EHR v Covid-19: MDPOA (power of attorney) & Advance Care Plans and the Covid BUMP

Full open-access paper here. https://preprints.jmir.org/preprint/21385/accepted

What I love about working in an academic health center is the luxury of being surrounded by people smarter, and more hardworking than I am. Here are Drs. Portz and Lum analyzing our data on the capture of patient’s Advance Care Plans – ACPs (including the Medical Durable Power of Attorney MDPOA) and other documents online via our patient portal.

We believe we are among the first in the country to offer the ability for patients to complete this online and designate a medical decision-maker in the event of their incapacity. Furthermore, we now accept photos of documents (easy and convenient via our patient portal app integrated with a smartphone camera — hooray modern tools for modern medicine) into the patient chart, and can see signatures, names, contact information, and details of MDPOAs, Living Wills and other ACPs.

And, during the anxieties of the pandemic, we had a significant uptick in patients completing the MDPOA and uploading images.

CMIO’s take? Another publication for our smart colleagues — good. Better patient care — great.

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.

COVID Incident Command: a day-in-the-life

The author, defended by his creature creations.

A recapitulation of a series of tweets about my recent experience at the UCHealth’s command center. I rotate the responsibility for the physician support position with about a half-dozen other docs. The command center has been up for almost 3 weeks now.

1/ A day @uchealth Incident Command Center. Constant stream of calls. Room is full of experts (infectious diseases, pulmonary, disaster) with a dozen other directors. Like being the frontal cortex of a massive organism…

2/ If you’ve never served in a Command Center, it is scary as heck, and also exhilarating. Things happen and decisions are made in minutes and hours, not weeks and months, as is more usual in a large organization… is that

3/ Sample incoming call: ‘ICU wants to know whether to send a second COVID test nasal swab on a patient whose test was negative yesterday but the team has high suspicion they have COVID.’ (Yes, not via nasal swab, but by tracheal aspirate for better sampling)

4/ Sample call: ‘Community organization purchased 10 COVID tests somewhere; would we send a medical assistant to perform swabs on their employees.’ (No, test performs poorly for patients with no symptoms.’ and, how do you choose who to swab? And, what would you do differently if you have a result? negative: stay home. Positive: stay home(!)

5/ Sample call: ‘Hey, if ventilators are scarce, we could build Iron Lungs faster: want some?’ (After internal discussion, no: COVID is associated with ARDS (adult respiratory distress syndrome). ARDS causes stiff lungs, unlike polio, and even then they didn’t work well), AND, how to manage IVs and catheters?

6/ Our converted conference room now is 24/7 staffed with executives, directors, nurses, doctors, staff who connect to every part of our 12-hospital, 600 clinic, 4000 provider system. Kinda like a neocortex…

7/ We sit and take calls from all over the system, clarifying the daily-changing policy, delivering nimble responses to moment-to-moment events in our EDs, our clinics, our hospital wards …

8/ We huddle in purposeful groups through the day: medical officers, informaticists, nurse leadership, respiratory therapists, ICU teams, hospitalists, data analysts, facility managers, tent-building teams(!) …

9/ We ‘run the board’ twice a day to ensure our top issues are addressed, re-prioritized, to keep our eye on the ball: racing ahead of the coming tsunami of COVID-infected patients collapsing on our doorstep…

10/ We marshal our supplies, build negative pressure rooms, re-allocate staff, negotiate new partnerships, create and dissolve projects to solve immediate problems…

11/ Dramatically expand our Virtual Health Center for Virtual Urgent Care, expand our nurse call line to handle COVID concern calls, go from 2700 virtual visits last year to 3000 virtual visits per DAY this week…

12/ Discover new trends: hypoxic COVID patients who are surprisingly not short of breath, patients who oxygenate better laying on their stomachs, how poorly bleach wipes interact with electronics(!) …

13/ We tearfully celebrate improvement: today a cluster of patients successfully extubated from the vent, a few patients de-cannulated from ECMO, a hallway of nurses applauding an ECMO survivor…

14/ And yet we have fun… Jurassic organisms battle for supremacy while modern organisms do the same.

15/ Our loyal administrative intern asked our Incident Commander at the end of her day shift: ‘How do you feel? How do you think we’re doing?’ …

16/ Her reply: ‘For the world, terrible. For our country, very worried. Here, we have prepped well, we have a great team, we forecast constantly, and we are going to meet this challenge.’ So proud of her, and us.

Unified Theory of Design Thinking for Social Systems (thanks to d_school at Stanford)

I recently attended a 6-day course Designing for Social Systems at the Hasso Plattner d_school at Stanford University. We sent at team from our Wellness initiative at the University of Colorado Department of Medicine, cutely named “WellDOM” (more on this in a future post). It was … a mind blower.

What is design thinking and why is it so cool?

  • It is a system of thinking that both expands and focuses creative thought.
  • It encourages curiosity and diving into the ethnography of individuals
  • It also encourages thinking about positive and negative influences at many levels of social systems
  • It actively encourages play, physical manipulation of prototypes and sticky notes to build a joint vision
  • It uses storytelling, rapid cycle development, ‘what if’ and ‘how might we’ statements to spark ideas.
  • It is FUN.

I’ve been thinking and digesting what I learned over the past few months and came up with the graphic above. I’m a visual thinker, and although it is quite cluttered, I think it finally encapsulates the scope of what I now appreciate to be Design Thinking for Social Systems:

  • It is Human-Centered (focused on emotion, story, experience), the inner yellow circle
  • It is Systems-Aware (complex social systems impact your success), the outer blue circle
  • It is Strategy-Focused (keep your end-goals in mind)
  • The inner and outer circles interact, and the strategy lane underlies the whole group of activities.
  • There are perhaps 4 dozen specific activities that allow you dive deeply into every part of this diagram, in your pursuit of a creative, lateral-thinking solution to complex, ambiguous problems.

Don’t wait! Take one of these courses! And start applying it today!

CMIO’s take? Creativity, and NOT Computing Horsepower, is the next frontier.

Pharmacogenomics (PGx) at UCHealth, getting serious about Personalized Medicine (published article)

Thanks to Pharmacogenomics Journal at Future Medicine

https://www.futuremedicine.com/doi/10.2217/pgs-2020-0007

Thanks to Christine Aquilante, lead author and main force of nature behind our early experience with Pharmacogenomics. Pharmacogenomics is the specifc branch of Genomics and Personalized Medicine that deals purely with “drug-gene pairs” or how a patients genetic variants might affect their ability to process and metabolize medication. The upshot is: some patients don’t respond well to some medications. There are now several dozen drug-gene pairs well described in the literature, where patients won’t respond well to certain medications because of their genomic variant. However up until now, it has been difficult to get any knowledge of such variants in front of the patient and prescriber at the most important time: when deciding on a new prescription.

UCHealth has a Biobank where we have obtained research lab samples from over 100,000 patients (drawing an extra lab tube in the course of routine clinical care) and have been testing samples for pharmacogenomic markers. In a few cases, we have found clinically relevant genetic variants that we are beginning to deliver back into the Electronic Health Record in the form of test results for clinician, in the form of test results and notification to the patient in the patient portal, and finally and most importantly, to the prescriber of the affected drug AT THE TIME OF PRESCRIBING for any affected patient.

This is groundbreaking, and hard work on so many levels:

  • Have to educate providers about pharmacogenomics: something that most did not learn in school
  • Have to educate patients on complexities of homozygous, heterozygous, population risks and multiple gene variants, balancing transparency with unintended alarm
  • Have to figure out when/how to alert prescribers at just the right time, for exactly the right population so that we don’t overstep what the science tells us is true in the research. In other words, don’t alert ALL patients with the genetic risk and a particular prescription if 99% of them will NOT ultimately have a problem with that prescription.
  • Lots of other things to think through (we just spent an hour just starting the conversation on our next drug-gene pairing)

CMIO’s take? We are happy to be among the few organizations setting up, and scaling up our efforts on Biobanking: conducting research AND benefiting patients in clinical care with PGx. Here we are expanding the boundaries of medical knowledge, and turning around to translate this into better decision making for our providers and patients.

The EHR fights Hepatitis A outbreak!

From UChealth.org

https://www-uchealth-org.cdn.ampproject.org/c/s/www.uchealth.org/today/hepatitis-a-outbreak-colorado/?amp

Always excited to see awesome work from smart, altruistic colleagues. Our own Kelly Bookman, Senior Medical Director, Emergency Department and physician informaticist, helped develop and deploy a Clinical Decision Support alert in our Electronic Health Record, in conjunction with Michelle Barron, infectious disease specialist and Infection Control director, among other analysts and experts.

With a major outbreak across the country, including the regions we serve at UCHealth, the team built an alert for Emergency department docs, scouring patient charts for those who are at increased risk for Hep A, and reminding docs to prescribe the vaccine during the course of their ER visit, regardless of original reason for the visit. This resulted in hundreds of additional vaccinations to protect our most vulnerable patients.

When patients can’t afford it, UCHealth covers the cost.

Finally, our team shared our design and code with other hospital systems in our region, to protect more patients.

CMIO’s take? THIS is what the EHR does well. I’m grateful to awesome colleagues, and hopeful about our future.

Zoom! Powers of 10 IRL! How about a zoomable EHR?

From Science News

https://www.eso.org/public/images/eso1242a/zoomable/

Click the hyperlink (not the image) above. This is a ZOOMABLE 9 billion pixel image with 84 million stars (thanks to Seth Godin’s blog for the link). Thanks to the European Southern Observatory for hosting this image.

Makes you think about our relative place in the universe. I’ve been fascinated with the night sky and have followed our exploits in astronomy, the Hubble, etc. BUT! to have a single image where you can click and zoom in (or shift click to zoom out) gives you a sense of the truly massive scale of our universe.

This reminds me of the movie we watched in elementary school: “The Powers of 10” from 1977 (see it here). What I did NOT know is that Morgan Freeman narrates a NEW version of the Powers of 10 that includes more modern discoveries (here!).

CMIO’s take? Humbling to say the least. How often do we get our nose off the grindstone and look up? And then to have such a depth of data and an amazing tool to zoom in and out of our place in the universe? Would that our EHR could do that as well… Hmm….

SOMAlogic proteomics and the future of personalized medicine BEYOND genes

Larry Gold and the team at SOMAlogic is doing some incredible work, using the key innovation of aptamers (RNA molecules that naturally attach to proteins, and using them as nanodetectors to pick up thousands of proteins on a chip, based on urine or blood samples.

This goes beyond genomics (studying individual patients based on the genes in their DNA) to proteomics (studying individual samples from patients for the proteins being produced AT THAT MOMENT). The key insight here is that genes are inherited, a one time snapshot of your makeup. Proteins are being made every instant, and we now know that these proteins can be shut down or overproduced, in response to environment, age, stress, diet, many different factors.

Suddenly there is opportunity to study what might PREDICT a heart attack, or onset of a new disease (diabetes, etc) based on the proteins detectable in your blood sample TODAY.

CMIO’s take? Information systems do better when there’s more data. Incorporating genomic data into clinical decisions is cutting edge. Incorporating PROTEIN expression of the moment into clinical decisions is a near-future dream, that some would call bleeding edge, or perhaps clotting edge…

Generative Adversarial Networks and ‘deepfakes’

I find it fascinating that current topics in Artificial Intelligence both scares and encourages me. In this case “Generative Adversarial Networks” is a way to pit two AI’s against each other, one trying to fool the other one about an image, gradually tweaking and adding snow to a summer scene, and then the other AI detecting falsehoods versus genuine photographs. With “deepfakes” gaining traction, the ability to make celebrities (or anyone) look like they’re doing or saying something that video never captured, how will WE or our tools be able to spot these fakes?

We’re living in an age when connectivity is both a wonderful asset and increasingly suspect. What can we trust if we can’t trust a video or audio clip?

CMIO’s take? Technology acceleration, done with good intention can help us live better lives. Turns out, there are a growing number of downsides, that will require good people working hard, to turn the tide.

A Second Sprint Team to reduce EHR-related burnout! UCHealth – Colorado

https://www.hcinnovationgroup.com/clinical-it/electronic-health-record-electronic-medical-record-ehr-emr/article/21105576/uchealths-wellness-effort-includes-ehr-optimization-sprints

We are so excited to welcome another 11 person team to our Sprint Optimization family!

Our success in re-designing the physician-clinical team-EHR interaction has led to substantial reductions in time spent in the EHR: 16 minutes PER PHYSICIAN PER DAY, and in our sample of one academic medical practice comprising 26 providers (advanced practice providers as well as physicians) this “average physician” is 0.4 FTE. Sixteen minutes is already no laughing matter, but it is possible to imagine that a physician spending 100% of their time in outpatient practice might conceivably save more than 30 minutes per day as a result of a 2-week Sprint.

As you may recall, we assembled an 11 person Sprint team, 1 physician informatics leader, 1 clinical informaticist (RN), 1 project manager, 5 trainers, 3 EHR analysts (who can build and alter items in the EHR). This team arrives on site, in a clinic (of up to 30 physicians and their clinical staff) and spends 2 weeks listening, watching, building tools, and most importantly, coaching EHR use and TEAMWORK and COMMUNICATION strategies to improve care of patients as well as reducing wasted effort.

This has been noticed by our organization (UCHealth) and we are now 22 strong, 2 teams conducting sprints every 2 weeks (with 1 week of recuperation), and 15 sprints per year.

CMIO’s take? It is gratifying when the snowball effect works in your favor. We are striving to shorten the cycle-time between repeated Sprints in clinics. This is a big step in that direction.