Category: PIG-let (informatics newbies)

Image prompt for Bing/DallE: a doctor, a nurse, a pharmacist, an IT guy work together to improve the lives of doctors who are using computers with patients, optimistic, impressionistic, colorful

Our EMO committee (electronic med-alert optimization) is looking to slash medication alerts dramatically. We asked our pharmacists to look at the current alert settings on “lactation warnings” (which of these medications should not be taken during breast-feeding) and weigh in on which could be turned off. For example, we had a number of obstetrics/gynecology professors tell us that “amoxicillin is safe during breastfeeding, please turn of this alert, it is not accurate.”

First of all, EMO: coolest committee name ever.

Secondly: how hard can this be?

When we gave this and similar requests to our clinical pharmacists, they were wary of removing ANY alerts.

“Yes amoxicillin is low risk, but it is not ZERO risk. We should still show this alert. Besides, I don’t want to be responsible if a patient someday has a problem with amoxicillin during breast-feeding and I said it was ok to remove this alert.” –anonymous pharmacist

This statement is clinically accurate, risk-averse, and operationally paralyzing.

Clinically accurate: Yes, every alert is based on actual patient experience, including rare events

Risk-averse: if we have a tool to show risk, we should show ALL risk. Right?

Operationally paralyzing: Show ALL alerts? We would drown. Or we start ignoring them.

Here is a thought experiment.

On one side, place a pharmacist whose only responsibility is to avoid ANY medication side effects that have been described in the literature. In the extreme view, almost no medications would be prescribed, or at least the prescriber would have to read numerous descriptions of potential high, medium and lower risk interactions and alerts. This would certainly minimize medication risk. Or at least, as designers of the EHR, it would not be OUR FAULT since we showed ALL the alerts and the prescriber was warned!

On the other side, place a physician/prescriber ordering medications to treat patient conditions. This prescriber is burdened with seeing patients quickly and to take reasonable precautions. Consider that every medication alert, especially those with “medium to low risk” is a nuisance and a cognitive burden and contributes to burnout. In the extreme view, almost no alerts are helpful. Turn them all off.

How might be reconcile these opposite viewpoints in a productive conversation?

PRINCIPLE: Disconnect the fear of blame from leadership responsibility.

One way to address the pharmacist’s concerns of being individually blamed for decisions about alerts is to develop committee consensus. Let a group of prescribers, pharmacists and operational leaders consider and agree on reasonable settings for these alerts. If an alert is “overridden” 95% of the time by prescribers, then it is being ignored. As a governing body, we agree to eliminate all alerts with more than 90% override so that prescribers are more likely to pay attention to future alerts. It is much more difficult to attack a leadership consensus decision than an individual’s decision.

PRINCIPLE: What are the conflicting and balancing metrics in this decision?

Bring multiple viewpoints to committee discussion. One-dimensional decisions “we need to show ALL the alerts” versus “We need to show the alerts for EVERY med” are impractical when the decision affects multiple roles differently.

PRINCIPLE: Overall, how might we do the right thing for the patient?

Keeping the principle of “Do the right thing for the patient” can help clarify thinking. Lets say we present ALL the alerts. As a result, prescribers stop paying attention to all alerts and even critical alerts are now ignored. This is also not safe for the patient.

LESSON LEARNED

Using these principles, make some reasonable decisions. Stop being paralyzed with opposing points of view. Choose a reasonable path.

The Reasonable Path can feel scary! In the back of all of our heads, we worry about the lawsuit for the rare side effect or interaction that was actually listed on the package insert on page 27.

To find the reasonable path, use committee consensus to resolve a difficult decision.

Angry individuals with pitchforks and torches will have a much harder time attacking a thoughtful committee of diverse experts compared to attacking any single individual’s decision.

In this case, our EMO committee is formed of representatives from medicine, nursing, pharmacy, and information technology. The principles are clearly discussed, the viewpoints are respectfully debated. A leader helps develop a consensus or a well-informed decision. EMO has developed an energy and purpose and has achieve remarkable results, dismantling noisy, unhelpful alerts and improving the signal-to-noise ratio of others. Lets go disrupt the status quo. Lets go ruffle some feathers!

TRY THIS YOURSELF

What components of your committees are effective and less effective? What will you do about it?

One of my colleagues recounted a story of failing to get an informatics committee approval for a BPA (interruptive best practice alert).

Here is the problem:

Occasionally, a patient will be admitted to hospital already wearing a medication patch. During hospital admission, we pay a lot of attention to the pills the patient is already taking and reconcile them with the new treatments and medications we need for the patient’s acute illness. However, it is easy to overlook any medication patches a patient is already wearing when they arrive.

Some recent examples:

a patient admitted with a blood clot in the leg (DVT) was wearing an estrogen patch that we neglected to remove (estrogen may have contributed to the clot). A patient admitted for pain control with a PCA (patient-controlled analgesia IV pain medication pump) was still wearing a fentanyl patch (absorbing conflicting pain medication through their skin). A patient admitted for blood pressure control was still wearing their clonidine patch that could interact with other medications.

Sometimes the nurse is too busy to remember to examine the patient for these tiny, nearly invisible patches. Sometimes the nurse finds one, but it is difficult to remember which doctor or clinical team is taking care of the patient. Often it is difficult to know where to write down that you found a medication patch, and then what to do about it.

My colleague determined to make this improvement: make it easy to remember to scan the patient for medication patches, document them quickly and then contact the treating doctor or team to request an order to remove or continue the medication patch.

Here are the technical pieces:

1. Add a flowsheet item on the admission navigator: Medication patch found on body: yes/no.

2. IF YES then BPA: EZ secure chat button to right clinician to order med or discontinue.

3. This change was requested and approved by Project JOY: RN click reduction program.

My colleague attended our CDS (clinical decision support) governance meeting. The proposal was rejected by the clinical leaders at the meeting, who argued: “RN’s don’t need another BPA. Go back and check with RN leadership and find another way.”

What went wrong?

It is always helpful to find a colleague to commiserate after a failed proposal and deconstruct what happened. Here are some ideas:

START WITH WHY.

Lay the groundwork vividly so that decision-makers see clearly how big a problem this is (medication error causing patient harm). It is possible my colleague was not as forceful as needed laying out WHY this is important. Have the committee feel the pressure, the anxiety, the discomfort of not doing the best we can for our patients. ONLY THEN offer your solution. NEVER come with a proposal emphasing the clever tool you built without STARTING WITH WHY.

For example, feel the difference between:

“I have an idea for an alert to make it easier for nurses to contact doctors about med patches on admission to hospital.”

Versus

“We make medication errors almost every day related to medication patches that we miss when a patient is being admitted to hospital. To make things worse, it is hard for a nurse who discovers a patch to do the right thing. Nurse leaders asked me to design something that would help.”

BRING YOUR ARMY.

If you have already obtained nursing leadership support, say so, and repeat it. If the leadership of the people who will be interrupted by your tool (interruptive BPA alert in this case) agree that this is a good idea, THEN SAY SO. You have an army backing your request. The worst BPA requests are from individual clinicians or researchers who want to interrupt OTHER people for their personal reasons (eg a cardiologist wanting all primary care docs and nurses to ask patients how many minutes they exercise per week, “because it is a good idea”. Committee response: sure, only if you get approval from all primary care leaders that they find this idea valuable. Ultimately, request denied). It is possible the CDS leaders did not understand that nursing leadership approval was already granted.

MOCK IT UP.

Make the change visible and easy to understand. You have to dance a line. Ideally, you would work with an analyst to build the actual proposed change in the non-live environment in the EHR to show how it works. However, this is a lot of work for something that may not get approved, or may have extensive revisions requested. Instead, build something in powerpoint, that requires much less effort and can still show “what it will look like when working.” This gives decision-makers an easy visual and reduces misunderstanding. And, it is easy to change if adjustments are requested. Without a visual, decision-makers may misinterpret that your request is “not serious” and “You’ve not put enough thought into the process. Come back when your idea is more mature.”

ASK FOR IMPROVEMENT, NOT APPROVAL

In this case, if you already have clinical leadership approval for your tool, be clear what you’re asking from this committee. “I need your help improving my design. Do you have a better idea?” rather than “What do you think, may I build this thing?” It will change the tone of the conversation, if you are able to do it.

PUSH FOR CONDITIONAL APPROVAL WITHOUT COMING BACK

Sometimes the committee will say “well, this fine, except for this one question we have that you can’t answer today.” If it is something you are confident you can get answered, ask for conditional approval. “If we find out the answer is A, we will build X. If we find out the answer is B, we will build Y. If it something else entirely, we will come back to discuss. If it is A or B, do we have your approval to complete this project?” Very often the answer can be yes and you cut time off of your project without having to come back to argue for approval again next month.

The Lesson Learned

Start with WHY. Bring your ARMY. Make a PowerPoint MOCKUP. Ask for IMPROVEMENT. Push for CONDITIONAL approval to avoid delay.

Try This Yourself

Try these techniques. Yes, CT Lin has created a forest of impenetrable committees to keep the EHR from becoming a “junk drawer” of everyone’s favorite pet projects. On the other hand, good ideas should not go to committee to die.

Use these techniques. Make “doing the right thing” easy.

Or maybe it is CT Lin’s fault. He’s the one who ruined healthcare anyway. He probably did this too. Moreover, his very poor use of Bing.com’s Copilot for drawing images results in the hilarious examples in this post.

You’re an expert! What could go wrong?

Let’s say you’re a physician informaticist. You’ve spent years training in your clinical specialty. Maybe you’re even a subspecialist, like a pulmonologist. That’s TWO boards that you’re certified in. Then, because you KNOW that clinical informatics is the way of the future in medicine, you also train and then board certify in Clinical Informatics. You ARE the doc of the future! Treating patients, teaching colleagues, designing templates and tools to make the right thing easy, to provide outstanding patient care, not only for yourself, but also for your entire clinic, your specialty, maybe your entire organization of 4000 providers.

Whew!

And yet, there are days like this.

Today is a Friday, and you’re staring at the clock. With a sinking feeling, you’re waiting for a busy clinician to deliver to you all the clinical specifications for a new SmartSet for template orders to make it easy to order the right pulmonary function test or inhaled steroid. Or, you’re waiting to design a brand new version of a progress note that has “disappearing help text” that guides clinicians on writing a concise, precisely-worded note that meets all the quality metrics, is easily understood by patients and colleagues, and points the way to high-quality care of a specific disease, say, asthma.

The project was SO PROMISING. This would improve care of asthma patients, reduce unnecessary variation because of the just-in-time nudges you’d construct, increase use of inhaled steroids and increase the fraction of asthma patients with an up-to-date PFT.

You had promised to build the tool so that it could be in use by Monday of next week. You had set aside all of this Friday afternoon to review the subject matter, design some options, consider teamwork and workflow, and then with your ten magic fingers on your magic keyboard, make something amazing come to life. You are a physician builder, and a master of both clinical medicine and the palette of informatics technical tools.

BUT you are staring at the clock at 3pm on Friday,

and no email or document from your subject matter expert has yet arrived. You can’t even get started.

The department chair is waiting to see if you will deliver what you promised. Your reputation is on the line. In fact, because of cutbacks, they’re considering reducing your informatics protected time to work on projects like this because “we just need more bodies to see more patients and generate revenue. We are in the red.”

How did we get here?  

I am surprised at how often a version of this story comes up, in my mentor/mentee conversations. Has this happened to you? A better question: how often has this happened to you?

PAUSE HERE. What would you do about this situation? Write it down or say it out loud to yourself before reading on. How do you compare?

What did you do about it? Multiple choice:

1. Go work somewhere else
2. Pick up the phone and YELL: “YOUR LACK OF PLANNING IS NOT MY EMERGENCY!!!” There. Feel better? Unfortunately, you just made the problem worse.
3. Send an ALL CAPS text or secure chat to vent your unhappiness
4. Feel guilty that you’re not doing a good job even though it’s not your fault
5. Mumble something about this to your mentor

When you’re done venting, stomping your feet, and popping more omeprazole to treat your enlarging stomach ulcer, let’s live the dream and design a future where this happens less often. After all, you can’t completely extinguish it. Like a zombie, this behavior always comes back to life somehow.

Some of the following ideas are good general principles. Others you pull out in extreme cases of non-cooperation. Choose carefully.

  —–

Try this: Start with Why, seek the Win-win

We are all working too hard. Your work colleague is probably balancing several top priorities. If they believe YOU are nice, maybe they’ll work on your project last and do some other critical work. How to change their mind or their priorities?

We sometimes forget to talk about WHY when requesting work.

Stop, and provide the WHY. What is the impact to the patient? To the organization? To you? To them (WIIFM: What’s in it for me)? One of these is sure to resonate with your work colleague. If none of these resonate, then perhaps you seek a different colleague in the future. Seek a win-win arrangement. When you work together on this, what will be the result? Will life be better for both of you? Try your best not to make this a win/lose proposition (e.g. You lose because you volunteer a lot of work for no recognition, and then I win when I build this fun tool). Providing the why and making the effort to be on the same page costs NOTHING and be EVERYTHING to the success of what you’re trying to do.

Try this: Anticipatory Guidance: Precision AND consequences

Your email or in-person request. If you plan to work on this on Friday afternoon, don’t say “Can you get this to me on Friday?” to which your colleague will be happy to start on this at end of day Friday and get it to you in the evening. You spend all day thinking you’ll receive something in the morning, but then get mad when the email arrives very very late, in your perception.

Instead say: “I need the statistics and the specific order details by end of day Thursday March 24^th.” Better yet, the Subject line of your email reads: “ACTION NEEDED: need all proposed elements by 5pm Thursday 3/24.” Your email is slightly less likely to be missed or ignored. And if they DO ignore it and deliver late, hold to your consequences. “Then, it will not be built. I have other deadlines and I will have moved on to other projects.” It may feel terrible both to you and to your colleague that time. If you are serious about the consequences, your colleague will learn this about working with you. Or if you are not serious, they will learn this about working with you. Either way, your behavior shapes the relationship. 

Try this: Align incentives, apply transparency

In a multi-person project, ensure that the project sponsor knows who is doing what, with which deadlines. Ideally, your work colleague for whom you depend on content also directly serves the same boss. Unfortunately, this is often not the case “I don’t care, she’s not the boss of me.” In these situations, you have to apply creativity: can you rely on your personal relationship to this person? Can you get your colleague’s actual boss to care? Can you trade something your colleague really wants for something you want? “If you deliver on time, then I will fix your template the way you always wanted.”

Try this: Set mile markers and leading indicators

For a multi-week project, set a regular meeting time, even if it is 10 minutes at 8am once a week. Set mini-deadlines (mile-markers) for each person each week, and the entire effort seems more manageable to everyone.  And, you get a warning if someone is NOT on track.

Try this: Design for the minimum viable product

Projects tend to spiral bigger during design meetings. “Oh, I know! I’d like it to be painted blue on one side! And, then it should have a disco ball spinning overhead!” Instead, you should be looking for the MVP: minimum viable product. What is the absolute minimum set of functions this thing needs to be immediately useful? “Once we deliver and use the MVP, then we can come back and add your ‘disco ball.’ How would that be?” Then, you’ve got a smaller set of requirements, and better chance that your colleague will finish their requirements.

CMIO’s take? Take your ulcer-generating, teeth-grinding interactions and go upstream to design any future interactions. Anticipate. Be precise. Set consequences and back them up. Seek win-win, Start with Why. Align incentives. Set mile markers. Design for MVP. Yes, these are platitudes, but as per the stories above, they also work.

We continue to evolve our Information Blocking / Sharing and Immediate Test Result Anticipatory Guidance (that’s a mouthful).

In case this is useful to other health systems working on similar projects, we believe that teaching our docs and providers about Anticipatory Guidance (shifting the counseling of patients about test results upstream to the time of ordering a test) is the best for everyone: less anxiety for patients, and fewer phone calls and messages for clinic staff.

See the screenshot above for staff and also provider guidance.

From a recent presentation about immediate release of results, some slides that might help.

And, here are the patient-facing and provider-facing 1-pagers in both PDF and WORD versions.

1-pager for doctors/providers (.PDF and .docx)

https://www.dropbox.com/scl/fi/kvbmgv2gbwk24meib9y9j/2024-04-InfoBlockingSharing-1-pager.pdf?rlkey=oxlsqza17bk2l33gnat71v3eu&dl=0

https://www.dropbox.com/scl/fi/fj67mir2za8lh4t6aaunn/2024-04-InfoBlockingSharing-1-pager.docx?rlkey=hx2s2x43alin2q4ih92p6xsu6&dl=0

1-pager for patients (.PDF and .docx)

https://www.dropbox.com/scl/fi/2ivo3b3vyleyt43xh35hc/2024-04-For-Patients-Getting-a-Test-at-UCHealth.pdf?rlkey=kn2xqqsnac8zz4b6g0ntz9r0j&dl=0

https://www.dropbox.com/scl/fi/eubtflr6rq77bxqbztjmv/2024-04-For-Patients-Getting-a-Test-at-UCHealth.docx?rlkey=ybobhdnl2cwmqzj4zh7tqubfe&dl=0

I hope these are helpful. Let me know if you develop something similar or better! A rising tide raises all boats.

Generative AI response to
“a physician informaticist caught between a rock and a hard place”

The scenario:

YOU are a physician informaticist. You are board certified in informatics, you are an effective physician builder, and enjoy an excellent relationship with your department chair and clinical colleagues. You have protected time to this work. You have excellent IT analyst colleagues who will collaborate and help get your projects over the finish line so that they’ll be used. You have built scoring tools, you have built smartforms to better capture clinical findings, you have built analytics reports that clearly demonstrate that you have improved the care of the patients in your clinics.

AND YET. Your organization is part of a large health system with byzantine socio-political dynamics. You have multiple bosses, and each boss has very different ideas on what you should and should not work on, and they don’t like each other. Projects that you initiate and introduce to your leaders disappear from view, only to resurface later as some one else’s idea.

A project that you were not initially involved with is now YOUR problem. Some project team built a Best Practice Alert that interrupts all the doctors, and no one is happy: it doesn’t have the right information to help with decision-making, the doctors are bypassing it, the intervention is not working, but HEY. YOU’RE the expert on workflow, so can you help us? Tonight? We need to fix this tonight.

Disrespect. Misunderstanding.

Why don’t they keep you involved on projects you initiated? Why don’t they involve you earlier on projects where you have expertise? Despite your best efforts to describe your dilemma, it seems your bosses don’t really get you and aren’t listening.

And, you have made accommodations for quite a while. Maybe it’s okay, maybe it will be better next time. Maybe you’ll finally get be publicly recognized. Oh, not this year? Okay, maybe next year.

A rant from a colleague

What if you heard this from a colleague? What would you do?
Multiple choice:

• Say “Goodbye!” Run for the hills and don’t talk to your colleague any more
• Say “Time to LEAVE, my friend. Freshen up your CV and get on the road.”
• Say “I’m sorry to hear this. That must be difficult.”
• Nod your head sagely and stay silent, and hope they feel the empathy waves coming off you and start brainstorming their own solution
• Jump right in a do the male/female Mars/Venus conflict thing and try to SOLVE THEIR PROBLEM without being asked to. (Have you seen the youtube video “It’s not about the nail?” Hilarious. And, I see myself. If you HAVE NOT seen it, go there, and then come right back)

Reader, I have used all of these responses in my long and confusing career. What a disappointment I have been to my mentees and colleagues.

The parallel universe

This time, though, in a recent conversation, I went a different way. This is something I vaguely learned during a leadership exercise, I’m not sure to whom to attribute this.

Given the scenario above, I said instead: Here is a task for next time we chat.

Take a time machine 2 years into the future. You have made some choices, advanced your career, and now you can’t WAIT to talk about the amazing things you’re working on.

How did you get here?

This task will take 2 hours.

Set aside some time. Get a bunch of blank pieces of paper, some color pens, sticky notes, scissors, glue, whatever you have to be creative. TURN OFF your laptop, phone, notifications. No interruptions. No electronics. No one around to judge you.

Your mindset: Blue sky thinking. Post-cards from your future. Turn off your editor brain that says “You can’t do that.” Everything is possible.

Be outrageous. Make a mess. This is your time.

Task 1: Quantity not quality. Fill an entire page with ideas of what you might be doing in 2 years. If you fill it, keep going.
* One column of ideas are “Redesigning my current role”.
* One column is “Stay in my current field but make a big leap”.
* One column says “NO limits. BUT, I cannot stay in my current field”
Fill the page. Most of the ideas will be terrible. Keep going. Dedicate at least 30 minutes to this. Your brain is not permitted to edit or cross out.

Task 2: Highlight the ideas that appeal to you in all 3 columns. Pick a few from each column and write a few sentences filling out the idea, just enough to develop some feelings around it. Does it excite you? Surprise you?  Disgust you? Bore you? Scribble some notes. Spend at least 30 minutes on this.

Task 3: Get up. Go outside for a walk. Think purposefully about NOTHING. You have just prompted your brain to jump out of its rut and be open to completely new directions. Don’t listen to music or an audio-book or podcast. Be silent with your thoughts. Let your mind wander. At least 30 minutes. Some would even argue that you should sleep on it and conduct task 4 tomorrow. This is to allow system 2, your subconscious and non-directed brain to explore.

Task 4: Were there more ideas to scribble down? Pick your favorite idea from columns 1, 2 and 3 and write a page about each one. Scenarios you see yourself in. Things you are working on in each parallel universe. Projects you’ve accomplished. The joys of that work. Draw a picture. Use scissors and glue to build an artifact. Envision yourself in that role. Feel it. Close your eyes and look around in that world. Spend at least 30 minutes.

As you conclude your time, look at your 3 papers. One of them speaks more to you than the others. In one of them your inner child rejoices. In one of them, your energetic younger self cannot wait to get going. What is it?

Your handwriting sucks

At the least, it can be fun to see: a) how badly your handwriting has degenerated as we handwrite less, and express more thoughts by typing or speech-to-text, b) what it feels like to be in kindergarten again, scribbling, coloring, drawing, c) see how your right-brain creativity can take some time to come out of hiding.

Who knows? There might be something really useful or interesting there. Is it time to act? If not right now, should we remind ourselves to do this exercise again in a year?

This is an exercise in lateral thinking. This is a way of jumping your brain out of the usual well-worn cobblestone paths with deeply-grooved ruts from horse and oxen-drawn carts rumbling along them for millenia. Sometimes going “off-road” can spark an insight.

CMIO’s take? What did you come up with? Are there fragments of these dreams that you can put into action now? Where did this journey take you? Take a picture, send it to me! Let me see!

Image above: From Dall-E via BING chat

To: patients and informatics colleagues out there:

Here is your problem of the day. Physicians and APP’s who order ultrasound tests for “screening for liver cancer” for example, have a difficult time understanding the LI-RADS categories that radiologists put into the radiology reports.

Brilliant! Our always-helpful radiology colleague recently began inserting the following just-in-time education intended for the physicians and APP’s receiving these reports:

Super! Everyone is happy. Physicians have a much better understanding of the interpretation of the report AND there is a helpful index at the bottom of same report explaining the LI-RADS category and also the Visualization score, and some sense of what to do next.

What could go wrong?

This was turned on about a year ago. A few weeks ago, one of my patients, who has full access to her EHR Patient Portal, and this immediate access to her ultrasound report, called me in a panic: “My ultrasound shows that I have POSITIVE – Observation Detected. Doesn’t that mean I have cancer? It says right here!” Fortunately, we had an upcoming in-person appointment and I asked her to bring the printout so we could discuss it.

I looked at the printout she brought in. Indeed, she had a benign appearing ultrasound report. What she was reading was the very bottom of the report that included the index of LI-RADS categories.

I then explained that this part of the report was only a reference tool for doctors and did not apply to her. After about 10 minutes of discussion, she seemed to understand, and then gave me a stern look: “This is very confusing. Why are you doing it this way?”

I took this feedback and sent it back to our well-meaning radiology colleagues, that our patients were now misunderstanding the LI-RADS explanation text intended for our physicians, and over-interpreting it to apply to themselves.

My radiology colleagues responded with the following addition in BLUE:

What do you think? Is it helpful? Is it enough?

In all of our radiology reports, that we have been sending to patients immediately for a couple years now, we have standard text that reads:

If you are a provider with questions, you can call Radiology Help Line at xxx-xxx-xxxx. If you are a patient with questions, please contact your ordering provider to discuss.

We do have an occasional patient who DOES call the Radiology Help Line, and in those rare cases, our radiologists are happy to have that discussion with patients, and patients are satisfied with those discussions.

The addition of the help text for LI-RADs is written about the patient in the 3rd person “the patient”, as opposed to the quotation above, which is written for the patient in the second person “you.

CMIO’s take? For now, the help text on LI-RADS is what our reports have included. We have had no more patient complaints registered.

What do our informatics colleagues and online patient communities think of our approach? Do you have a suggestion on how to make it better? We want our radiology reports to be a WIN-WIN: more easily interpreted by both our ordering physicians/APP’s as well as by our patients.

https://www.dropbox.com/s/y2449iiq8xles9m/2023-06%20Info%20Blocking%20Immediate%20Results%20Release%20White%20Paper%20SBAR.pdf?dl=0

The general idea of information sharing between a clinic / hospital / physician/APP and their patients seems like “Mom and Apple Pie”. However, the devil is in the details. How do we approach this at UCHealth?

We do have over 2 decades of discussion on these topics, and these are now distilled for you. I’ve published earlier versions of this document (search info blocking on my blog and you’ll get them).

I was prompted by hospital leadership, as we rebuilt our “physician/APP onboarding” education plan, on how to explain Open Notes and Open Results to our newest providers. I thought of including our latest document from 2020 (wow, that is 6 internet generations ago!), but there were lots of outdated statements.

CMIO’s take? Here you go! My up-to-date version of Information Blocking / Sharing / Open Notes, Open Results introductory document for our newest colleagues at UCHealth; feel free to share amongst yourselves. If you make improvements, please let me know! We’re always looking to improve.

from Bing / Dall-E image generator

Opportunity: Opt out of alerts?

We have a new tool from our EHR vendor to allow physicians/APP’s to “opt out” of future similar interruptive alerts about medications.

For example: “Magnesium in IV for pregnant patient” or
“Ibuprofen interaction with __ drug”

Previously, our physicians/APP’s would either take action (cancel the prescription) or override the alert and state that benefit outweighs risk, EVERY TIME.

Now, our colleagues can FILTER or SUPPRESS these warnings specifically or categorically. As an informatics working group, we have some choices on how to configure this.

Won’t you come along and be a back-seat driver for our conversation?

Q1: Shall we turn this on at all?

I mean, we are doing SUCH A GOOD JOB ALREADY (we are top/worst quartile in “overridden alerts” by our users, among our EHR vendor customers).

A: Yes, we are going to turn this on.

Q2: The pop-up alert allows the prescriber to choose:

Filter for ALL patients or Filter for THIS patient. When we suppress this alert, shall we turn it off FOREVER? Or bring it back every 6 months? Or longer, or shorter? On the one hand, we should respect physician decisions, right? And never show it again? On the other hand, who knows how fast that physician is moving when selecting to “suppress everything — I hate all of you.”

A: Well… after debate, we will leave it at 6 months. Not too burdensome to ask a prescriber twice a year whether they still want this to be filtered. That is 363 days a year we stop asking. And, intermittent re-inforcement is more sustained learning (showing alerts sometimes prompts better retention than every-time alerts that become noise and aggravation).

Q3: What about that choice for THIS patient?

Should the alert be suppressed FOREVER if a prescriber chooses THIS patient? Obviously, the incremental benefit to the prescriber is tiny (I have thousands of patients, so if I choose THIS PATIENT ONLY, I MUST have thought about THIS patient in more detail and we should honor that choice with a FOREVER suppression). For example, “ibuprofen in hypertension” alert. Perhaps THIS patient has tried dozens of other treatments and the ONLY help for migraines is ibuprofen, and yes, I know it affects hypertension, and the risk is worth it. Why remind me again? And, because the benefit is small to the prescriber, the THIS PATIENT setting should be infrequently used, and ONLY with thought.

A: We are investigating if we can make THIS PATIENT suppression setting different from the ALL PATIENT suppression setting.

Q4: What if there are particularly HIGH RISK drug interactions?

Can/should we remove the ability to suppress those interactions? How paternalistic should we be?  EG: Paxlovid and lovastatin: can we allow this to be suppressed?

A: TBD. We are unsure of the granularity of the tools, and we will investigate this further. This will end up being a consensus decision of our committee, backed up by proposing these major decisions to our clinical leaders for approval. It is always a good idea for operational committees like EMO (comprised of practicing clinicians / informaticists / pharmacists / IT analysts / clinical nurse informaticists) to work together to build consensus. Many of these decisions are NOT slam-dunk, as you are starting to see.

Q5:  There is an option to “require a reason” to suppress.

What shall we put there? Should we give several “best guess” reasons, for example:

• Low risk interaction: benefit exceeds risk
• My literature review disagrees with this alert
• Only show this to students and residents. I am an expert
• This is stupid, remove this for everyone (GROSS: Getting Rid of Stupid Stuff)

A: Although the last option is a real project (look it up: GROSS is a clever and memorable acronym invented by other informaticists), this is too many choices. We went with ONE choice “Clinical Judgement – Suppress for 6 months”, because A) No one wants to spend more time on this alert, there will not be much signal here to detect, and B) Suppress for 6 months RESPECTS THE USER by telling them what to expect, and when this will re-appear, to reduce the frustration of “I thought I got rid of this.”

from Bing / Dall-E image generator

Q6: Shall we require a narrative explanation after the choice “Clinical Judgement” override?

Maybe they’ll tell us something useful that we did not expect!

A: NO. NO. NO. In the past, our required clinical fields have often been perceived as Nuisance. Requiring completion results in answers like: “.” and ”  “, or even “jkljlkj”. The least number of keystrokes to make the stop sign go away. Or it results in hate mail “This is stupid. You are stupid. ” Burned out physicians/APP’s can easily pass the burnout to our IT and informatics team members. Leaving it optional leads to better signal/noise and more thoughtful comments from the rare commenter.

Q7: Whose job is it to review these exceptions and comments? And how often shall we review?

A: We plan to bring these exceptions back to the EMO committee to look at, perhaps 1 to 2 times year and see if it is performing as expected. Also, if we can spot patterns of the most ‘overridden’ alerts, we can look at removing the alert completely, looking to reduce our need for overrides in the first place.

Q8: Shall we give a choice called GROSS (get rid of stupid stuff) in the suppression reasons?

Why don’t we leverage the wisdom of the crowd to finding the lowest value alerts?

A: Unfortunately, doing so may empower our “go fast” physician/APP phenotype: “I hate all alerts, so I’ll choose the one least likely to show up again”. We worry about these “over-suppressers” who over-estimate their ability to catch important interactions and defeat the systematic protection of the EHR. We do NOT plan to offer GROSS as a choice, but instead will look at “Clinical Judgement” frequency (if a LOT of prescribers choose to suppress, there is signal there, don’t rely on individual prescribers to accurately choose GROSS). A subtle point, but there you go.

Q9: Who do we report these decisions to?

Shall we announce it in the newsletter? Shall we get approval from our busy CMO (chief medical officer) council?

A: Machiavelli teaches us, whenever you make a bad change, do it all at once. Whenever you make a good change (this is a good change; ability to suppress alerts customized to the individual prescriber), TAKE CREDIT FOR EACH CHANGE SEPARATELY. Yes, we will announce this in the newsletter as a separate news item every time there is an improvement. As for authority, we have agreed with our CMO’s to bring, on a quarterly frequency, a summary of the changes the EMO committee is making, to ensure they are overseeing the changes. This will come as an FYI, no decisions necessary, as we have established trust that we are not making crazy decisions, based on past presentations this year.

CMIO’s take? This is a taste of the discussion and decision-making at EMO. Maybe you have an interesting or different take on this informatics work? Let me know!