I love stories like this. Jimmy Choi has a TikTok page where he documents his athleticism. He also has Parkinson’s Disease, with an uncontrollable shaking in his arms. At one point, he complained about how difficult it is for people with Parkinsons to take their medications; the shaking often completely spills the pills from the bottle.
As a result, a community of TikTokkers began brainstorming and then modeling and then 3-D printing an innovative pill bottle design that ensures only ONE pill is dispensed at a time.
CMIO’s take? Having access to the brain power and creative energy of the world, via communication technologies like TikTok and other Social media tools, is, I think, a wonderful antidote to our recent experiences, and the best expression of humanism. How can we design to augment this, the better angels of our nature?
Turns out, those of us in healthcare informatics and in the midst of the pandemic think the world has come to a halt. But no, WIRED magazine reports that robots and other tech development have not slowed down. Awesome reporting.
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.
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?
I love these stories about entrepreneurs coloring outside the lines. “That can’t be done” or “There is a big gulf between theory and reality”. These are statements everyone faces when trying to change the status quo, including in healthcare.
The proposal in brief, use a massive centrifuge to speed a rocket up to 5000 mph and launch it like a slingshot so that it can coast up to the stratosphere and then a tiny rocket pushes it into orbit: it avoids the Tyranny of the Rocket Equation – that most of the mass of a rocket is dedicated to massive engine and the fuel it must burn to put a relatively tiny payload into space.
More power to folks like these. Yes, they might flame out as they get closer to a real trial, but imagine if they succeed:
Launch costs of $400k, instead of 10x as much
Being able to launch 5x month instead of 5x a year
Commoditizing access to space without massive rockets
CMIO’s take? Color outside the lines! I give it a 50:50 chance this is viable as a commercial enterprise after vaulting all the potential hurdles.
Billie, Alex, and some crazy doctor, newly recruited Pit Crew. Biggest innovation? Billie’s smiling face on her button! Why haven’t we all done this!?
Our team is at it again!
The Rockies and Coors Field welcomed the UCHealth crew, this time for a 2-day, 10,000 vaccine event Jan 30 and 31. It was a smashing success, and tremendous fun, to boot.
Our fearless leader, Ali Hererra, giving last-minute tips to an eager 630am crew.
The new kid on the block
The new kid on the block: a neck-lanyard, battery-pack augmented iPhone with the EHR mobile app installed for on-the-fly vaccine documentation from QR bar-codes.
Our vaccine clients show tremendous gratitude; we love the spontaneous cheering and applause that break out at times while the cars are moving through. One even handed us an unexpected gratitude card today!
What’s the count?
Here’s my tally for one day of vaccination: 150 for each day, 300 for the weekend. Unanticipated outcome? Donning and doffing gloves 150 times in quick succession causes some hand irritation and a need for heavy doses of vaseline petroleum jelly at the end of the day.
I proudly showed my clinical informatics colleague my collection of vaccine caps in my pocket (see how clever I was to keep track of my productivity?), and she promptly told me: Well, it is easier just to run a report (Thanks, Kristin). Um-hm. And I call myself a CMIO.
Efficiency tip? Here’s the latest: Non-dominant hand: bandaid on the thumb, half peeled. Vaccine, ready to go. Pre-peeled alcohol swab. Dominant hand: Mobile device on a lanyard or in a coat-pocket, QR code scanner ready, some quick screening questions and screen-taps, vaccine documented in EHR, give vaccine, walk back to tent and re-supply while our student hands out the vaccine card and follow-up instructions. Rock-and-Roll.
First of all, our team CRUSHED the scheduled volume today. At our peak, we vaccinated more than 1000 people per hour, with average throughput times of 22.5 minutes (that’s INCLUDING the 15 minute observation).
To say that another way: we timed cars arriving at Check-in Registration at time ZERO, got screened, registered, consented, and vaccinated in about EIGHT MINUTES. And 15 minutes after that, they were rolling out of the observation area. WAT?!
We had numerous people exclaiming: “This is unreal, how smooth it is.” With masks on, we’re getting good at reading the smiling eyes. Wave after wave of grateful vaccine recipients.
Current Vaccine Tent workflow
The Tent 8 “A-team.” Billie Martinez, medical assistant, Brittney Poggiogalle, PA student, Alexander Jimenez, medical assistant (working hard). Thanks for making us all look good!
Turns out it is easy to “infect” colleagues with the enthusiasm I have for optimizing our workflow, which is now:
Vaccinator sets up the non-dominant hand with vaccine, bandaid and swab (see above)
Patient arrives with QR bar code ready on their phone (from My Health Connection or a printout). No Bar code? No problem, a last name search is only a few seconds more. Beep! 3 screening questions, done!
Pivot our positions, and our student volunteer steps up and hands the vaccine card with followup instructions to proceed to observation area and to NOT MISS their next appointment (already booked for 3 weeks from now).
DONE! our best cycle time: ABOUT 70 SECONDS INCLUDING DOCUMENTATION.
Perhaps even more exciting, talking to each other about Lean process, discussing throughout the morning, how to stay safer: remember to tell drivers to put it in Park! Remind each other as we walk up and down, to stay out of the driving lane! When standing at your work table, prep your supplies with your body turned facing the line to be aware of your environment. Tell each other if you see something to improve.
All 3 vaccinators have their own neck-lanyard mobile documentation tool, and we can give about a vaccine every 1.5 to 2 minutes including drive-up time, and one student keeps us supplied with peeled bandaids, filled-out vaccine cards, and explains next steps to the drivers, allowing the vaccinators time to re-set for the next care. It is a beautiful dance.
A Lean Lecture?
Talking with a colleague later, I reflected that I got so excited about our efficiency, that I gave a mini-lecture during the morning to our team and student volunteer on Lean process. My colleague then replied: “Oh no, Student! Wrong Tent! Wrong Tent!” implying that no student needs a lecture from an over-enthusiastic CMIO on a weekend. (Thanks for the commentary, Dr. Bajaj).
Our previous worries about backlog of paper charting needing later data entry?Gone!
The cool thing about this setup is: we did not pre-identify which cars had slow-down factors like: more than one scheduled vaccine recipient per car, no bar-code, occasional technical glitch, or lots of clinical questions. Occasionally, if one car took a little longer, the other 2 vaccinators would walk up the line and greet the next car. Once the line opened up, everyone slid forward easily. A handheld mobile and a one-hand vaccine supply made us nimble. None of us was waiting around, unless our line of cars emptied out entirely.
I enjoyed hearing the pharmacists on-site, who were mixing up batches in real-time (the Pfizer: needing to defrost and reconstitute from -70!), on the walkie-talkies discussing which tents needed more vaccine: “We’re almost out again at Tent 8.” “Okay, on the way with another batch of 25.” With our throughput (3 vaccinators, cycle time about 2 minutes simultaneously), that batch would only last us about 18 minutes. Loved every minute of it.
The CMIO in me wanted up-to-the-minute vaccine stats from the other tents. Not that I was feeling competitive. No. Not me.
The Pit Crew
Not being satisfied with even this, mid-morning we were asked to transition to a Pit-Crew method being piloted by our Clinical Informatics nurses. In our standard lanes, cars would pause at one of 6 Registration lines, drive down a lane and then be split into 16 vaccine tents. The Pit Crew were doing both Registration AND Vaccination in the Registration (big white) tent. Then, no second stop, straight to Observation. It was going so well, we recruited additional people to run a second line.
INSIDE the big tent. Four cars in a row. One stop to do it all. We don’t have all the timing numbers yet, but we believe this may take additional seconds or minutes out of our cycle time. There are some potential downsides to this configuration VERSUS our vaccine tent configuration; the registration workstations on wheels (WOWs) aren’t as nimble in traffic compared to our handhelds, so walking upstream when there is a delay is not practical, and if one car takes longer inside the tent, there is more potential delay. The upside: one stop could make the transit time much shorter per vehicle.
At the end of the weekend, ZERO DOSES WASTED. 10,000 given. ZERO significant complications in the observation area. Dr. Richard Zane calculates that the 10,000 vaccinated patients means that 157 fewer people will die of Covid as a result of our actions this weekend. Wow.
Stay tuned! We’re already performing at a high level, but we think there are yet improvements to make, while keeping patient and team safety our top priority. The work of our Incident Command structure has been a joy to watch, with team leads in constant communication with the Rockies, the Denver Police, the State, County and City.
Here’s a CBS Denver news article about us, with more photos from a drone.
CMIO’s take. Who knew that Toyota Lean Process could help vaccine administration? Furthermore, I’ll say it again: Get us more vaccine! We can handle it.
Outdoor vaccine guy says: come along, I’ll show you what I learned.
The UCHealth team held its first Mass Vaccination trial at Coors Field on Sunday 1/24. This was the first Mass Vaccine effort in Colorado, and was coordinated with the City and County of Denver, CDPHE (Colorado Department of Public Health and Environment), Denver Police, Verizon, Denver Health, Stadium Medical and the Governor’s Office. Weeks in the planning, dozens of clinicians, staff and coordinators swarmed the location assembling, arranging, tweaking.
2 hours: 1000 vaccines?
For this event, we planned to give 1000 vaccines in 2 hours to stress-test our design plan and to see if we could maintain or exceed this pace for future events. This was an invite-only event with 500 patients selected from UCHealth existing patients and 500 from newly-signed-up for vaccine from the UCHealth website for the general public aged 70+ per State current guidelines.
Between 6 and 7am, we assembled, got last-minute instructions for our many roles: runners, flaggers, registrars, traffic control, vaccinators, timers, process engineers, clinical observers, flow coordinators, etc etc. Here, I’m standing under a heat lamp, warming my hands for the day to come. The big white tent is registration-confirmation. Sorry, no drop-ins.
Team Number ONE!
With Dr. Jenny Bajaj, CMO of UCHealth Medical Group and Andrew Mariotti, medical student and process timer. We, of course, snagged Vaccine Tent #1. For work like this, snow pants recommended.
The UCHealth team set up a small batch of cars to arrive between 8 and 9am, to work out the kinks at every vaccine station; each station received 2-4 cars to test our supplies and workflow, and see if the runners, pharmacists, flaggers, observers had any questions about their jobs.
We then huddled between 9-10am to debrief questions from the team, then BOOM. Our full-speed test was from 10-12am with 1000 cars to come through in that time.
From the fourth floor of the Coors lot parking garage, the command center station. The RTD commuter trains run along the left, Blake Street on the right, the big white registration tent, where we catch and release any folks without appointment. The Mass Vaccine event (like EVERY Covid vaccine clinic) is highly calibrated down to our last vaccine. If we accepted drop-ins or family members, we would run out for our scheduled patients.
In the right row of tents, the first (most distant from us) tent is for registrations taking longer than usual, so that no registration line gets held up. Vaccine Tent 1 is thus the second (tiny) tent on the right. See me waving? No? No.
Our observation area (not shown) is actually behind the photographer, on the other side of the parking garage, with flaggers guiding the way.
Work station setup.
We re-arranged our area to be increasingly efficient. Working in teams of 2 allowed us to iteratively reduce our cycle time for each vaccination. Orange bucket 1: our vaccine supply (closely guarded by pharmacy and defrosted just-in-time). Orange bucket 2: pre-opened bandaids. Nothing is harder than cold, gloved hands opening bandaid packets when in a rush. Supply of gloves, alcohol swabs, gauze if needed. Raise the Yellow laminated card to indicate to runners if we needed supplies. Red card: help needed. Pink ribbon: attach to drivers side mirror for those warranting extended observation (eg previous history of anaphylaxis).
*One person waves down the car, checks “Please put it in Park!” (about 1/3 don’t unless asked!) asks the screening questions, confirms which arm, which passenger. *Simultaneously, second person (vaccinator) doffs/dons gloves, opens alcohol swab, snags a pre-peeled bandaid, grabs a syringe *Pivot! first person files the screening paper with identity and signatures for later data entry and grabs the vaccine card *Simultaneously, vaccinator: Swab, Pre-attach 1/2 bandaid, Vaccinate in one motion, auto-retract needle (more on this below), Swipe bandaid across, Done! *Pivot! first person explains the card, answers any questions, reinforces importance of second appointment, directs driver to proceed to next flagger to wait for the standard 15 minute observation time. *Simultaneously, vaccinator disposes the syringe, clears trash, dons/doffs gloves and preps the next setup.
With this setup, Dr. Bajaj and I started with about a 90 second cycle time, and with iterative adjustments, pushed our best time down to 59 seconds, with our average running 1:15 to 1:20, if no questions (or profuse thankfulness) from the patients.
On debriefing this, we had several thoughts: the time it takes to chat and manage paper is about the same amount of time to swap gloves, manage supplies, setup. Seems like the 2-person team is, at present, an optimal setup.
In the coming weeks, it may be possible to incorporate a clinician-mobile-app adjunct to our Electronic Health Record that would allow on-the-fly documentation that would take the place of paper questionnaires and signatures when in the field.
Paper is fast, but…
From an informatics perspective, the paper process was a win from a through-put perspective, but an opportunity to streamline data-flow. We had runners taking our paper to the Documentation Tent to be keyed into the EHR in near-real-time.
Contrast that with our in-hospital based vaccine clinic (see my lastpost) where vaccination and documentation occur in real-time, the EHR and the State Vaccine Registry being updated almost immediately, and with a cycle-time (with one vaccinator/documentor) at about 3 minutes.
as my sister is fond of saying. At the end of our time, Vaccine Station 1 reported 67 vaccines given in 90 minutes. That is EIGHTY (80) seconds per shot. Taking into account the times when our station did not have a car, we think we could have completed 10-20% more shots. We are NOT Throwin’ Away OUR SHOT.
Here’s our high-level debrief. Team leaders from each of our major roles reported in: paramedics, police, City and County and State leaders, the Rockies (THANK YOU FOR OUR USE OF YOUR MASSIVE PARKING LOT AND TRAFFIC EXPERTISE). Very smooth. We think we could increase the pace beyond 1000 per 2 hours. We are targeting 5000 vaccines per day for 2 days next weekend. We’ll see!
Total throughput time per car?
Measured another way, we found that cars moved from Arrival at the Registration Tent to Leaving the 15-min Observation Area: 21-27 minutes. TOTAL.
Zero anaphylaxis events. No paramedic transports. There were very infrequent side effects observed in the observation lots. Everyone drove away successfully.
Local news coverage of our event
Sky9 aerial footage (about half way down the linked article). Tent 1 and my white coat is visible at 20 minutes. Woo!
Oh, and here’s a gif of the auto-retracting needle. So cool. How did they even fit a spring into the barrel of this tiny thing?
When done correctly, depressing the plunger completely means that the needle retracts from the patient, completely into the barrel of the syringe, eliminating the chance of unintentional needle-stick. Innovation FTW!
CMIO’s take? Mass Vaccination: another chance to innovate, another chance to take a chunk out of the Covid pandemic. Send us more vaccine. We can handle it.
UCHealth, like all health systems across the state of Colorado, are following the guidance of the Colorado Department of Public Health and Environment (CDPHE). As the guidelines change (sometimes daily!) we follow the guidelines. Our supply of COVID-19 Vaccine is closely tracked, and each next shipment depends on our adherence to guidelines.
We are now opening up vaccination signups to segments of the general public beyond health care workers. See the CDPHE guidelines here: https://covid19.colorado.gov/for-coloradans/vaccine/vaccine-for-coloradans. Based on the state’s plan, UCHealth is focusing efforts on vaccinations for people 70 years old and older. You do not need to be a UCHealth patient in order to get vaccinated.
Here is how it works
Keep in mind that most health systems in Colorado are working on vaccine distribution. Please first check with your primary care provider or primary health system. For those over 70 with interest in getting their vaccine from UCHealth,
We will use My Health Connection, the patient portal for UCHealth’s electronic health record, to communicate with people. If you have an active My Health Connection account, you will automatically receive updates regarding the vaccine. If you do not have an active My Health Connection account, please create one to receive these updates. To learn more and create an account, go to www.uchealth.org/covidvaccine.
Over 80% of patients at UCHealth have a MHC account, and we’ll be using our Electronic Health Record (EHR) to determine our patients who meet the criteria for vaccine (currently, using date-of-birth to calculate age 70+).
You DON’T have to be an existing UCHealth patient or be seeing a UCHealth provider to create an MHC account and to indicate your interest in the COVID-19 Vaccine.
You WILL need to have an email address and be able to access the patient portal yourself. You may have a proxy (trusted designee) sign up for you; keep in mind that this proxy would also potentially have access to your UCHealth electronic health records as well.
At this time, we do not have enough vaccine doses to offer it to everyone. As UCHealth receives shipments of the vaccine, we are providing it as quickly as possible, according to the state’s plan. As we receive additional quantities of vaccine, we will send vaccination invitations through our randomized selection process to give everyone the same chance of receiving a vaccine.
When vaccine becomes available to your phase of distribution, you will receive an invitation from My Health Connection with instructions about how to schedule your vaccine appointments. Please be patient until you see the message titled “Urgent: Schedule your COVID-19 vaccine”. When you receive this message, you will be able to schedule both vaccine doses. You will have 48 hours to get your appointments scheduled. If you miss the 48-hour time frame, you will receive a new opportunity to schedule in a future distribution phase.
An appointment is required to receive the COVID-19 vaccine; walk-ins cannot be accommodated.
This process has worked well for our first 37,000 COVID-19 vaccinations, and we plan on scaling up further, as vaccine availability improves.
Some may criticize us for using an electronic patient portal and perhaps leaving out those without access to the internet. (I have even heard the term “digitalism.” However, looking that up, it seems to mean “being poisoned by digitalis from the foxglove plant.” Hmm. But we digress.)
At the same time, we’re putting plans in place to ensure that those without access to a computer or smartphone also have access to the vaccine. Through phone hotlines, clinics that target low-income areas of the state, and outreach to underserved communities, we aim to provide the vaccine fairly to everyone. Some of these efforts have already begun.
Our main point from using our patient portal was that, using our existing infrastructure where we already have nearly 1 million patients, we could move quickly, filter our patients by age, and create and send invitations thousands at a time. This contrasts with those who might have to postal-mail invitations or make phone calls and set up (and staff-up!) a phone bank, that could take days and weeks.
We launched the invitation and scheduling process over one weekend (thank you and sorry to our IT and project leaders who built this) and offered vaccines the next weekday after receipt of our first batch. I’m so grateful to work with such amazing colleagues and their amazing teams, and grateful that we have an existing information technology infrastructure that allows this. The EHR is our superpower.
Despite N95’s and protective gear, the entire Life Flight Crew came down with COVID the last time they transported your patient on a ventilator to a higher level of care. Now what?!
How are intubated and ventilated Covid-19 patients transported? As a hospitalist located at Yampa Valley Medical Center in Steamboat Springs, I have had to intubate and initial mechanical ventilation on a number of patients infected with Covid-19.
Initially, following the onset of this pandemic, these critically ill patients were being transported via rotor or fixed wing aircraft to our larger UCHealth facilities on the Front Range for optimal care by flight crews donning PPE which included N95 masks, goggles or face shields, gowns and gloves.
Despite this protective gear, many of the flight crews contracted Covid, which resulted in some emergency transport services becoming grounded until crews could recover. A better, safer option for transporting these patients was needed.
Originally developed to transport patients infected with the Ebola virus, The ISO-POD is negative-pressure patient isolation and transport system which allows us to safely transport critically ill Covid-19 patients, while simultaneously providing protection to our emergency personnel. The device has a port which allows for ventilator tubing, IV lines, and monitoring lines to pass, as well as 12 gloved iris openings to allow the flight crew staff access to the patient from head to toe.
Packaging the patient
The patient is placed into the ISO-POD, and the bag is closed and sealed, then sterilized over the exterior surface to allow for transport. Air movement into and out of the device passes through filters to remove viral pathogens, ensuring that flight crews remain safe during transport, which can only occur in a fixed-wing aircraft.
Packaging patients up in the ISO-POD is a logistic challenge, often requiring 1-2 hours for crews to safely prepare patients for transfer. The majority of our transfers from Steamboat are via Classic Air, who maintain three reusable ISO-POD devices, and a flight crew of over 300 people. The ISO-POD has allowed Classic to transport numerous Covid patients without any crew infections.
Keeping our flight crews safe, and allowing hospitals to fight this thing together
The “Covid bag” has become an invaluable, and all too familiar tool, allowing us to transfer our critical Covid patients to larger UCHealth facilities in order to receive optimal care, while still keeping our flight crews safe. As a physician caring for these patients, I am incredibly thankful to our dedicated flight crews for job they do, and appreciative of innovative technology such as the ISO-POD.
—Gary Breen MD Physician Informaticist Hospitalist, Internal Medicine Yampa Valley Medical Center, UCHealth
Covid-19 Vaccine! I got mine! And University of Colorado Hospital is set up to give over 1000 doses per day just at our hospital.
As you know, Covid-19 vaccine is out in the wild. Colorado received the first shipment earlier this week, and we at UCHealth received the first 17,000 doses. We set up an infrastructure to schedule vaccinations through My Health Connection, our patient portal. We sent out over 10,000 invitations this week, and already 5000 health care workers have already booked their appointment. IN 48 HOURS! Never have I ever heard of something moving this fast. 97% of physicians/providers state their willingness and intent to be vaccinated.
Among my colleagues, many of us were hitting “refresh” waiting for our invite to schedule the vaccine. Last night, I was super excited receive my invite. Woo! So organized the portal ensures you book both appointments at the same time. Super simple!
Then, super easy on arrival; we use our patient portal to e-check in, verify my demographics, read the consent form for the vaccine, so that my check in can be super simple and super quick. Yes!
And here we are! 8 check-in stations humming smoothly. Everyone masked up, smiling, everyone so excited to be part of DOING SOMETHING to fight back against the pandemic. Bam!
Here we are in our auditorium. Sixteen vaccination stations, with appointments every 10 minutes, and vaccine service hours from 5am through 9pm. I calculate our capacity to vaccinate about 1000 people a day. This just at UCH; we have 9 other vaccine locations throughout UCHealth’s hospitals in Steamboat, Fort Collins, Colorado Springs, Pikes Peak, also actively vaccinating. Our goal: to administer our entire received batch before Christmas day. Zowie!
I got mine! 15 minutes socially distanced in the auditorium to observe for immediate reaction, and then done! In and out in about 30 minutes! Woo!
As you know, the FDA and CDC guidance is: Healthcare workers and long term care residents and staff first (winter), then high risk general public (spring) and then general public (summer). We are getting started, and have infrastructure now to deliver shots just a quickly as possible. We anticipate vaccinating up to 20% of all people of the State of Colorado. Hope to see you here soon!
CMIO’s take? I am NOT throwin’ away MY SHOT! (could it be there is a new ukulele song/rap? … stay tuned!)