Category: PIG-let (informatics newbies)

Simple vs complicated vs complex decisions: a leader’s approach (HBR and Colin Powell) and a reflection

How does electronic Surgical Case Request and electronic Informed Consent illustrate decision-making in complex environments? Here is some of my own heartburn. Also, what does Colin Powell have to say about decision-making?

In our monthly meeting, our surgeon informaticist and I were discussing our Electronic Surgical Case Request and Electronic Informed Consent projects, and the swirling, interconnected decisions we are facing, and it occurred to me that we were facing a COMPLEX project with challenging decisions to be made.

In brief, I recall from an HBR article (A Leader’s Framework for Decision-making) that there are simple, complicated, complex and chaotic environments.

from HBR.org Cinefin framework
  • Surgical Case Requests (SCR) are currently scribbled on paper, sticky note, email, many forms – we want to make them electronic, trackable, standardized, accurate, with few to no verbal handoffs
  • We know (from others) that Case Requests and Informed Consent (IC) forms should be implemented together, synergistically
  • There are several ways to implement SCR and IC, it is unclear which pieces of hardware, and what software packages are best to use in the peri-operative space.
  • There is an idea that combining a surgical Consent and an anesthesia Consent (as is done by our Children’s Hospital colleagues) would simplify workflow and eliminate 50% of patient-required signatures, while retaining (or improving) patient-physician discussion of consent.
  • A combined consent form is a novel idea in many circles and would require consensus from: Legal, Compliance, CMO, Surgery leaders, Anesthesia leaders, IT leaders to agree on the strategy and tactics
  • It is not at all clear that surgery leaders and our 1000+ of surgeons are ready to abandon their (potentially error-prone, but familiar) existing paper/sticky-note/email/text/other-method-here workflow for this new process
  • This project MUST be completed in the next 12 months, as per C-suite prioritization
  • At a high level, we DO have buy-in from Surgery, Anesthesia, Chief Medical Officer, Chief Operations Officer, all the right stakeholders.

But…

Do we really want to take on “Combine Anesthesia and Surgeon Consents” at the same time as these 2 massive projects? Do we?

In this case, I think we’re encountering something Complex.

How to execute this project successfully?

This is something we are wrestling with right now. One significant decision to make now:

  • Whether to use the Burning Platform of the Surgical Case Request / eConsent project to push forward the ‘combine anesthesia and surgery consents’ at the same time, OR to skip it (as it distracts from the major goal of succeeding at Case Requests and Consents across the system

Argument FOR unification of consent

  • Reduced time pressure in the peri-op area, where patients have already fasted for hours, mentally prepped for their surgery, and NOW have to meet the anesthesiologist, have a detailed discussion of risks/benefits of anesthesia, and sign a consent form
  • Reduced number of signatures a patient needs to sign
  • Reduced hardware elements that could go wrong: a electronic signature pad connected to a PC or Workstation on Wheels, an iPad running consent form software on the right patient, a patient portal account running on a smartphone or other patient’s device, receiving a consent form.
  • Reduced management of customized consent forms, as instead the anesthesiologist can focus on having a thoughtful conversation and documenting the result in the note INSTEAD of explaining a form and chasing a signature.

Argument AGAINST

  • Too much change: eliminating a consent process that has been used for decades (on paper) might result in unintended consequences, reduced quality of documentation, missed steps in the peri-operative suite
  • Risk of delay or cancellation: if we bet everything on unified consent and we have a hard-stop disagreement from Compliance office, Legal office, CMO office, Anesthesia Leadership, Surgeon Leadership, Operations Office, Nursing, Patient Advocates, will our timeline be able to survive?
  • The IT team may not be able to delete and rebuild 2 consent forms at the last minute if our governance decisions cannot keep up with project mile-stones.

Therefore…

In Complex Environments, leaders must watch for emergence, as there may be no prior guidance “best practice” for THIS situation. One must “probe, sense, and respond.” From early conversations, there are many objections to the proposed consent unification, and we sense that the risk to the project may be too great to insist on adding this additional objective.

In this case, I think we must simplify. There are too many risks to the timeline and major hills we already must climb for the Case Request and Consent projects to be successful. Our metrics will include:

  • Improved Accuracy of CPT coding (reduced insurance coverage rejection for incorrect CPT code) and thus $$ we have to “write off” due to clerical or administrative error.
  • Reduced patient frustration for above billing errors
  • Improved OR scheduling (right CPT code leads to better estimates of how long the procedure will take, and the right amount of time can be set aside)
  • Improved matching of surgical equipment to the right procedure and reduced need to “emergently flash-clean equipment” that is not ready

Make Decisions with 70% of Data needed?

  • Colin Powell tells us to make decisions when you have 70% of data you need, avoid making a decision when you only have 40% of the information you need. I find this: uncomfortable, and probably about right.

How to explain complexity simply?

  • One Pager: This is another example of the usefulness of building a vision of WHY, high level explanation of HOW, predict the potholes in this big project, and explain what is needed by leaders and front line to make this happen, and what will be gained as a result.

CMIO’s take?

Simplicity is the ultimate sophistication.
–Leonardo DaVinci, Steve Jobs, maybe others

Don’t under-appreciate Complexity and how to make decisions differently in such circumstances.

APSO Notes: what Machiavelli taught me

What does a book from the 15th century, my own pediatric record, and APSO notes have to do with modern informatics?

from wikipedia

It is the year 2009. We are 8 years into our EHR journey (Allscripts Touchworks, at that time). Physicians are dutifully recording progress notes by dictation, by typing, some using templates, to record their observations and thinking about patients in the longitudinal record. We scribble in paper charts (not every clinic is electronic yet: we have a 10 year plan to convert all the clinics).

The complaint: EVERYONE KNOWS that when the EHR team comes to town, we will put our notes into the (#$^@ computer and no one will be able to read them any more.

Exchanging illegibility for unreadability

SOAP format implies: Subjective, Objective, Assessment and Plan, and has been this way since Larry Weed proposed his organized way of tracking patient data. With brief notes, and prior to all the federal regulations on what NEEDS TO BE in the note (if you didn’t write it down, it didn’t happen), SOAP notes were terrific. Even today, surgeon notes, on a global surgical fee (eg surgeon’s can’t bill on length or complexity of notes in the perioperative period), SOAP notes can be pretty darn brief:

S: Postop day 2. No complaints. Pain improving. Not passing gas yet.
O: Vitals stable. Wound looks good
A/P: Healing well. Teaching dressing change. Anticipate DC in AM if eating.

Here’s an example of MY pediatrician’s medical record on me. 16 years of my life on one piece of paper. OK, maybe just a bit TOO succinct.

In contrast, our electronic progress notes at the time were reaching 5, 7, even 15 pages long, full of regulatory language and audit trail signatures and time stamps.

A terrible example of Emergency Department note, circa 2010. Notice the red circles around the crucial elements in this 15 page note. And that the last page is all signatures and time stamps

What is worse, these long notes are particularly hard to read on a screen. In an EHR, that means: Find Chart Review – the listing of all notes, find the note you want to read. Click to open the document, then scroll 12 pages down to find the A/P. It’s not on the Last page, because that is full of signatures and time stamps. It is about page 10 out of 12. Then, Click – scroll, scroll, scroll for the A/P of the second note.

After about 3-4 of these, you get tired and STOP LOOKING for more thinking from other doctors. IT IS TOO HARD.

What a sad state of affairs. What to do?

My solution: APSO notes!

Yes, that note is 12 pages long, yes, we need to work on shortening it. In the meantime, how hard would it be to teach docs to put their ACTUAL THINKING at the top of the note? Assessment and Plan AT THE TOP.

This way, you could write your note in the same sequence: Subjective, history, past history, etc, then Objective, exam findings, lab results, and then MOVE BACK TO THE TOP and complete your Assessment (I think this is what is going on with the patient) and Plan (This is what we’re going to do about it).

By doing so, as the patient’s history and number of visits with various specialists gets longer, it continues to be EASY to click – (no scrolling) read the A/P, Click – (no scrolling) read the next A/P. Many times easier to browse the chart and get a concentrated dose of physician/APP thinking.

In my mind, I’m a genius.

How hard could it be to change doctor behavior?

You know what is coming. I did not.

I built a new note template: APSO format, to sit alongside SOAP format. I user-tested it in 1:1 meetings with about 80 colleagues, who all agreed “This seems better, easier.”

I launched the note template, held my breath …

I got to a 70% adoption rate. Woo-woo.

Many folks (EVEN AMONG MY SELF-PROCLAIMED FRIENDS) did not change behavior. “Oh, I forgot.” “Oh, I am planning on trying that sometime.” “Oh, I was very busy and running behind. Not today.”

Bleh.

Another failure for the Failure Resume.

About this time, I was reading Kotter’s Leading Change and also Machiavelli’s the Prince. Between the 2 texts, I had some insights.

1. The Burning Platform (Leading Change)

I knew we were headed to adopting a new EHR platform in 2011, which was sure to cause significant disruption in many ways. Never waste a good crisis. Use the Burning Platform: when everyone jumps, give them a good place to land.

If you’re going to mandate APSO notes in the EHR, why not do it from the ground-zero of installing a new EHR? This is what I set out to do. The ground-work: the standard template for all progress notes would be APSO format: Assessment/Plan/Subjective/Objective.

I told the white lie: “Sorry, our new EHR only comes with APSO notes.”

I got the leadership to back me up (see below): APSO notes are much more readable than standard scrolling SOAP. This is the right moment to make this major change in policy. Don’t let individual complainants revert back without a thorough review with all leaders.

2. How to build meeting consensus  (Machiavelli)

Having re-read my Machiavelli text, I set up my next plan. I needed medical leadership consensus on making such a broad-ranging change.

By the way, for those of you who equate Machiavelli with self-serving, power-hungry, win-at-all-costs reprobates, well sure. HOWEVER, his text is ALSO full of practical advice for leaders.

He states: if you go into a meeting and you do not already know how everyone will vote, you have not done your job.

There are 40 members of the multi-disciplinary Ambulatory Medical Directors group; they are a rowdy, tough-to-wrangle group with strong egos, lots of opinions, and rare consensus across primary care, medical specialty and surgical specialties. If you have worked any amount of time in healthcare, perhaps this is familiar to you.

I determined to meet 1:1 with the majority of the group, including of the most influential members.

My tactic:

CT: “Don’t you hate it when it is hard to read the notes of [other specialty here]?”
CT’s targeted medical director: “Yes! Their notes are TERRIBLE. Ours are fine, by the way.”
CT: “Right! Well, I’m planning on enforcing APSO format for their notes so it is easier for us to read them.”
Target MD: “That sounds great. It is SO NEEDED.”
CT: “However, in order for me to get them to change to APSO, I need YOUR specialty to change to APSO. We need to be unified and apply pressure to THEM to change.”
Target MD: “But, our notes are fine. We don’t need to change.”
CT: “I can’t do this without you. The actual change for you is minimal. Just start part way down the note at Subjective (that is F2 key pressed 2 times), your patient visits and documentation sequence doesn’t change, just the final display of the note is different. For a minimal investment on YOUR part, we ALL benefit from THEIR NOTES being more readable. How about it?”
Target MD: “Hmm. I suppose it is worth it. You can get THEM to change though?”
CT: “Yup, you give me your approval for your specialty, and I will get THEM to change.”
Target MD: “Deal. Makes sense. Minimal change for us, big improvement on their part.”

CT repeats this conversation WITH EVERY OTHER MEDICAL DIRECTOR. Each of whom have the same thing to say about every other specialty. “We’re great, but those guys are terrible.”

As a result, the following Committee discussion was a non-discussion: “CT is proposing standard APSO format for all notes written in Epic. Any discussion?” “Nope. Makes sense to me.” “Sounds ok.” And then discussing some minor concerns, we were done.

APPROVED! But…

Perhaps 20 hours of planning and 1:1 meetings for a 5 minute agenda item.

What’s that? This is unworkable for the majority of decisions? You are absolutely right. We pull out all these techniques ONLY for the BIG decisions. But it can and does work. To this day, Primary care notes (we write about 1 million a year), are 100% APSO format, and specialties are about 88% APSO.

CMIO’s take?

Years later, I gave this talk at Epic UGM and it has become an Epic Classic (link requires userweb login). In subsequent years, readability and note format continue to be debated, and at one point I was referred to in a UGM session as “unlike those Radical Extremists at UCHealth who standardized on APSO, we can’t get our people to adopt it like that.”

Thanks for the … compliment?

And now you know how this particular sausage was made. Thanks to Machiavelli and Kotter, and all the smart people before us.

Machiavelli, “The Spare” and Medical Informatics? A reflection

What does “The Prince”, Prince Harry’s new book, and Medical Informatics have in common?

It is a joy to have a son in college who is still interested in speaking to me, the old fuddy-duddy born in the Last Century. He is attending St. John’s College in Santa Fe, where they study the Great Books curriculum, or as his sister says, “Oh, so you read about ideas from old dead white men?”

Machiavelli

It so happens that his class, which started with Aristotle, has worked their way up past Copernicus (my recent post on changing world-views), and now in the sophomore year, is now reading Machiavelli, perhaps my favorite of the classics, since it so much to say about the challenges of leadership.

Over dinner last week, my son and I discussed what I remembered from reading the Machiavelli’s “The Prince” in our Physician/APP Informatics Book Club (yes, we did), and the quotes that I use almost every week at work.

Why Change is Difficult to Lead

The reason that change in an organization is so difficult, is because at best, your proponents are lukewarm, and your detractors have ALL THE PASSION IN THE WORLD –CT’s recollection of quote

And it should be considered that nothing is more difficult to handle, more doubtful of success, nor more dangerous to manage, than to put oneself at the head of introducing new orders. For the introducer has all those who benefit from the old orders as enemies, and he has lukewarm defenders in all those who might benefit from the new orders… The lukewarmness comes from the incredulity of men, who do not truly believe in new things…  –Original text from Machiavelli

How to Manage Bad or Good News

If you have to manage change that people will like, be sure to do it a little at at time and take credit for every improvement, to sustain the atmosphere of good will. If you have to manage a change that people will NOT LIKE, do it all at once. In fact, hire someone to make that change, and, at the end, when they are very unpopular, BEHEAD THEM. Problem solved.
–CT’s recollection.

For injuries must be done all together, so that, being tasted less, they offend less; and benefits should be done little by little so that they may be tasted better.
–Original Text from Machiavelli

Application: we have a new committee, EMO (electronic medication optimization) where we are learning to remove low value medication warnings (eg: multiple stimulants in one med list – many patients have more than one Adderall pill strength needed for the right dose). Suppressing such alerts that are 90% overridden, is a benefit. Every time we reduce clicks, we Broadcast it. Take credit for every reduction, every improvement.

On the other hand, when there is something ‘bad’ we must change, we do it all at once. We have to wipe out physicians’ old radiology order preferences in order to install new radiology orders that incorporate secure chat buttons and more effective routing. DON’T get rid of them piecemeal (they will hate you every time you make a change) rip off the bandaid all at once and remove ALL the preference lists and start fresh instead. ONE painful change. But, the ONE event fades faster in memory than many smaller changes. (Yes, I know that CT Lin ruined healthcare, regardless of what he chooses).

Close readers of the blog will remember that our book club also read Leading Change and also Buy-In by John Kotter. Really practical advice on tackling the sticky issue of how to set up important changes for success.

How to Build Consensus

Back in 2009 when I invented APSO notes (a future post) I had difficulty convincing colleagues to switch to a different format of document. In brief, SOAP notes are how docs have written standard notes for 70 years. APSO puts the assessment and plan, the most important part, at the top for increased speed and readability.

However, I had failed. In our EHR (Allscripts Touchworks at that time) I made APSO a selectable option next to standard SOAP notes. Result? 16% adoption rate, even among my close friends and colleagues.

I had an opportunity in 2011 for a platform change (we were adopting Epic) and I had a committee meeting to see if I could get APSO as the default standard.

Machiavelli teaches us that, if you don’t already know how everyone will vote at an important meeting, you have not done your work.

In brief, I made 30 minute appointments with EVERY influential medical director in that 30-member meeting to discuss APSO, answer their questions and in some cases do some horse trading (this for that) to gain support. Took a couple weeks to do this ground work, for this crucial decision.

Result? I achieved consensus at the meeting. APSO notes were the default (and for a time the ONLY) format available in our new Epic EHR. Thanks, big M.

Spare

This brings us to Prince Harry. I recently listened to his book “Spare”. I had not followed the royal drama closely, and did not know that Spare was a disparaging name for himself, in contrast to “The Heir” Prince William, as in “there’s the Heir, and there is the Spare.” How awful. See last week’s blog post (below).

One presumes that the Royal education includes the reading of The Prince, for modern princes.

One also presumes that palace intrigue, public scrutiny, the fickleness of public opinion, all weigh heavily, magnified to searing intensity by social media and paparazzi (what would Machiavelli say about paparazzi?).

Similarly, those leading projects in large health systems must contend with large populations, difficulty communicating effectively, rumor, innuendo, opposing viewpoints, resistance to change (but perhaps, not paparazzi).

Medical Informatics

To bring these threads together, one sees ancient and modern examples of leadership, managing communication, remembering that smart humans lived many years ago and wrote down their ideas. It is up to us to learn history or be doomed to repeat it. Remembering my personal failures, my 16-year journey to Open Notes, my nearly-failed plan to implement APSO notes, and now our struggles to deploy, maintain, study and improve Open Results, these innovations have all been guided, in some way by Machiavelli.

CMIO’s take? Who is the historian in your leadership group? Who reads the literature, learns from the past, and gives your teams perspective? How do you ensure a diversity of opinion, of thought? How do you challenge and disrupt yourselves to avoid complacency? I worry about this all the time.

CT Lin’s CMIO interview with SeamlessMD

Thanks to Joshua Liu and Alan Sardana for a great chat spanning decades of my informatics career. We cover:

  • My ukulele origin story
  • My failure resume examples
  • How AI is nibbling at healthcare
  • P-values versus Change Management
  • How CT Lin ruined healthcare

https://seamless.md/blog/tdp-96-uchealths-cmio-dr-ct-lin-measuring-and-benchmarking-clinician-nps-augmenting-cds-with-ai-and-making-clinical-informatics-fun-ft-ukulele

My conversation on Designing for Health (podcast and a ukulele song)

What does mindfulness mean to a CMIO? Also, patient engagement, information transparency, and FAILURE? And finally, gratitude. Listen all the way through for a special treat. #Podcast #healthcare #healthIT #hitsm #whyinformatics #hcldr #somedocs

https://www.nordicglobal.com/blog/designing-for-health-interview-with-uchealth-cmio-dr.-ct-lin?hss_channel=lcp-819886

Swapping or Merging EHR’s? Don’t Make Me Start with a Blank chart! Or Should We?

You’re kidding right? No one wants to start with a BLANK EHR screen when seeing patients. There HAS to be a way to automatically move data from ___ EHR (fill in name) to ___ EHR (fill in name), RIGHT? RIGHT?

It is a tale as old as time (or at least since the early 2000’s when clinics started installing Electronic Health Records). HEY, my EHR sucks! That other one over there MUST be better. Let’s rip out the current one and put in a new one. SURELY that will fix everything.

First of all, that is a fallacy. 20% of the success of an EHR project is due to the technology. 80% is due to the socio-political skills and workflow designs of those doing the installation.

Secondly, maybe we’re too late, and the NEW system is nearly fully installed. We’re just waiting on the data-load. How much data do you pull out of the current system and push into the new? Easy, right? ALL OF IT! Surely all that typing, mousing, clicking that our physicians and APPs and nurses and staff did entering data CAN’T BE WASTED.

In fact, I’ll make it easy:

Here’s a list of data to pull over

  • Problems (clinical diagnoses, billing diagnoses, problem list)
  • Medications (historical meds, active prescriptions)
  • Allergies
  • Immunizations
  • Past Medical History / Surgical History / Social History / Family History
  • Progress Notes, Hospital Notes, Emergency Department Notes

Done! W00t! Our new system is pre-loaded with lots of useful stuff!

Happy, nāive CMIO moving data around.

Not so fast, Sherlock.

Here are a sample of problems we encountered trying to make this happen in our organization:

PROBLEM LIST

We tried loading ICD10 codes from one EHR to another. Maybe 1/2 of the codes come across okay. Others start with “Adrenal Adenoma” and end up with “Adrenal Mass, Not Otherwise Specified”. In many charts, our physicians complained that “It would have been easier to enter NEW diagnoses rather than fix the details of the ones that imported incorrectly.”

Another issue: sometimes you end up merging EHR’s between two organizations. Then, you’ll get “Diabetes, type 2” and then a semi-duplicate “Diabetes, poorly controlled, type 2” and “Elevated Glucose” and “Diabetes, type 2, well controlled”. And then your physicians end up cleaning duplicates OR worse, just leaving the mess as is.

Medications

We transitioned EHR’s, years ago, from Allscripts Touchworks) to Epic. We pulled 2 million medications out of one EHR and ported it into the other. Unfortunately, data stored in Allscripts was, for example:

Lisinopril / 10mg / 2 tablets / once daily / quantity 180 / refills 3

The data Epic expects on the import was:

Lisinopril / 10mg / total dose: 20mg / once daily / quantity 180 / refills 3

As a result, the third field caused an error, and now the result of the import:

Lisinopril / 10mg / __ (defaulted to 1) / once daily / quantity 180 / refills 3

And the physician using the new system might prescribe the wrong dose. Thus, we hired a team of pharmacy technicians to go through each patient and FIX THE ERRORS. It turns out to be MUCH FASTER to enter an entirely brand new prescription than to correct an imported one. Booooo.

A Human Team for importing data

We ended up hiring a team of abstractors. How did we do this cost-effectively? As UCHealth grew as a system, we would add new clinics and hospitals, often with patients in common (eg, electronic data in 2 EHR’s, in health systems that were coming together). Automation and importing tools are still not up to the task of seamlessly merging data sets (eg: here is a lisinopril prescription from 9/2019, here is another one from 3/2020. Are they the same?). As a result, we thought about the most efficient way to fund a team to do this work. We ended up with:

Pharmacy Technicians, supervised by a Pharmacist.

Import Team work

We would send a team into a clinic, to look at the clinic schedule and import Problems, Meds, Allergies, Immunizations. We decided AGAINST importing Past Medical History, Past Surgical History, Social History, Family History. These last 4 were generally of poor quality. Garbage In, Garbage Out (and costly in person-hours).

Pharmacy Techs do well at meds, allergies and immunizations, and diagnosis selections were easily trained.

Sometimes clinics would pay overtime to MA’s, RN’s and some clinicians in advance of the EHR cut-over (bonus: increased time spent on the newer EHR grew their skills).

The team would abstract charts up to 3 to 6 months while using the new system, thinking that the most complex patients in a clinic would be seen more frequently, and then the bulk of the complex patients would be loaded.

Scanning?

We chose NOT to bring scanned images wholesale into the new EHR. We did a trial for a busy primary care clinic, and scanned 1 month of about 30,000 images. Usage / viewing of those images by clinicians and staff after a year was … ONE PERCENT. About 300 images were ever viewed, and most of the views were insurance cards!!! This is a very low utilization rate for a high cost, slow process for scanning, importing and indexing. Perhaps newer  OCR (optical character recognition) and AI – self categorization tools might help in the future…

Instead, we asked clinicians to do EITHER: A) Incorporate data from old notes/EHR into the new one in their progress notes or problem list. We kept the old EHR live for one year, so that clinicians could cross reference without importing.

And/Or, B) Allow clinicians to “tag” individual scans from the OLD EHR to be individually moved to the NEW EHR. This resulted in a small, manageable list of scans to bring over that were most useful (discharge summaries, consultant notes, critical radiology reports).

Data transitions between EHRs? Hire a team. Maybe give them Red Shirts.

Grow humans, not IT employees (PIG-let series)

What do the books Good to Great (Collins) and How to Raise an Adult (Lythcott-Haims) have to do with Informatics? Don’t you wish you knew… (UPDATE! Link to Sinek’s Infinite game 2 minute summary)

Above: Using Craiyon to illustrate mentorship in the style of Picasso. (Thank you to Dr. V’s 33 charts blog for the innovation of harnessing AI to generate images for lazy bloggers like me)

I had a chat recently with a mentee that was enlightening, I think, to both of us. This new informatics leader was stressed about having a slate of recent failures:

  • Medical assistants in clinic their clinic tend to leave their small practice after a year or 2 of working with this person
  • Newly hired clinical informaticists (supporting physicians/APPs using the EHR under this person’s direction) were talking about leaving for a different job

However, what came out after further discussion was that:

  • These MA’s left to go to nursing school, to physician-assistant school, to physical therapy school
  • These informaticists were interested in growing their careers as well
  • Those who left often drop by to leave a to-go lunch, or leave gifts

So, which is it? Is this a failure or a success?

Of course, asked in this way, on my blog, in hindsight, the answer is obvious. On the other hand, faced with such situations in a busy, overworked clinic or informatics team, high-performing individuals leaving can be felt as a personal blow. “Oh, I spent so much time growing and mentoring this person over the past year, and THEY’RE LEAVING ME. WHAT AM I DOING WRONG THAT THEY WON’T STAY?”

Sure, it would be important to debrief these folks and make sure you’re not missing an obvious pay gap, or deficiency in the job responsibilities, or needed resources, or unhappy work environment. But in this case, these were all superstar performers leaving for positions that would allow them to grow.

In Good to Great, Jim Collins talks about Level 5 leaders who are humble enough to lead from below: to promote team work and team members and succession plans, and also to put the right people on the bus. Sometimes this means finding outstanding candidates who will outgrow their job and leave.

One could choose to look the employees leaving as a failure: all that expertise is walking out the door. Or, one could choose to see it as a success: we mentored this person, grew this human into their greater potential.

A thought experiment: Wouldn’t it be a tragedy for a superstar MA to spend a decade being a superstar MA, instead going on to become a Physician Assistant? a Nurse? a Physician? Of course, some will want to stay and BE that superstar MA… and that is okay too.

In How to Raise an Adult, Julie Lythcott-Haims notes: “Our children are not hot-house orchids, instead, they are wildflowers of an unknown genus and species.” And, there is nothing we, as teachers, mentors, supervisors can do that is as important as growing them, teaching them effective teamwork, giving them confidence, and letting them spread their wings.

In The Infinite Game, Simon Sinek states, that, unlike the Finite Game, in which the goal is TO WIN versus the other guy, the Infinite Game, the goal is to STAY IN THE GAME. What better way to stay in the game than to grow your future colleagues, where-ever they may go?

CMIO’s take? In being a Mentor, I contend, your goal is NOT ONLY to serve your organization with outstanding informatics work, BUT ALSO to GROW THE HUMANS under your care. Sometimes to grow, they will leave. And what they do after, may astound you.

Help! Secure Chat in Epic, a ukulele EHR parody

The latest ukulele song. Yet another illustration of how Culture Eats Technology for Lunch.

We’re working on a Unified Communications strategy at UCHealth. We have a history of implementing multiple communications channels over the years:

Bell-boys

291586658668_1

Bell-boys (the precursors to pagers), with verbal alerts. You call a phone number, you record your 8 second message, and a minute later, someone, somewhere in the hospital hears this coming from the bell-boy at at their hip. Usually, you say: “This is East-8. Please come to bed 8217. Patient vomited blood.”

Worst case, you have excited nurses who don’t give you complete information. My favorite bell-boy utterance: “Doctor! Come Quick!”

Hmm. Which floor wing of the hospital? Which of the 12 floors?

Pagers

motorola2bpager

Then, there have been actual pagers, those infernal beeping machines that were the bane of residents and attendings worldwide (but the badge of honor for medical students offered one for the first time).

Of course, there’s Pager Inversus, but that is a blog for another day.

Doc Halo, Vocera, Tiger Text

And then came the flowering of 100 new ideas. “Hey, I think my department could really use X. We don’t really like Y because, X is better. Everyone know that. And because our organization in years past did not have a well-centralized decisionmaking body, every department went and did as they liked. As a result …

Pandemonium

Why can’t the nurses and operators page me in time? They are SOOOO SLLOOOWWWW. We need to hire more.

Well, imagine this. The number of places a nurse has to look in the paper or electronic chart to find the contact information for any one physician or APP was in non-overlapping, non-cross-indexed dictionaries:

  • Handwritten pager number in the progress notes
  • Call my service and my staff will then reach me on my private cell. I don’t give that out
  • Look me up in Doc Halo’s website
  • Look me up in Tiger Text index
  • Look me up in Vocera

Fortunately, we finally have a tool in Secure Chat in Epic EHR that will replace all these technologies.

Network Effects

(image from wikipedia.com)

Over years, the building of telephone networks made owning a telephone increasingly valuable. The larger the network and more people you can reach, the more useful the tool.

The opposite is also true: the more different and non-connected communications tools you use in an organization, the worse it gets, and the harder it is to reach anyone.

I think we’ve finally learned this lesson: Secure Chat it is.

Culture Eats Technology for Lunch

Of course, the IDEA of unified communications and getting rid of older networks, like pagers, other secure chat tools in favor of one, seems simple. Don’t under-appreciate the need for LOTS of meetings and discussions.

In fact, it might be time to re-read Leading Change.Have to think about finding the Burning Platform, building Buy-In, building a Guiding Coalition, and so on. Informaticists would say, it is the classic 80:20 rule. Technology, as hard as it is to create, is only 20% of your success. The other 80% is the socio-political skill of those deploying the tech.

CMIO’s take? We are, after years of effort, growing our success. And to celebrate, this song (youtube link above).

 

How to write an effective 1-PAGER (Informatics PIG-let series)

Ever done this? You have a major presentation, and as the expert, you want to anticipate ALL questions, so you write a 17 page white paper to CRUSH ALL DISSENT. HA! You think, TAKE THAT! I’m sure to win everyone over.

The Internist’s Problem

This is the story of my life. As a detail oriented (read: Obsessive-Compulsive) Internal Medicine physician, I’m trained to sweat all the details, think through complex situations, and explain them as carefully as I can to my patients and colleagues. That’s what I’m good at.

Do you have a few hours? Let’s get into it! (Sorry, you’re right, this is a blog, just kidding).

The problem is, this is NOT the skill you need in organizational leadership. No one has time for an hour-long PhD dissertation. You get maybe 5 minutes, maybe just 10 seconds, to make your point in a board room, a steering committee.

Furthermore, as an introvert, I’m not good at punchy one-liners, off-the-cuff banter, deft debate skills to win over recalcitrant colleagues. What to do?

Don’t do THIS!

That is exactly what I did wrong in 2001. I helped conduct a research study to show that Open Notes and Open Results (releasing notes and test results online to patients) was safe and effective. I wanted to win over my colleagues in a large, multi-specialty University practice. I wrote a 17-page Q/A handout answering ALL POSSIBLE QUESTIONS. It did not go well. Maybe you heard of me and my disaster? –> My 16 year journey to Open Notes. 

So, what to do?

In the intervening, wound-licking years, I developed a solution: the 1-PAGER. Other names you may hear me say: The Executive Summary, the SBAR (Situation, Background, Assessment, Recommendation; a format familiar to nurses, and their effective communication analog to the physician SOAP note).

General Principles of a 1-pager

  • Don’t exceed one side of one page. This restriction forces clear thinking and writing, like a newspaper article with limited space, cutting away unnecessary words and information.
  • The title should be specific and direct, START WITH WHY
  • An executive summary, in 3-4 sentences, giving some nuance to WHY and WHAT needs to be done.
  • Include both data AND ALSO stories and quotes. (Daniel Kahneman: “No one ever changed their mind because of a number. They need a story.”
  • With every item on the page, ask yourself “Who is my audience? Do they care about this item? Does it help tell the story? Does this align with the audience’s or organization’s goals?” Slash ruthlesslessly.
  • Include interesting graphics; no one will pick up a boring paper with dense small font, but a picture? or a curious graphic? Maybe you have a chance.

Here are some examples to consider

My 1-pager describing our move to adopting OurNotes patient questionnaire across 80 primary care clinics, about 400 primary care providers, where patients co-author their own progress notes. Proposal: accepted.

Download document: 2022-0208 OurNotes Patient Questionnaires Future Exec Sum

My 1-pager describing the benefits of our outpatient Sprint program, both data and stories: “I no longer seek early retirement to escape EMR.” Similar documents helped get Sprint teams funded.

Download document: 2018-08-ExecSum-Sprint-Aggregate

My 1 pager describing “How long will my IT/EHR request take?” Our leaders better understand why some things take a longer time than others.
Download document: 2020-0707 EHR Pyramid of Possibility CTL

My 1-pager advising patients what to expect when expecting a test result. Download document: 2020-1026-for-patients-getting-a-test-at-uchealth

My 1-pager advising clinicians how to avoid potholes in writing a progress note that will be read by patients. Notice: it is no longer 17 pages long. Download document: 2017-0904OpenNotesDocuTipsCTLin

Beginner’s Mind

Heres’ the thing. An expert knows a LOT of detail and has trouble holding back all those details. A beginner / learner / leader needs to know just enough to make a judgement whether to support a project or not. How can an expert adopt a beginner’s mind? Start with WHY, write a disciplined ONE PAGE argument, tell a STORY backed with data. Revise, revise, revise until it is clean, succinct, and passes muster with a colleague or mentor who is willing to critique your writing.

Piglet?

Oh, are you still reading? What is a PIG-let, you ask? One of my newer physician informatics colleagues, poking fun at our Large PIG / Small PIG meetings, wanted a PIG-let meeting, for the newbies. Cute. Like Tony Hsieh did, for Zappos in “Delivering Happiness”, I’m looking to build an on-boarding set of skills for our PIG-lets. Skills, tools, books.

CMIO’s take: What do you think? Have you tried this? Do you disagree? What has worked for you? 1-pagers for everybody!

My black book for non-device note taking (Informatics PIGlet series)

According to my smart younger sister, all west-coast startup CEO’s carry black books, wear blazers, ironic T-shirts, and sneakers. I figure I could at least carry a black book. What’s in it? What’s it good for?

 

Then, I take a set of 3 inch square post-it notes and cut them up the to the size I like so I can use them to index my black book (see the sharpie marks on the right edge, to index the sections), and then use my opening page for major projects so I can glance at what I and my team are working on. In short: too many priorities. 

I know. It is. A struggle.

 

My BHAGs are aspirational. BHAG: Big, Hairy, Audacious Goal. The idea: setting small goals and achieving them doesn’t inspire dramatic action. For that, you need a BHAG. From Great by Choice (Collins). Something I’ll aspire to. One day I will sleep 8 hours every night. I do read regularly and am happy with that. I enjoy mentoring and want to keep getting better. I like seeing the forest for the trees, when I remember to do so. I constantly remind myself to prune down the priorities to ONE THING and use Pomodoro technique to manage my time. And who couldn’t use a dose of mindfulness through the day? 

 

I have a terrible memory for names, so as I meet new people, or continue to struggle with names, I write them here. My cheat sheet. And then I track the talks that I have given and the ones I’m thinking about and planning.

 

And… here’s the mess. The daily meetings, the jotted notes, Anything that I want to highlight gets an accent color. My to do list also gets a checkbox and sometimes a color highlight. My direct reports get a dedicated page or two to improve my continuity of notes. 

 

When you cut up your own stickies, you need a supply on the back page to draw from when you’re away from your creative desk. 

 

And then, if I take my book on trips, I’ll find time to sit and sketch. Ideally I do the sketching on-site, but sometime (like this), I sketch from a photograph, shown on my phone, propped up, by lamplight, just before bed. I find sketching to be relaxing, all-absorbing, focus. I know I’m not good. 

The only point of showing you, is to say, spend an hour, don’t self-judge, and see what art you can churn out. Do it when you can, and you might surprise yourself. I do sometimes. 

 

Here’s the Seattle Public Library, a feat of architecture and engineering and art. And my poor attempt to recreate a corner of it. 

OTHER IDEAS. at times in the past I’ve written THREE GOOD THINGS as a daily reflection. Think of three things you’re grateful for from that day, that your action may have helped. That lasted about a week. Pretty cool. 

I’ve tried a daily sketch. That lasted about a week. 

I’ve tried “One thing I learned today.”

In short, there is no end of interesting things you can scribble in a book. 

My preference is for paper with no lines so I can sketch something anytime. Others like lines, or like a grid. I LOOOOVVEE going to stationary stores to buy pens, new moleskin books, stickers, tape. 

Finally, I try to avoid taking notes on my laptop or phone, as doing so is indistinguishable (by others) as drifting away, not being present, doing some other work when you could be paying attention. Another reason, is that research shows that when others in an audience can see your screen, NOT ONLY is your screen decreasing your comprehension of the lecture/session, it is decreasing the comprehension (increased distraction) for EVERYONE WHO CAN SEE YOUR SCREEN, even if they can’t see it clearly.

I know, electronic note take allows “search” and “indexing”, and also that there are Rocketbooks and other hybrid devices, but I have not tried them as yet. 

Finally, I do love the tactile nature of paper, the expressive personality of handwriting, the ease of drawing lines and sketches to link ideas, and also know that handwritten notes INCREASE COMPREHENSION compared to electronic notes. Go figure. 

CMIO’s take: Make your black book anything you like. And then when you inevitably run out of pages to draw, sticker, jot, doodle in, get a new book and try a different design, a different strategy. My sister tells me that “All start-up CEO’s carry a black book, and consult it. It’s where all their good ideas come from.” What do you do for creativity, note taking, tracking? Do you like it? 

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