Xenobots are coming: Tiny Blobs of Programmable Tissue (WIRED)

From WIRED.com, the application of DNA engineering not only to the sequencing and reading the DNA and RNA of viruses and organisms, but now to CREATE “tiny blobs of programmable tissue.”

REALLY?

Watch it above, and read it yourself: https://www.wired.com/story/synthetic-biology-plan/

Sign up for COVID Vaccine at UCHealth. (The EHR is our superpower).

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.

The change

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,

  1. 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.
  1. 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+).
  2. 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.
  3. 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.
  4. 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.
  5. 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. 
  6. An appointment is required to receive the COVID-19 vaccine; walk-ins cannot be accommodated.
  7. For the most current information regarding COVID-19 vaccines, go to the COVID-19 vaccine page on the UCHealth website.

The EHR is our superpower

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.

News items

Fox31 news (patients 70+): https://kdvr.com/news/coronavirus/covid-19-vaccine/uchealth-patients-over-70-start-getting-vaccinated/

The Coloradoan: https://www.coloradoan.com/story/news/2021/01/05/covid-19-colorado-next-up-vaccine-heres-what-know/4127958001/

9news (mass vaccination): https://www.9news.com/article/news/health/coronavirus/vaccine/colorado-hospital-systems-get-ready-for-mass-vaccinations/73-3f1a2fbb-df90-4007-8f1d-35c372c71414

KOAA news (mobile clinic):
https://www.koaa.com/news/covering-colorado/uc-health-goes-mobile-with-covid-19-vaccine-in-colorado-springs

UCHealth mobile vaccine clinic: https://www.uchealth.org/today/older-adults-receive-covid-19-vaccine-at-home-through-mobile-clinic/

UCHealth older adult vaccine news: https://www.uchealth.org/today/older-adults-rejoice-as-they-begin-getting-coronavirus-vaccines/

CMIO’s take? We are excited to be part of the solution for our community throughout Colorado and the Rocky Mountain region!

Transporting patients in the Covid Bag (guest post: Gary Breen MD)

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?!

The Problem

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.

The ISO-POD

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

I am NOT throwing away my Shot (I got mine today!)

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!)

Podcast alert: Alphafold and the Future of Physicians

First, go listen to the story. It is only 10 minutes and worth it.

Then

Here

Are

My

Observations.

There. Just wanted to give you some space to listen and then come back. Here’s my take. I did this originally on twitter, but it turns out, I need lessons on creating an easily connectable twitter thread (yikes, another thing to learn and master).

This Podcast is excellent.

@Doctor_V is spot on. Agree: industrialization of docs means there is no time for most docs to tinker with test tubes in the back office of their busy clinic. Even academic medical centers find the legendary ‘triple threat’ docs (clinician, teacher, researcher) increasingly rare. 1/

And then, information transparency means medical literature is widely and instantly disseminated: the myth of the all-knowing doc is eroding. Some patients with rarer diseases can study enough to be nearly as expert and up to date, albeit without the broad clinical experience of years of medical practice. 2/

Furthermore, the explosion of new information and knowledge is too fast for ANY human to keep up with. This is due in part to the technology acceleration, due to growth in globalization and ability to communicate and connect many minds with many ideas. Only purpose-built AI’s have a chance to digest such a deluge. 3/

The bad news: human minds will not keep up, from here on out. The good news: we can become centaurs: half human, half horse (or AI-assisted). Chess, for example, in unlimited tournaments, is most often won by human-computer hybrid teams. I think this is our foreseeable model in healthcare, and in a growing number of fields. 4/

And in the long run, perhaps we are all out of a job? I don’t agree with that either. TV did not knock out radio. Cable did not knock out broadcast TV. Internet did not knock out cable. The landscape just looks different. 5/

Finally, I agree with Dr. Vartebedian’s point: we need to look up more from our grindstones and see what is on the horizon. If the technology acceleration continues, it will come at us faster. And we need to prepare ourselves and educate our patients, our communities. Thanks for reminding us. Amazing things ahead. 6/end.

Metabolomics, University of Colorado, and the Tour de France

from university of colorado website

https://news.cuanschutz.edu/news-stories/metabolomics-the-science-behind-a-tour-de-france-winner

NEWS FLASH

I so enjoy working at a University with such a broad spectrum of interests. The latest is the move to more precision medicine. We began with genomics: the existence of mutations or gene variants in patients or persons, then moved on to proteomics, the expression from genes into proteins (remember transcription from high school or college or medical school science?), and now metabolomics, which is not just protein expression, but the interaction of these proteins, and WHEN they exist in a patient’s or person’s body.

Complicated?!

Turns out, the more we learn about the body, the more there is to understand. Not only do we have genes and variants of genes (remember sickle cell disease, for example?), we also have messenger RNA, the strand that copies off a specific gene, which can be turned on or off. Turns out mRNA can also interfere with OTHER mRNA, increasing or decreasing the effectiveness of those molecule strings. Also, mRNA is translated into proteins depending on the environment, and THEN, those proteins interact with each other. This happens, and possibly slightly differently, in every cell. How are we even alive?

A glimmer

So, now, we can measure proteins in this metabolome with increasing precision, and start to glance at the dance behind the curtain. Some exercise physiologists have spotted some patterns in the metabolome in regards to elite athletes, and this has led to some breakthroughs in performance, to-wit, the most recent Tour de France champion. Read on.

CMIO’s take? The metabolome rocks.

UCHealth launches OurNotes: how patients co-author clinic progress notes

As of November 2, 70 primary care practices went live with Our Notes. Read more about OurNotes here. Dr. Tom Delbanco and Jan Walker, researchers at Beth Israel Deaconess initiated and ran the study.

In brief, it is a way for patients, just ahead of an upcoming appointment to tell their provider what has happened to them since their last visit: changes in medication, new or changing symptoms, life changes. And then to ask up to 3 questions they’d like to discuss with their provider at the visit.

These notes were then automatically inserted into the providers’ progress notes. They could then be cited in their entirety, with no action needed by the provider while composing the rest of their progress note. Or, the provider could edit for clarity before signing the note. In this way, both patient and provider contribute the data from that visit, improving communication and collaboration.

We were so successful from our pilot test, conducted in coordination with Beth Israel Deaconess Medical Center (BIDMC), in our one primary care clinic, we have now launched it for ALL primary care clinics throughout UCHealth.

Our early findings showed that over 90% of providers (physicians and APP’s: advance practice providers) responding to surveys viewed OurNotes positively and wanted to continue, as did over 90% of patients who participated.

Not all patients who have a patient-portal account respond to the OurNotes questionnaire ahead of their visit. Those who do not, have a regular visit, just like before. About 15-20% of patients who have an appointment respond send an OurNote, and providers are using the notes regularly.

Others are catching the OurNotes trend as well, including Sanford health, UCLA, and the original OurNotes health system research partners: BIDMC, University of Washington and Dartmouth-Hitchock. Thank you to all the trailblazers out there for transforming patient-centered care.

CMIO’s take? More like this please! IT is a win-win-win: better engagement for patients, shared documentation for providers, more readable, narrative notes in our EHR’s.

UPDATED FOR INFO BLOCKING rule: UCHealth’s 16 year OpenNotes Journey (and a ukulele song)

Since the passage of the 21st Century Cures act and the INFORMATION BLOCKING rule, I’ve gotten a ton of questions about our experience with Open Notes and Open Results. AND A UKULELE SONG

patient20and20doc_2

Image courtesy of Healthcare Informatics

OCTOBER 2020 UPDATE. 

In this update:

  1. A ukulele song on Open Notes! What?! Read to the end…
  2. Our current interpretation of INFO BLOCKING rules and our current plans
  3. Links to important tip sheets that you can use/share

Since the passage of the 21st Century Cures act and the INFORMATION BLOCKING rule, I’ve gotten a ton of questions about our experience with Open Notes. Followers of this blog the Undiscovered Country will have heard this before. However, if you’re new here, welcome! I’m updating my original post from 2017. This now will include:

Important Links

  1. Link to my post on INFORMATION BLOCKING and the 1-page WHY plus 4-page HOW/WHAT that we are circulating at our Health System, affecting 6000 docs.
  2. Link to my post on HOW TO WRITE AN OPEN NOTE, with language suggestions.

UCHealth’s INFO BLOCKING settings

FYI, in regards to INFO BLOCKING, there are tons of nuanced decisions healthcare organizations are making, since the 1200 page rule still leaves some specifics quite vague, and the often-rumored FAQ that will clear up some of the vagueness is not here yet (less than 30 days until rule takes effect!). Here are our (interim) decisions at UCHealth:

  • All outpatient, emergency dept, urgent care provider progress notes will release immediately upon signature to the patient (already doing this)
  • All clinical notes associated with those visits (MA, RN, technologist) notes will also release immediately
  • All hospital progress notes will release to patients upon signature. This will include: H/P, daily progress notes, consult notes, operative reports, discharge summaries.
  • All medical student notes that are cosigned by physicians and used for billing will be immediately released. We are in discussions about the remainder of medical student notes that are NOT part of the legal medical record.
  • All resident and fellow notes will release immediate upon attending signature
  • All nursing and clinical notes that can be considered progress notes will release upon signature
  • NO psychotherapy notes will release to patient (they are not stored in our EHR)
  • NO notes that may be involved in legal, criminal or similar proceedings
  • NO notes that may ruin research randomization if revealed to patients
  • SOME of our psychiatry provider progress notes already release to our patients. Three of our 8 psychiatry clinics committed to Open Notes in 2017 and have had no issues. We are still working through this, in discussions to release more behavioral health progress notes (psychiatry, psychology, social work, case manager, others) to patients. There are some concerns about the possibility of risk to staff for patients reading some of these notes in real-time. Stay tuned!
  • All progress notes, inpatient and outpatient have a “DO NOT SHARE” button where providers can individually opt a note out of sharing with patient if it is deemed a risk. Our share rate is typically in the 90% range.
  • We already release all lab results immediately to patients, including sexually transmitted diseases, hepatitis B and C, etc.
  • HIV is on a 7 day delay and will move to immediate
  • We already release all plain film radiology and ultrasounds immediatelly.
  • Complex radiology: CT/MRI/PET are moving to immediate
  • Pathology, Cytology is moving to immediate.
  • We plan to manually release a handful of genetic tests, including Huntington’s disease only AFTER discussion with the patient. The remainder are moving to immediate release.
  • We have over 850,000 patients on our patient portal, so these settings will affect a great many patients.

Our 16 year journey to Open Notes

Thanks to @RajivLeventhal of Healthcare Informatics for a nice write up of our Open Notes work at UCHealth. The journey to “overnight success” can sometimes take a decade or so. To paraphrase Machiavelli: “Nothing is so difficult as Change in a large organization, as your proponents are, at best, lukewarm, and your detractors have ALL THE PASSION IN THE WORLD.” I discuss some of my hard-won lessons in Change Management on the journey to OpenNotes.

Link to story (March 16, 2017):
UCHealth’s OpenNotes Journey: From a Few Docs to Enterprise-Wide Acceptance

Original Research in 2001

The original research on SPPARO (System Providing Patients Access to Records Online, conducted in 2001, 10 years before the official, and better-named Open Notes initiative) is still available:

Ross, Lin, et al. Providing a Web-based Online Medical Record with Electronic Communication Capabilities to Patients With Congestive Heart Failure: Randomized Trial. J Med Internet Res. 2004 Apr-Jun; 6(2): e12.

Earnest, Lin, et al. Use of a patient-accessible electronic medical record in a practice for congestive heart failure: patient and physician experiences. J Am Med Inform Assoc. 2004 Sep-Oct;11(5):410-7. Epub 2004 Jun 7.

And … a song!

A ukulele song on Open Notes: Doc Prudence.

CMIO’s take? It has been a long time coming. Information Transparency for patients is the RIGHT THING to do. For myself, it was a 16 year journey from our first research studies, completed in 2001, until system-wide adoption of Open Notes for clinics, emergency depts and hospital discharge summaries in 2016. For others it is hitting them all at once here in 2020. It is a better place we are going to. In the meantime there is a lot of work and culture adjustment until we get there. Good luck to all of us.

The Centaur in Healthcare: AI and humans (WIRED)

from WIRED magazine article

https://www.wired.com/story/algorithm-doesnt-replace-doctors-makes-them-better/

In the battle between the future of super-intelligent Artificial Intelligence and the paltry skills of increasingly left-behind human brains, some rays of hope. There are a growing number of projects dedicated to combining the skills of AI and humans to perform better than either alone.

The WIRED article above discusses Dermatology AI and how it improves the performance of physicians in detecting skin cancer. However, it mainly improves resident and primary care physician performance, and not expert dermatologists.

Is this good? Bad?

And, what is a Centaur? A horse-human hybrid from greek mythology.

I think this illustrates Arther C Clarke’s (paraphrased) saying:

Any teacher physician who can be replaced by a machine should be.

This is not necessarily a bad thing. Consider: if we can allow AI to be trained to augment physicians or advance practice providers in every case where the providers’ experience is not expert-level, we could raise the standard of healthcare throughout the country, or the world.

AI’s still can’t hold a hand, counsel patients on complex and competing issues, be compassionate, and create human connection.

We already have our computers helping remind us of the mundane yet critical tasks of doing the right thing for out patients: remembering tetanus and pneumonia vaccines, remembering to screen patients for colon and cervical cancer, remembering to repeat diabetes exams at frequent intervals. Why not allow them to give a second opinion on whether a skin mole is likely to be malignant?

CMIO’s take? More like this please. The co-evolution of AI and human is accelerating. We are finding a way forward.