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

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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?

Let’s start at the top. Having read Steal Like an Artist (Kleon), I love the idea of separating my desk into a CREATIVE desk (no computer or devices, just glue, pencils, pens, stickies, shapes, yellow pads) and then a PUBLISHING desk when the creating is done (PC, smartphone, printer, etc), I have a stash of kindergarden-grade stuff I like to play with. It helps me think. So, I covered my staid black book with stickies.
So, I’m still a kid. I don’t care if you judge me. 

 

 

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? 

Tips on Mentorship (a conversation)

The PAC mentor program

I recently had the chance to sit down with David Bar-Shain MD, of MetroHealth, who single-handedly started the a mentorship program in the PAC (Physician Advisory Council), hosted at Epic in Verona Wisconsin.

The program has been running for 4 years now and has matched over 70 mentor-mentee pairs, over 170 people involved, supporting young physician and APP informaticists by matching them with mid- and late-career informaticists (and some who serve as both mentee and mentor!).

We recently had a chance at the Epic 2022 User Group Meeting to sit and chat about the fundamentals of mentorship, and what I find interesting and fun about being a mentor.

What did we talk about?

  • The importance of having more than one mentor
  • Mutual curiosity: telling our own journeys
  • Who sets the agenda for our meeting?
  • War stories and are they appropriate?
  • 1-pagers
  • Storytelling
  • 80:20 rule of informatics: socio-political vs technical skill
  • Book club and leadership
  • Learning from outside of healthcare
  • Mentorship is about asking open ended questions
  • 3 psychological principles that apply to therapy as well as mentorship
  • Rowing downstream, not upstream
  • Advocacy, offering connections from your network
  • Peer mentorship
  • Blind spotting
  • Validation and encouragement
  • Lateral thinking
  • The Failure Resume

Here’s the audio-only interview (33 minutes).

CMIO’s take? Let us know what you think! From YOUR experience as a mentor or mentee, what have YOU learned?

Where do you keep the (informatics) pixie dust? (borrowed from NYTimes)

This is hilarious: angsty flowcharts to help guide readers. Must-read article.

Fawzy Taylor, social media and marketing manager of the bookstore: A Room of One’s Own, Madison, WI, via NYtimes “These Memes Make Books More Fun”

Thank you to Fawzy Taylor, whose brainchild this is. Fantastic in so many ways.

Why can’t we build our informatics and our internal education this way? For example, for newbie informaticists, how about my book-recs graphic above, based on the same idea?

CMIO’s take? What do you think of the graphic? of the style? of the content? Guess what? It doesn’t matter, if it gets us talking!

This video about storytelling will change your life

I have followed Andy Goodman’s work (he teaches storytelling to nonprofit organizations), and have learned so much about how to be effective at my own work.

It is nearly an hour long, and who has an hour? You do, if you know what is good for you.

But, I know you’re busy, so, if nothing else, watch at 10:30 minutes for 7 minutes. It will be the best 7 minutes.

Then, since you’ll be hooked by then, watch the whole thing. You won’t regret it.

No one ever made a decision because of a number. They need a story.

Daniel Kahneman, in Thinking, Fast and Slow

CMIO’s take? Storytelling by masters like this change lives. He did mine.

What TikTok teaches us about effective communication

Those of us stuck in the “last century” take heed: TikTok and 15 to 60 second videos are IN.

 

My Tiktok channel: https://www.tiktok.com/@ctlin99

The TL;DR? 15 seconds should be the length of your educational videos. Wanna know why? and how? read on.

I was a Late adopter of Facebook

I’ve been thinking about the evolution of social media. In early days, I was a late adopter of Facebook, not getting why it was any better than email. Now, I get it: saying something once allows your network to see it, from close friends, to casual acquaintances. Medical residents explained to me that photos and memories were easier to share more broadly. AND, an existing large network made participation more valuable (hey! look at all the people I already know on here!).

Just like in the old days, getting a telephone was INCREASINGLY useful if there were MORE people and stores you could call. The network effect.

LinkedIn, Twitter

That led me over the years to LinkedIn (mostly for work contacts and posting my CV and work products publicly) and Twitter (still figuring it out, but a good way to keep up with news if you curate your network carefully, and also a way to post blog content). Also, Twitter allows you to curate for yourself an international community with similar interests, like #medtwitter.

And, my brilliant younger sister taught me that Twitter could also be good for lecture commentary and discussion (she will give a talk on 2 screens: one with her slides and another with a live pre-filtered Twitter feed: how brave! and give out a custom hashtag, like #postitpearls_lecture, and ask the audience to submit questions this way: wow).

YouTube

And, some of you know that I’ve dabbled in amateur song-parodies with EHR songs on my youtube channel.

IFTTT, blogging

Finally, I’ve figured out how to blog regularly and then use IFTTT to cross-post my content auto-magically to my other platforms (Facebook page, Twitter, LinkedIn) so that I can seem more connected and omni-present than I really am (Thanks for another great tip, Sis).

Tiktok?

BUT! TikTok is another thing altogether. My colleague and her daughter suggested that I take my latest Hamilton parody song (that I had gamely posted to YouTube and here I am shamelessly showing it to you again)

#notthrowinawaymyshot and now post it on TikTok, a post-millenial social media platform restricted to 60 second videos. Leaving aside the recent kerfuffle about Chinese ownership and control, this is qualitatively a different animal: getting your thoughts across in 15 seconds (preferred duration, and the time restriction being a result of the music industry’s maximum replay length of a copyrighted song). It has since been extended to 60 second maximum if you have an original soundtrack on your video.

So, I dove in. Unlike my “dozens” of views on my YouTube channel (with which I was satisfied; my broadcast domain is, admittedly to a relatively small physician informatics audience), my TikToks quickly blossomed to nearly 1000 views in 2 days.

Wow! I thought. I am AMAZING on TikTok.

What I did not appreciate is the 15 to 60 second format is much more attuned to the rapid “swipe” of post-millenials, and EVERYONE racks up lots of views. And, ultra-short videos are so easy to consume one after the other. AND, TikTok doesn’t need you to establish your network before your video gets out there; it shows your video to a random selection of viewers, and then those who LIKE it or SUBSCRIBE to you trigger the algorithm to show it to more viewers. So, an easy way to game the system is to use trending (but highly inaccurate) hashtags, like #superbowl, etc. Sadly, this user does not seem to have understood, or be willing to follow, some of these informal rules.

Furthermore, if you read online chatter about TikTok views “500 views total, is pretty sad; what you want is 500 views per hour.” For example, Nathan Evans, of Sea Shanty fame? He went viral at about 250,000 views, and now he’s at 12.9 million. Oh, well. Here’s my paltry Covid Sea Shanty, currently at 62 views (not 62,000) and SIX LIKES.

In contrast, our Informatics team at UCHealth just retired/deleted a 17-minute video I made a 10 years ago for a full “walkthrough” of how to use the Electronic Health Record for our ambulatory clinic physicians. Whew, how out of touch was THIS guy? Here’s a one minute snippet of the kind of video I posted back then, when we were on Allscripts Touchworks. So young, so naive.

Our more recent training videos are more like 1-2 minutes and focused on ONE technique or tool. Now, I’m thinking, maybe we need to shoot for 15-30 seconds. The cool thing about TikToks is that you can trim seconds, speed things up, because those viewers who “get it” can be done watching in 15 seconds, but the video can be paused and also it automatically replays so the viewer can catch subtle details. Hmm, is this a paradigm shift? Should we embed TikTok length education videos into our EHR?

Put Road Signs On the Roadway

As we say internally, shouldn’t we put the Road Signs and Driving Directions (our tips and tricks) on the Roadway (where our users are actually using the EHR) and not in the Garage (our online reference library and training webinars)? Aren’t our users more likely to click on tips WHEN they’re doing work, rather than when “oh, I have some time, let me see what I can go learn.” (which is never)

Austin Chang is my hero

There clearly is an entire evolution of thinking needed to succeed in this TikTok medium. And I don’t have the savvy (yet), the luck, or the persistence to grind out the many tries needed to break through. However, there are medical professionals who have. For example, Austin Chang.

Austin is … well, just go watch him. In 15 seconds, with hilarious music over-dubs, he uses captions and terrible dancing while in scrubs (ok not so terrible), to get his medical facts out there.

I both bemoan the general public’s deterioration of attention span (15 seconds now? Really?) and his ability to fit his tiny education bites (bytes?) into this format. It works. Some of his TikToks are over 2 million views. On MEDICAL TOPICS. Nice. Here’s the NYTimes writing about him.

This reminds me of reading The Shallows, a book about what the Internet is doing to our brains. Are we losing the ability to read a book? I don’t know. I, for one, did not finish reading the book. Ironic.

CMIO’s take: Beat ’em or Join ’em? What are YOU doing about TikTok in your field?

My Failure Resumé (a talk)

What lessons can we learn from CT Lin’s failures?

 

Thanks to the Colorado Chapter of HIMSS (Health Information Management Systems Society) and to Bonnie Roberts and Rich Morris for co-hosting my presentation.

Based on my recent Failure Resumé 1 pager. Here are some personal stories, life lessons, and 3 exercises to help you build a failure-tolerant future.

With, of course, a bonus ukulele song at the end.

CMIO’s take: Have you written a failure resumé? Are you building a failure tolerant future? Let me know in the comments.

INFORMATICS: Put the road signs on the road, not in the garage

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.

NOW

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?