesium in IV for pregnant patient” or
“Ibuprofen interaction with __ drug”
Previously, our physicians/APP’s would either take action (cancel the prescription) or override the alert and state that benefit outweighs risk, EVERY TIME.
Now, our colleagues can FILTER or SUPPRESS these warnings specifically or categorically. As an informatics working group, we have some choices on how to configure this.
Won’t you come along and be a back-seat driver for our conversation?
I mean, we are doing SUCH A GOOD JOB ALREADY (we are top/worst quartile in “overridden alerts” by our users, among our EHR vendor customers).
A: Yes, we are going to turn this on.
Filter for ALL patients or Filter for THIS patient. When we suppress this alert, shall we turn it off FOREVER? Or bring it back every 6 months? Or longer, or shorter? On the one hand, we should respect physician decisions, right? And never show it again? On the other hand, who knows how fast that physician is moving when selecting to “suppress everything — I hate all of you.”
A: Well… after debate, we will leave it at 6 months. Not too burdensome to ask a prescriber twice a year whether they still want this to be filtered. That is 363 days a year we stop asking. And, intermittent re-inforcement is more sustained learning (showing alerts sometimes prompts better retention than every-time alerts that become noise and aggravation).
Should the alert be suppressed FOREVER if a prescriber chooses THIS patient? Obviously, the incremental benefit to the prescriber is tiny (I have thousands of patients, so if I choose THIS PATIENT ONLY, I MUST have thought about THIS patient in more detail and we should honor that choice with a FOREVER suppression). For example, “ibuprofen in hypertension” alert. Perhaps THIS patient has tried dozens of other treatments and the ONLY help for migraines is ibuprofen, and yes, I know it affects hypertension, and the risk is worth it. Why remind me again? And, because the benefit is small to the prescriber, the THIS PATIENT setting should be infrequently used, and ONLY with thought.
A: We are investigating if we can make THIS PATIENT suppression setting different from the ALL PATIENT suppression setting.
Can/should we remove the ability to suppress those interactions? How paternalistic should we be? EG: Paxlovid and lovastatin: can we allow this to be suppressed?
A: TBD. We are unsure of the granularity of the tools, and we will investigate this further. This will end up being a consensus decision of our committee, backed up by proposing these major decisions to our clinical leaders for approval. It is always a good idea for operational committees like EMO (comprised of practicing clinicians / informaticists / pharmacists / IT analysts / clinical nurse informaticists) to work together to build consensus. Many of these decisions are NOT slam-dunk, as you are starting to see.
What shall we put there? Should we give several “best guess” reasons, for example:
A: Although the last option is a real project (look it up: GROSS is a clever and memorable acronym invented by other informaticists), this is too many choices. We went with ONE choice “Clinical Judgement – Suppress for 6 months”, because A) No one wants to spend more time on this alert, there will not be much signal here to detect, and B) Suppress for 6 months RESPECTS THE USER by telling them what to expect, and when this will re-appear, to reduce the frustration of “I thought I got rid of this.”
from Bing / Dall-E image generator
Maybe they’ll tell us something useful that we did not expect!
A: NO. NO. NO. In the past, our required clinical fields have often been perceived as Nuisance. Requiring completion results in answers like: “.” and ” “, or even “jkljlkj”. The least number of keystrokes to make the stop sign go away. Or it results in hate mail “This is stupid. You are stupid. ” Burned out physicians/APP’s can easily pass the burnout to our IT and informatics team members. Leaving it optional leads to better signal/noise and more thoughtful comments from the rare commenter.
A: We plan to bring these exceptions back to the EMO committee to look at, perhaps 1 to 2 times year and see if it is performing as expected. Also, if we can spot patterns of the most ‘overridden’ alerts, we can look at removing the alert completely, looking to reduce our need for overrides in the first place.
Why don’t we leverage the wisdom of the crowd to finding the lowest value alerts?
A: Unfortunately, doing so may empower our “go fast” physician/APP phenotype: “I hate all alerts, so I’ll choose the one least likely to show up again”. We worry about these “over-suppressers” who over-estimate their ability to catch important interactions and defeat the systematic protection of the EHR. We do NOT plan to offer GROSS as a choice, but instead will look at “Clinical Judgement” frequency (if a LOT of prescribers choose to suppress, there is signal there, don’t rely on individual prescribers to accurately choose GROSS). A subtle point, but there you go.
Shall we announce it in the newsletter? Shall we get approval from our busy CMO (chief medical officer) council?
A: Machiavelli teaches us, whenever you make a bad change, do it all at once. Whenever you make a good change (this is a good change; ability to suppress alerts customized to the individual prescriber), TAKE CREDIT FOR EACH CHANGE SEPARATELY. Yes, we will announce this in the newsletter as a separate news item every time there is an improvement. As for authority, we have agreed with our CMO’s to bring, on a quarterly frequency, a summary of the changes the EMO committee is making, to ensure they are overseeing the changes. This will come as an FYI, no decisions necessary, as we have established trust that we are not making crazy decisions, based on past presentations this year.
CMIO’s take? This is a taste of the discussion and decision-making at EMO. Maybe you have an interesting or different take on this informatics work? Let me know!
