Pandemic skills: Giving feedback successfully: I Like … I wish … What if … ?

Theater and acting: a life skill [icon from thenounproject.com]

During this pandemic, many of us have been stuck in front of our screens, like talking heads (Max Headroom, anyone?). If “sitting is the new smoking” (or perhaps not), then I’ve been “smoking” a lot.

Virtual meetings are draining, and I’m on them up to 8 hours a day, even busier now with all the EHR modifications, keeping up with policy changes, what Covid-testing is available, how we admit, treat, discharge, follow, track patients.

At the ends of long hours, long days, long weeks, our nerves are frayed.

I’ve observed that interactions between people have everything to do with the interpersonal skills of the individuals. Sometimes the conversation does NOT go well. Whether it is by email (worst for crucial conversations), by phone (slightly less bad), by online video meeting (slightly less bad) or in person (best, when possible), it is certainly worsened by the pandemic situation.

I’ve been taking a Story Skills Workshop (by Seth Godin and Bernadette Jiwa) that recently concluded. I have to say that I’ve learned quite a lot, and not what I was expecting to learn. I highly, highly recommend it. Seth and Bernadette offer a series of online lessons, released over time. There are about 6 expert coaches, and the instruction is to sign up for an interest group or ‘accountability group’. You’re given a story structure (the 5 C’s: Context, Catalyst, Complication, Change, Consequence) and then specific lessons to write and polish specific elements of your own story in this framework. The cool part is the instruction to ‘first write your own story, and then go comment on at least 5 others.’

  • I learned that it is possible, in an online-only course, to develop a sense of community and collegiality in a short 30 days.
  • I learned that it is crucial to be gentle in first contact with others online. For example, when giving feedback on others’ stories, DO NOT start right in with ‘why don’t you add more Emotion to that moment in your story?’ You’ll learn (as did I) that conversation either stops or becomes defensive. Remember that online conversations carry ZERO nonverbal: no Kind tone of voice, no Friendly posture. All you see are the words, and it is automatic to imagine them coming from a frowning critic with crossed arms, shaking his brutish head. [Pause for self-reflection amongst my blog-readers, as well as from myself…]
  • Instead, try something my theater-trained son taught me:

‘I like… I wish… What if …’

My highly emotionally intelligent son
  • Framing any response this way allows your recipient to hear something positive, then a neutrally posed concern, followed by a tentative suggestion. Having been on both sides of such a well-formed critique, I can say: it is EASY to write, doesn’t take longer, and on the receiving end FEELS COMPLETELY DIFFERENT. It FEELS like a close friend, reaching a hand over to pull you up to a higher step.
  • FOR EXAMPLE: Take one of my story-critiques of a co-participant in the story workshop, not done well on my part: “Why don’t you add more emotion to your story? It reads like a timeline, but nothing about what you felt, or how that impacted you.” I thought I was clever, to point out one of the main points of that week’s lesson. What I received was… no response. Hmm.
  • Rephrasing the reply using this framework, when I replied to a different participant’s story, sounded like this: “Hi, Joe! I liked your story, especially the unexpected part about running away from home at 16. I wish I could be there at that moment when you made the decision, everything boiling-over, and then a crucial moment. What if you paused in your story and told us what you were thinking and feeling right then? I would be riveted.” Guess what? We had a great online conversation after that, and he re-wrote his story, and I WAS RIVETED. Win-win.

CMIO’s take? Story telling: cool. Gentle, effective feedback: cooler. Don’t we all need to get better at this?

Improving Communication with Video Visits: now with shorter video!

17 minute walkthrough
1 hour seminar version with intro and Q/A

Thanks to my excellent colleagues at UCHealth, Echo Vogel, Hillary Duffy and Duane Pearson, co-conspirators to spend an hour on a Zoom webinar to review Patient Experiences with online Video Visits. We are all on a rapid learning curve. Come spend some time with us as we review what we’ve learned.

Here is a link to my original post on Video Visits, and on Patient Experience with Video Visits.

And here is my one page PDF on best practices (including communication strategies) with Video Visits.

CMIO’s take: What are YOU learning with Video Visits?

EHR v Covid-19. Follow the data: Hemoglobin, Viral tests, ‘data humility’

For all the talk about Covid-19 testing, and testing for respiratory viruses, keeping mind, that the UCHealth (and most health system) labs do SO MUCH MORE than virus testing. Hemoglobin, for example. Hemoglobin is the measure of how much oxygen-carrying protein we carry in our blood, a way to detect anemia, blood loss. Look at the dip in the orange hemoglobin line in early March. Our testing volume throughout UCHealth fell in HALF. As we all reconfigured our hospitals to prepare for pandemic, we also stopped all surgeries except for emergencies. And the various colored lines at the bottom are all our previously described viral tests (see previous post). How puny and miniscule.

Okay, so wait a minute, lets look back at those virus tests: what’s this? Remember that purple was Influenza B, Green was Influenza A, yellow was RSV (respiratory syncytial virus). Then there are 3 viruses (including Rhinovirus) that SPIKE in March! OMG! None of those are Covid-19.

CT Lin is a GENIUS! He has discovered the TRUE CAUSE of the pandemic: out-of-control mutated winter viruses! AND, there are THREE of them, all spiking at once! Triple infections for everybody!

Well? What do you have to say for yourselves? You gonna buy it? Pause and think. Hmm.

.

.

.

Okay, you’re all smarter than me. Yes, you’re right. When we started Covid-19 testing, we also threw in RVP (Respiratory Virus Panel) testing on the same swab. This graph shows, not the “testing positive” results above, but TOTAL VOLUME OF TESTING, and RSV testing increased 700% in a month, due to co-testing on Covid-suspected patients. Aha!

So, layer in the Covid-19 positive results, and we see this, temporary bumps in 3 viruses (due to all the co-testing of Covid-suspect patients: blue, dark-blue, red), and a persistent and growing number of Covid-19 positive patients (purple). And then, we have cut back the co-testing since then. AND we near the end of the season for those other viruses anyway. Okay, this makes more sense.

Hooray! Let’s celebrate, we made some sense of the data!

But, wait.

Of course it is not a good sign that each week we detect more Covid-19 positive patients. It is either: more patients are showing up for testing, OR we have more test kits, OR we have relaxed the standards (all symptomatic patients can be tested now, instead of just health-care workers and critically ill patients), OR the exponential spread of the pandemic is not over, OR something else we haven’t thought of yet. Wouldn’t you like to know which one it is? Yes, so would I.

CMIO’s take? I hate living in the middle of the pandemic, when every night, we go to sleep in the middle of a cliff-hanger. I hated those season-ending episodes in those shows I loved so much. Here’s hoping our heroes solve the cliff-hanger in time for next season!

EHR v Covid-19. Follow the data: Visits, Testing, Symptoms, Codes?

It is time we looked back at the past month to update our data. Since we initiated social distancing in mid March, and then the Colorado Stay-at-Home order in late March and subsequent mask use, what has happened to Covid-19, and what about symptoms? other viruses, the geographic spread? Hold on to your hats. This is all UCHealth data from our Slicer de-identified data tool.

  1. Virtual visits are up, and stable at about 4000 visits a day. In person visits are way down from baseline in early March. Overall visit volume is way down, as it is for most health organizations right now. As Colorado starts to ease restrictions from “Stay at Home” to “Safer at Home”, we will see what comes next. Regardless, there will be repercussions from this some time to come.

2. Covid RNA testing is up (not enough), supplies for testing are short nationally, and unlikely to change quickly. The state is ramping up, and we all agree that widespread community testing is critical to safely opening up restrictions. Furthermore, antibody testing, although everyone’s working hard on this, is still not ready for prime time; the accuracy of the tests (false positive, false negative rates) are still too high to be trusted.

3. Cough, Fever, Shortness of Breath, Diarrhea is all decreasing as we reach the end of the worst virus seasons. What does this mean about Covid? Of course, mixed in, is the decrease in visits overall. This curve is worth watching over time as the state “opens up.”

4. Where is the spread across 12 hospitals. University of Colorado Hospital on the far right, Greeley Medical Center on the far left. The higher bumps in the middle are for Poudre Valley, Medical Center of the Rockies, Memorial North, Memorial Central. Some of our hospitals are seeing very little. Interesting regional variation. We are also intentionally protecting some of our hospitals to be Covid-free as much as possible, in case of future surge demand.

5. What about ICD10 diagnoses by docs? You may know that CMS published an new set of ICD10 codes (international classification of disease, version 10) that contain Covid-19: including: Confirmed Covid, Suspected Covid, Exposure to Covid, etc. Grouping them into Confirmed versus Suspected, here’s what you get in our visits since March (orange: suspected, blue: confirmed). This is a reflection of the scarcity of testing. Again, interesting to see where this goes. NOTE: The last down-tick on the orange may be due to counting a partial-week in the data.

So what do we learn?

A. We need more testing to figure out what the community prevalence is.

B. Virtual visits, even scalable at 20x previous volume, will not save the day.

C. Social distancing and stay-at-home are followed quickly by a dramatic reduction of Covid-like symptoms seen in clinics. BUT, be careful of conclusions: social distancing could also have affected the USUAL winter virus spread, OR patients are not choosing to be seen, OR the virus is mutating into a less severe form, OR distancing policies might really be working. Wouldn’t you like to know which it is?

D. ICD10 codes are being used in our clinics! But the trends don’t mean anything yet. It might be promising that “suspect Covid” codes are growing more slowly.

F. Covid is going strong into the late Spring (wasn’t it supposed to evaporate magically likes SARS CoV-1? That outbreak in 2003 largely evaporated by late May, early June). Covid-19 (more accurately, SARS CoV-2) is going strong and is likely to behave quite differently, not a good sign for us humans.

PREVIEW OF NEXT POST: How does testing for OTHER VIRUSES compare to COVID testing results in the late winter/spring? and what does Hemoglobin testing teach us about Covid-19?

CMIO’s take? The lessons from Pandemic are numerous and they just keep coming. Be sure to take a break, and take care of yourself. Don’t worry, I’ll be back soon.

EHR v Covid-19. Nurses help families of ICU patients, from home

ICU rounds at PVH, photo credit: Lydia Baldwin

These are our healthcare heroes at work: From ICU rounds at Poudre Valley Hospital, part of UCHealth: Starting from the left standing we have Respiratory Therapy, Palliative Care PA, and Chaplain. Sitting from the left are RN, intensivist MD and Charge RN. In front of the intensivist (in green scrubs) is a telephone on the desk. The telephone is on ‘speaker’ and dialed in to a conference line. Also dialed in are: Pharmacist working remotely, Nurse Communication Liaison working remotely, Social Work.

So many great things going on here: Social distancing as much as practical (too much further and you can’t hear each other over the din of electronic alerts across the ICU), N95 masks (all day every day), reviewing data together from so many disciplines, discussing each patient in detail and taking immediate actions (placing orders, creating consensus on medical decisions, dividing tasks for rapid action).

In times of pandemic, the hospital follows infection prevention protocol and isolates very sick, very infectious patients. In this case, we have grouped and isolated all Covid-19 patients into a distinct unit, away from non-Covid patients. AND, in most cases, patients are not allowed to have visitors.

This is both good medical practice, and heartbreaking to families who cannot be present at a patient’s most desperate hour.

Out of this swirl of confusion, Julie Griffin, Nurse Manager of Care Management, thought: we have highly qualified nurses on-leave at home (orthopedic unit nurses with no post-op surgical patients; pregnant nurses for whom Covid infection would be particularly dangerous); how might they help share the burden of patient care with bedside nurses, and still minimize risk of contagion and exposure?

And so was born: Nurse Communication Liaison. Nurses from home, helping keep families connected, and reducing the burden on bedside nurses. We haven nurses helping with med/surg units as well as ICU’s. As described by ICU nurse Molly:

7AM: My day starts at 7: I review the Epic EHR chart from home for patients in the ICU. I read the notes from the nurses and the doctors overnight in our 12 bed unit. By the way, our unit has moved to double occupancy, and we’ve expanded to be a 23 bed unit. So much has changed, we’re so much busier.

8-10AM: I start receiving calls from family members and I give them updates on their loved ones, that I can, based on what I know. I am using Epic secure chat (a HIPAA-compliant text message service) to communicate with the ICU bedside nurses, social worker, respiratory therapy to get and give updates. I LOVE secure chat because it means the bedside nurse: who is gowned, gloved, doesn’t have to scrub out to answer another nuisance phone call interruption; they can catch up with chat-messages when there’s a break in the action.

10-11AM: Daily ICU rounds (picture above), where the team discusses every patient and I’m on the conference phone. It is a complete team with everyone pitching in.

11AM-430PM: We have designated ONE main contact family member for each ICU patient. We have found it can be overwhelming to have many family members calling each day for updates. I am so happy to be able to serve as the main contact for these family members and unburden our extremely busy bedside nurses to focus on their patients.

Some great unexpected moments:

Jamie: “Bedside nurses often spend 15 minutes on the phone with family. Multiply that by 5 patients and it becomes a big part of your day. We all wish we had more time to talk to families, but we’re often too busy caring for patients. I love helping connect with families and reassuring them.”

Jamie: “One gentleman was was not doing well. He was very quiet on the phone, and would never ask for anything. I spoke with his close friend at home, who noted that he was Jewish, and might appreciate a visit from a Rabbi or the Chaplain. I was able to arrange that.”

Jamie: “Being an ortho nurse on a medical unit, I was anxious at first. But communicating with the bedside nurses by secure chat and occasionally the phone, I found that even if I couldn’t answer families’ questions, I could always find out. Families are always so appreciative of the extra communication. I love this role. It is really awesome.”

Dawn: “The difference with this role is: There’s only the person on the phone. It is quiet at my home on my end. Normally when I’m at the bedside, I’m always trying to ‘wrap up the conversation’ with family: there are so many other things needing my attention. I can really feel good about being focused, connecting with family, and freeing up the bedside nurse to do their jobs.”

Dawn: “I was on the phone with the husband of a Covid patient. I noticed he would occasionally grunt, while we were talking about his wife. I had to ask him: ‘Are you okay?’ He told me he had had a fall, and had to pull on his pant-legs to go up the stairs. I recognized the signs of a major injury. It took some convincing, but I finally got him to call his doctor. Turns out the next day he was admitted and had emergency surgery himself.” As an ortho nurse, she was probably the perfect person to help.

Davida: “Sometimes you can remind the bedside nurse by secure chat: ‘his daughter would like to see his face today. Can you get the tablet in there for a Zoom visit?'”

Davida: “I feel really useful, being able to connect with PT, social work, bedside nurse all by non-interruptive but efficient Secure Chat, and then calling to make sure the family stays informed.”

Molly: “It is completely weird not to be an ICU bedside nurse right now. I think I will be better at charting in the future. Not being able to see the patient lets me understand what families want to know, that I rarely wrote down before: how do they look? are they following commands? can they squeeze? How scary this is for the family, and although it is a tricky role for us, it feels great to be helping.”

CMIO’s take? Thank you to our amazing UCHealth nurses: Lisa Claypool, Julie Griffin, Jamie Deschler, Davida Landgraf, Molly Carrell, Dawn Velandra for their experiences and stories.

Dr. CT Lin’s Covid-19 advice for patients. KOSI 101 and Mile Hi Magazine

In the link below, it is the interview from April 12, 2020.

https://kosi101.com/mile-high-magazine-public-affairs/

I had the pleasure of being interviewed by Mile Hi Magazine last week in regards to questions about how patients can cope with Covid-19 at home.

I responded to such questions as:

  • So many people contract but recover, is this what our body is designed to do?
  • Can people determine whether they have the virus without a test on symptoms alone?
  • When contracted, quarantine is the first step. What’s next in terms for two weeks – nutrition, special foods to eat to help the immune system fight?
  • Any special foods we should be eating now to be in top immune condition should we contract?
  • Any over-the-counter medicine to take for the fever or diarrhea?
  • Should people change out bed linen during the two-three weeks period?
  • Once fever breaks, is this a key sign that its over?
  • Should people exercise while body is fighting the infection?
  • Once over, should person we wait a couple days to ensure no symptoms return?
  • If Covid-19 is a flu strain, will it mutate into another strain as flu does each season for next winter?
  • Anything else you feel is pertinent to help people feel they can get over it if infected.

I made one particular point at the end of the interview. I shared our family’s strategy for coping with the anxiety and stress during this pandemic:

  1. Exercise every day
  2. Play or make music every day
  3. Limit yourself to 30 minutes of news or social media daily
  4. Three Good Things. At dinner each of us discusses THREE THINGS we are grateful for, today. INSTEAD of our natural tendency to focus on the negative, this exercise helps us reframe our day in a positive light.

CMIO’s take? I challenge all of us to do THREE GOOD THINGS with our loved ones at dinner every night.

EHR v Covid-19. Video Visits: How to Improve the Patient Experience

The new normal? No white coat during Video Visits! (c) CT Lin

Executive Summary: We have a global pandemic, daily policy changes, we work from home, have new video tech, and we are learning to communicate and build relationships in new ways. It is easy to forget that there may be a scared patient on the other end, counting on us. How might we improve the patient experience? Some ideas:

IDEA                                                    DETAILS

Secure Chat with your MAScrub your schedule together, days ahead for patients more appropriate for telehealth vs in-person visits, med rec, troubleshooting, visit focus
Arrange your room, selfSee tipsheet in Epic “Demonstrate Professionalism.“ How is: your room, your light, your clothing?
Eye Contactand, put a sticky note on PC cam to “LOOK HERE!”Arrange the camera at eye level if possible. For some, looking down = frowning? Eye contact on video visits is EVEN MORE important. “If I look away it is because I’m looking at information in your chart”. 
Avoid running lateIf you DO, inform your MA by Epic secure chat & they can inform patient
Greet the patientI like to raise my arms in surprise when we connect: every human connection now, is amazing. Maybe thank them for connecting with you. Ask if they’re in a safe private spot (eg: advise patient NOT to be driving!)
Talk, human to humanAsk: how are you coping (aside from medical concern)? Scared? Worried?  
Reflective ListeningEven more important now in this time of anxiety. You can reflect or say back Data, Ideas, Feelings, Values. It strengthens connection: for example  DATA: “It has been 5 days of worse symptoms?”  IDEAS: “so you think it might be gout?”  FEELINGS: “you’re worried about work? Hmm.”  VALUES: “so, what’s important to you is your family.”
PEARLSSome clinicians may have taken the Excellence in Communication course. The PEARLS acronym can also be helpful. Some examples:   Partnership: “We’ll get through this together.”  Empathy: (reflective listening, as above)  Apology: “I’m really sorry that happened.” “I’m sorry for my part in it.”  Respect: “You have worked really hard on this.”  Legitimization: “Anyone in your situation would feel that way.”  Support: “My team and I are here for you. We aren’t going anywhere.”
Physical Exam creativityTeach them to take a pulse “say beep when you feel it” and YOU can count. Patients may have a BP cuff, Pulse ox, flashlight, thermometer. 
Ask for help from familyOthers may help add to history or exam findings
They may ask about YOU as a human“How are YOU doctor? Are you staying safe?” So many surprising comments from patients worried about their doc. Thank them! 
Brief LIFE adviceDuring pandemic, consider: A) Limit news/social media to 30 min/day. B) Exercise daily. C) THREE GOOD THINGS exercise: proven to reduce depression, anxiety if done consistently “What 3 things are you grateful for today?” Can become a great family habit at dinner. 
AVS,
Open Notes
From My Health Connection, they can see your AVS (after visit summary) and your Progress note (called Clinical Note) to remind them of details of your visit. Maybe at end of visit, ask: “Sometimes I don’t explain myself well. Can you tell me what you’ve heard, so we’re on the same page?”
Reassurance and Hope“We’re going to get through this!” “Stay in touch with your loved ones.”
Ending the visitConsider: a handwave OR palms together, nod OR thumbs up OR “You Got This!” Forecast next steps or if your MA will call them after.
Secure chat with your MAHandoff any items after visit for continuity (referral, next visit, lab, etc)

Link to PDF of this document.

And, here is how our Medical Office looks now, deconstructed. One part is in my basement …

The deconstructed doctor’s office (c) CT Lin

And here’s Medical Assistant Becky, hard at work keeping both the patient and the doctor on track at her home. That virus has got no chance against us.

CMIO’s take? Hang in there! You Got This!

Thanks to all my colleagues for letting me “borrow” their ideas for this post.

EHR v Covid-19. Cough, fever, shortness of breath in the data

Okay, I acknowledge that I’m a data dilettante. Hmm. Interesting concept. I guess that is one step up from me being a data ignoramus. Having an anonymized population graphing tool in the EHR leads to amateur data exploration. Come along, won’t you?

DATA SET 1: 3 Years of CHIEF COMPLAINTS

The above graph shows 3 winters of data from our records, chief complaints of patients across our healthcare enterprise (4000+ doctors, several million patients) and number of patients each month with complaints of Cough (purple), Fever (blue), Shortness of Breath (yellow), and Diarrhea (red). Keep in mind: UCHealth grew in size over the past 3 years, with a growing number of hospitals and clinics, so the denominator number of patients is not the same from left to right. It also does not account for individual medical assistant or physician behavior who may or may not enter similar chief complaints across different patients, across different practices.

Nevertheless, I think you’d agree there is an interesting pattern here, including a higher peak of cough and fever this year! Wow: Covid19! But wait, that peak started in January. Unlikely the Covid-19 arrived IN SUCH VOLUME in January. But our old friends, other cold and flu viruses are plentiful. Hmm. So: Rhinovirus? RSV? Flu? See last post.

Look carefully, though, there is an interesting uptick in Shortness of breath in March 2020, out of proportion to the last 3 years … hmm. Interesting, but inconclusive.

And interestingly, diarrhea does not spike in winters, and doesn’t spike this winter either, despite (some) reports of Covid-related GI symptoms. Notably abdominal pain did not spike either (data not shown).

CONCLUSION 1: Fever, Cough, Shortness of breath are prevalent in our region BEFORE major Covid-19 activity, but some peaks seem higher.

DATA SET 2: REGIONAL CHIEF COMPLAINTS

Okay, lets take another step. What if we track SYMPTOMS (chief complaints), group them together and then see if we can find a Hot Spot where ONE region (UCHealth has 5-ish distinct geographic regions) has symptoms going up, disproportionate to other regions?

SURELY this means something!

See the yellow line shooting up at the beginning of March! This is the Denver region, compared to northern Colorado, southern Colorado, and a couple of other regions. These are percentages, not actual volume.

So, what does ACTUAL visit volume look like?

Slightly different view, by county and by actual volume of visits, and now you see a consistent plummeting of patients with “chief complaint” of fever, cough, shortness of breath. What is going on here?

The larger phenomenon is the Social Distancing order 3/21 and then the Stay at Home order on 3/26 by the governor of Colorado. So the sharp drop begins on the week of 3/21 and continues to plummet. At the same time UCHealth ramps up its Virtual Urgent Care and Primary Care service (allowing patients to see healthcare providers by video visits from home), which grows by hundreds and thousands of visits in late March. And who are likely the folks driving up Virtual visit volume at end of March? Yes, probably patients with Covid-19 symptoms.

Furthermore, Denver Metro is (I believe) more likely to have heard of UCHealth’s virtual urgent care and virtual visit service, more so than people in other Colorado communities.

Finally, looking at the newly Covid+ patients in each of our hospitals during that same time frame (not a cumulative hospital census number), you DO see an increase in admissions the week of 3/20, and yes, more cases in the more densely populated metro Denver (blue line) but the peaks are synchronous and NOT trending differently from the other regions. If the divergent yellow Denver line (above) represented a real increase in spread, the below blue line should spike and continue to grow off the chart.

CONCLUSION 2: Be careful what you conclude! Knowing some of the underlying story, I conclude the divergent yellow line is NOT a disease spike, but a change in behavior and a new service starting AND some increased rate of spread in Denver.

DATA SET 3: COMPARE ONE REGION’S SYMPTOMS VS HOSPITALIZATIONS

One more exploration: could chief complaints (Cough, Fever, Shortness of Breath) of patients presenting to clinics BY REGION possibly explain an increase in Covid+ patients a few weeks later BY REGION? Perhaps use the data as an early-warning signal for hospitals that a Surge is coming, that the curve is about to go exponential? A leading indicator and not a trailing indicator?

Here’s Chief Complaint in Denver Metro (percent of visits):

Here’s Chief Complaint in Denver Metro (actual visits):

Here’s hospital admissions for Covid+, Denver Metro:

What is your analysis? Make up your mind … then scroll on.

CONCLUSION 3: I see the “percentage” of complaints start growing steeply on Feb 21. I see the hospitalizations start to rise Mar 13, about 4 weeks later. I see “actual count” of complaints peak and decline after Mar 13. I see hospitalizations peak and decline Mar 27, about 2 weeks later. We Found a Signal!

Danger, Will Robinson!

This is post-hoc data analysis at its best, looking back at the data in hindsight and saying “Of course I was right all along.” It fits a good story, infection rising in the community and the sickest showing up about 4 weeks later, infection falling in the community, and Covid-19 admission cases falling a couple weeks later. Maybe there is some truth here.

However, looking at data and graphs from another region, the Fever/Cough/Shortness of breath curve stays mostly flat, and yet the Covid-19 hospitalization bumps same time as Denver.

Go figure.

I hope this jaunt through the data gets you interested in thinking about data, in seeking patterns, in questioning your findings, in considering viral behavior, disease behavior, human behavior, health system behavior, government behavior.

And, we are thankful that our infection rate, our hospital capacity, our leaders in Colorado, our government/business/public health/health system/community leader relationships are strong and can work well together.

CMIO’s take? Data analysis is hard. Sometimes you find signal. Sometimes you find noise. Sometimes you mistake the one for the other. Armchair theorists and even amateur data dilettantes (including some enthusiastic CMIO’s) should be careful.

EHR v Covid-19. Other Confounding Viruses! and graphing data

The Epic EHR has a tool called Slicer/Dicer that allows clinician-users to set up qualitative analyses of our populations in sophisticated ways. Of course this doesn’t replace the need for report-writers and more sophisticated analyses. But it is amazing what an informaticist can come up with, sitting in an Incident Command Center on an Easter Sunday with unusually few escalation phone calls to deal with.

For example, the curve above shows Influenza Positive test at UCHealth (12 hospitals, 600 clinics) over that past 3 winters: 2018-2020. Be cautious about interpreting the data: UCHealth has grown in number of clinicians and in patient volume, behavior of testing for “flu” may have changed. But it does look like the annual peak of flu positive patients is Jan or Feb each year.

Taking this further, our lab distinguishes Influenza A from B, and looks like “B” positive peaked in December vs “A” peaking in February.

Respiratory Syncitial Virus (RSV) peaked in February.

Rhinovirus peaked in September.

The “other” coronaviruses peaked between December and March.

Human Metapneumovirus peaked in March.

Finally, Our Coronavirus RNA test shows an ongoing increase (that last column showing Zero is an artifact of delayed reporting during my report run).

These are of course Lagging Indicators: trend lines that occur AFTER the fact: patients are in our hospitals, or are positive healthcare workers with symptoms. The constraint of insufficient testing kits to test everyone who has symptoms and indeed everyone who was exposed or has concern, gives us very little surveillance data to look forward for future outbreaks. More on surveillance ideas in an upcoming post.

It does occur to me, that in the coming months and years, that Medical Education could be turned on its head. In the past, I was clever enough to show our medical school leaders that this same Slicer tool could “make the textbook come alive.” For example, a student could create a graph, from existing UCHealth patient de-identified data, that the percent of patients with hypertension increased if you compared those with a BMI of up to 20, then 21-25, 26-30, 31-35, 35-40, and then greater than 40. You could see the that the percentage increased from 5% into the 32% range. Voila: possible relationship between Body Mass Index and prevalence of hypertension!

Repeat with diabetes, high cholesterol, asthma. See what blood pressures are typical for patients on a particular BP medication.

And for our current topic, have students figure out when respiratory viruses peak over the year, instead of reading a book chapter on ‘Pathophysiology of viruses.’ That would be a med school class I’d like to take. Maybe have students help with our CURRENT problem of trying to use our EHR to detect signal for patients about to deteriorate for Covid-19.

CMIO’s take? The EHR is becoming an integral part of how a modern doc takes the deluge of health data and uses that power for good.

EHR v Covid-19. Prepping for the Surge: Inpatient Guide for Outpatient Doctors – Guest Blog

Inpatient Guide for Outpatient Docs: Table of Contents

Covid-19 threatens to hospitalize an exponentially increasing number of patients in the coming weeks. In addition to building more physical space and finding more equipment, what happens when we run out of hospitalists to manage their care? What if, instead of our usual 10 teams of hospitalists, we need 20 teams? Thirty simultaneous teams?

Thanks to CT for the guest-blogging spot.  I’m a physician / programmer working at the University of Colorado and UCHealth, helping our system prepare for the Covid-19 crisis. 

Seeing the the massive surges in patient volume related to the Covid-19 pandemic that befell our colleagues in China, Europe and New York, we knew that we would have to find “surge capacity” among providers in our area.

We guessed that outpatient docs (like CT and me) would be needed to support the inpatient service, where neither of us have been for a long time.

I for one, was relatively panicked by the thought of serving on the inpatient service.  Not only is it a different branch of medicine at this point, more than a decade from my training years, but from an informatics perspective, the workflow is completely different.  I figured that if someone with my (relatively high-level) of comfort with the Epic EHR was feeling stress, others would be as well.

So roughly four weeks ago, I reached out to my informatics colleague on the inpatient service and suggested that we leverage our existing training videos to quickly produce a comprehensive written and video guide to the inpatient service, targeted at these likely recruits.

He and I, together with three other hospitalists, another outpatient internist and an informatics neurologist, quickly compiled a comprehensive document of workflow and tips.

We were gratified to find that a large number of internists practicing outpatient (clinic) medicine were willing to serve as part of the Surge teams and were interested in this just-in-time training.

There was so much interest in our training tools (document plus embedded videos) that the University of Colorado General Medicine division re-arranged the Grand Rounds schedule, and we presented this material to 150 interested outpatient internists at this week’s Grand Rounds, held by Zoom meeting.

We are so grateful that our cross-specialty relationships and shared technical expertise that are unique to informatics allowed us to create and present this material in a matter of days. Our wish:

  • That our surge of hospital patients is manageable
  • That our hospitalists stay safe and healthy
  • That any outpatient providers who are called to duty stay safe and healthy
  • We are grateful for the role we’ve played, and will continue to play
Rich Altman, MD, University of Colorado

I hope that you can benefit from these documents. However, the longer view and greater message is the value of a strong informatics team which is uniquely positioned to rapidly mobilize and meet unforeseen needs.

Richard Altman, MD