“E in EHR does not stand for Fax” — Steve Hess, CIO

I constantly enjoy the creativity of my colleagues. In this case, Steve Hess, our CIO at UCHealth, made this statement during a discussion about our fax-server software linked to our EHR. As our organization has grown, we have added hundreds of clinics, and now we’re approaching a dozen hospitals in our network, all on a single instance of an EHR.

Consequently, our communication and IT architecture is primarily based on within-EHR communications, the so-called Inbasket. However, we often communicate with healthcare entities (insurance companies, out-of-network clinics and hospitals, skilled nursing and rehab facilities, etc). To force others to use our EHR’s inbasket is unrealistic.

So, even in this 21st century, the lowest common denominator for communication between healthcare entities is … FAX. Our organization faxes millions (yes, MILLIONS) of virtual sheets of paper each month, a veritable blizzard of paper. Furthermore, our faxing volume now is bumping against our licensing limit, and Steve, very rightly, is pushing back against any increase in our faxing capability, and this is where he notes:

“The E in EHR does NOT stand for Fax.”

Which is hilarious. And sad at the same time. Where is our national interoperability? Haven’t we been working toward electronic seamless communication for over a decade as we furiously install EHR’s in every clinic, every ER, every hospital? Yes, and nothing is ever that easy.

So, thinking through our fax problem, several things became clear:

  1. Faxing STILL is the lowest common denominator. If our clinic notes and other messages to other clinicians MUST go through, fax is still the best most reliable method. Who wants to go back to stamps and envelopes? (let’s not talk about mailing test results to patients, as we still do that for some patients: don’t get me started)
  2. For all clinics and hospitals willing to use our web-based secure portal, what we call “Provider Connection”, we can set our communication strategy to send e-messages through that portal. Independent clinics and hospitals who are closely affiliated with use, do use this, and this works well.
  3. For all clinics and hospitals (independent of us) who use their own licensed version of the Epic EHR, we are gradually learning to turn on between-organization messaging, and these e-messages will gradually replace fax. This is getting going.
  4. For all clinics and hospitals on our instance of our EHR, we should be sending ALL notes and messages electronically through EHR e-messaging to our respective inbaskets.
  5. For all clinics that have connected to CORHIO (the Colorado Regional Health Information Organization and other Health Information Exchanges cannot get up to speed fast enough for us) we should be able to turn off our point-to-point communications like Fax because we deliver all notes and results from our EHR to CORHIO’s exchange, which then can deliver results to ANY EHR in the state.
  6. There are still hundreds of organizations out there who use a non-Epic EHR with no capacity for electronic interconnection to CORHIO, or who still use NO EHR. Then, these clinics only have ONE method to send or receive all these incoming messages: FAX. Sad.

Here is where we run into some surprises. Turns out, not ALL of our clinicians in our OWN ORGANIZATION have agreed to use e-messaging and still rely on Fax. What? Old habits die hard. It turns out, while our attention was elsewhere, some of our clinicians and clinic managers were able to convince someone in the IT organization to alter the setting for delivery of test results and referral letters from e-messages BACK TO FAX. On the one hand, I can see a reason why. Some clinicians are used to having the sound of the fax and the presence of paper in the fax-received tray as their TO DO task list, and never “got into email” (really?!). Some clinicians work at multiple healthcare organizations and do not want to check the inbasket of their general email, and the inbasket of the EHR for hospital 1, and the inbasket of the EHR for hospital 2, etc. I could see this being a huge hassle, where ONE fax machine could be the single TO DO list. SO, THIS PROMPTS SOME ACTIONS on our part:

  • All employed clinicians at UCHealth MUST use e-messaging. We will embark on a clean-up of our internal process. Why install an EHR and then let people continue to fax within our organization? It is like buying a Porsche and then cutting out the floorboards and pushing with our feet like Fred Flintstone.
  • Re-examine every affiliate clinic and hospital and figure out how to switch as many communications from fax to e-messaging with Provider Connection. In some cases, like the clinician with multiple hospitals, such a switch might dramatically worsen their clinical work, and we would make exceptions there.
  • Push on CORHIO and other HIE’s to improve between-organization messaging and link our EHR to their systems to make such messaging seamless.
  • Accelerate our investigation of Epic EHR interconnect messaging so that we can send/receive messages from other organizations that also use Epic.
  • Consider a drop-dead date (like “killer app”, this is a terrible term in healthcare) when we might say: “Fax is dead. In order to receive clinical messages from us, you must use Epic EHR or Provider Connection.” I think we’re not quite there yet.

CMIO’s take? Quotable quips are easy to say, and make us feel ridiculous sometimes. But then you have to take a hard look at yourself, and your organization, and the state of healthcare technology, and decide what to do. Do you have a similar story? Let me know.

Happy holidays from the Large PIGs, JIG, and CMIO

Dave Corry arriving late to our group photo, to the CMIO’s amusement and dismay

I hope that you are making plans to celebrate the season, to connect with friends, colleagues, family, and take time for yourself.

I consider myself so fortunate to work with such a great group of informaticists or informaticians (inforMAGICIANs?!), or informatics people, whatever we call ourselves. The work we do, sometimes seems like a grind, but keep in mind, fellow informagicians, that we strive to improve the lives of patients, colleagues and staff by improving the information systems we use for the greater good. 

We try to keep it light in our naming of projects and committees. For example, our Joint Informatics Group (including clinical informatics nurses as well as physician informatics) is JIG. Our physician informatics group are the PIGs. This leads to the New PIG book club, the Small PIG leadership group, and the meeting, which encompasses all physician informaticists: Large PIG. 

And, be sure to throw up your hands and have a good laugh once in awhile. By the way, here’s an updated picture with Dave raising a glass. 

CMIO’s take? Here’s to you and the good work we all do. Cheers!

CT meditates: a comedy (25) Merry Christmas- Holiday- Kwanzaa. And Zen Shorts!

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Merry Christmas! Happy Holidays! Care-filled Kwanzaa! Happy Buddha!

A book I gave to my physician and clinical informatics teams this year is ‘Zen Shorts.’ This is a terrific children’s book with wonderful watercolors. You don’t have to be a child or a Zen master to appreciate it. However the stories it tells are deceptively entertaining. Think about a little longer and it becomes a life lesson. Read this; you won’t regret it.

Take time to be mindful and grateful today. I hope you have a quiet, restful, joyful day.

CT meditates: a comedy (23) pomodoro timer

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So, maybe some of you have read this far. Thank you for coming along! One of the threads of mindfulness and meditation is developing Focus. So maybe you’ve now blocked out 2 or even 4 hours of your day to dive deeply. But once you’re here, cleared your desk, turned off your Internet, laid out your pen and paper and resources, and you find your mind wandering off. Darn! Three minutes, breathe, OK, focused again. Oh! Wandering off again! Just remembered things I have to do!

So, for those of you struggling with focus, consider the Pomodoro Timer. There’s lots to read online, and now I guess there’s a book and maybe courses to take. In short, a tomato kitchen timer is set for 25 minutes. That is short enough to trick your brain into staying on track and long enough to get something concrete done. Then there is a 5 minute break, and back at it. Four timers and then a longer break. You can then do this all day. Over time you get better at predicting what you can accomplish in 25 minutes, and then how many segments of 25 minutes it will take to do something. Then you’re less frustrated at the end of day as you get better at predicting how much can be done.

Furthermore, the quiet, insistent, calming tick of the time reminds you to stay on task. There are more tricks, like having a pad of paper handy to write down any ideas that spring to mind, to distract. Writing it down allows you to let it go and return to task.

Try it. I think you’ll like it. You can buy a IRL pomodoro timer from the store. I downloaded an app called Focus Keeper that I really like. Works for me.

From the Book of Joy pg 56: Richard Davidson, neuroscientist tells us that there are four  independent brain circuits that influence our lasting well-being.
1. Our ability to maintain positive states
2. Our ability to recover from negative states
3. Our ability to focus and avoid mind-wandering
4. Our ability to be generous

So, at least one way to well-being is a tomato timer!

Remember: those coming on the journey: 3 minutes of meditation every day! I’m holding both of us accountable to this important habit!

CMIO’s take? Pomodoro Timer is one of my secret weapons.

Keep your eyes on your goal, not your obstacle

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Post-call

Some years ago, I was a post-call intern at UC Davis Medical Center. I had been up for about 30 hours in a row, but was hoping to get out for a quick bike ride on the American River bike trail in downtown Sacramento, near where I lived. I called up a fellow intern, and headed out for a quick training ride on a lovely bike trail by the river.

I was proud of myself for getting out, getting some exercise, connecting with a friend, even though I was post-call. In those heady days, I often followed the bike racing events like the Tour de France. My friend and I were learning to “paceline” or draft off each other as we rode through the early afternoon glades.

The lawn

On our way back, there was a large lawn in between two bike paths, one that goes up to the bridge toward home, and one that continues underneath the bridge, heading towards downtown Sacramento. Due to a miscommunication, I nearly tangled with my riding partner, and swerving slightly to miss him, ended up splitting the difference of both paths and riding into the smooth green lawn.

No, problem, you say?

The trash can

I immediately spotted a trash can about 30 yards away, sitting by itself, no obstructions around it on this nice green lawn. I was headed straight for it, at about 20 miles per hour, a good clip.

My post-call brain went into emergency mode. My eyes locked on the obstruction as it grew rapidly larger, my hands locked onto the brakes, and I began to skid across the grass.

It became clear that I was slowing down, but not enough to miss the trash can. Now, keep in mind that the trash can was about 3 feet wide, in a large grassy lawn that is about 1/2 acre in size, and no other hazards nearby. I was making a beeline for the can.

The next thing I notice is that the trash can is starting to elevate into the air. Up … up … up; I puzzled over this for some moments until I realized that I was GOING OVER THE HANDLEBARS. This resulted in a flipping movement, my bike tumbling gently to one side, unscratched, and I

Clang

… did a complete flip, landed on my back, knocked the wind out of myself, and my cycling-shoe’d feet CLANGED violently against the empty green monster.

I lay there, chagrined. Maybe post-call and hence cognitively-impaired, high speed pace-lining wasn’t the best idea.

Furthermore, my friend comes over, holds me on the ground to stabilize my neck (he had just learned about cervical spine precautions in his ER rotation that month) and says: “Don’t move! I’ll call 911!” In a fit of inconsiderate and impaired judgement, I swiveled my neck, looked up at him and said, “Nah, I feel fine.” He yells: “I can’t believe you just cleared your own C-spine!” After some recriminations and an apology on my part, we rode home.

Don’t look at the obstacle

This is just a long winded way of saying that our brains work in mysterious ways. You will very likely  hit what you’re looking at. SO DON’T LOOK AT YOUR OBSTACLES. LOOK AT THE CLEAR PATH AHEAD. On subsequent bike rides, some across very technical terrain strewn with boulders and sand traps, this really worked.

In my years of practice, this is one of my favorite personal stories I use as a cautionary tale to my patients. Don’t think about how bad smoking is, think of how you’re going to feel great when you haven’t smoked for a week. Don’t think about your weight, think about how good exercise feels when you get home. Don’t think about the difficult conversation you just had; think about the ideas to craft a win-win outcome from your next discussion. My patients always get a chuckle out of my personal failures.

CMIO’s take? A lesson from cycling: I can still see that trash can. Sure, acknowledge your obstacles, but don’t stare at them. There’s a path. Stare at that. Your body and mind will help you steer you through.

Review: Houston, We Have a Narrative: Why Science Needs Story

Houston, We Have a Narrative: Why Science Needs Story
Houston, We Have a Narrative: Why Science Needs Story by Randy Olson

My rating: 5 of 5 stars

So many scientists and doctors I know are terrific at science, and SO impressively smart. Kudos to their years of training, discipline, self-sacrifice. And yet … many (perhaps most) have no idea how to tell a story. In fact, “telling stories” is often construed as lying, or at the very least, being unscientific, and not “evidence-based.”

It is a terrible tragedy, therefore, as the Internet echo chamber relentlessly promotes those who can write a tagline, a teaser, a STORY (autism and vaccines, anyone?), and those scientists and researchers with deep knowledge and expertise, have no effective training to fight back, and are drowned out in the hue and cry.

Michaelangelo said: “I saw the angel in the marble, and I carved until I set him free.”

Reminiscent of the great artist, this book laid out 3 techniques to help me see the narrative inside our lengthy, cluttered, many-faceted, detail-oriented scientific pursuits. This book was written by a dissatisfied, tenured Marine Biologist, who quit his job to go be a screenwriter in Hollywood. Screenwriters, he says, are the “working class storytellers of our age.”

CMIO’s take: I thoroughly enjoyed and devoured this book, and now, like the ageless Hero described by Joseph Campbell, and with the aid of such books as this, I will face my personal limitations, and transform myself in order to face and overcome my challenges.

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Review: The One Thing: The Surprisingly Simple Truth Behind Extraordinary Results

The One Thing: The Surprisingly Simple Truth Behind Extraordinary Results
The One Thing: The Surprisingly Simple Truth Behind Extraordinary Results by Gary Keller

My rating: 5 of 5 stars

So, is it realistic to clear 4 hours of your work day EVERY DAY to work on your ONE THING? Yes, I agree, not going to happen, even if Gary Keller tells you to. However, it is inspiring to read about new ways of working, new ways of structuring the day, the week, the month, to think about focus. Given the 17 priorities I’m working on now, and my many colleagues with highly variant concerns and demands, I completely understand where this book comes from and its audacious goal.

I also know, from my recent work on APSO notes (inverting the SOAP progress note written by doctors, to place the Assessment and Plan at the top of the note, for easier reading and understanding by all), and making this change (highly resisted, because IT’S DIFFERENT AND UNFAMILIAR) throughout the 3000 doctors at our hospital system, that this was my primary focus for years, until it was achieved as a universal standard. Focus does have its benefits. When I look back on my career, it is NOT the hundreds of smaller projects, or the hundreds of thousands of emails I crafted or responded to, it is not the ‘crucial conversations’ I had with individual docs and patients that maybe moved their beliefs and attitudes very slightly. Instead, I look back at BIG projects that were HARD, and where we accomplished something as a team, as an organization.

CMIO’s take: In hindsight, it was the unintentional “One Thing” attitude that put these projects over the top. Perhaps I could learn from my past, of the projects never reaching fruition, and the few that did, and allow the “One Thing” more of an influence in what I do. Highly recommended as a book.

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Review: Steal Like an Artist: 10 Things Nobody Told You About Being Creative

Steal Like an Artist: 10 Things Nobody Told You About Being Creative
Steal Like an Artist: 10 Things Nobody Told You About Being Creative by Austin Kleon
My rating: 5 of 5 stars

This is a fun read. If you’re human, you are creative. This book gives you permission to open your arms, in big scribbled words, to something new, and not let your frontal cortex shut it down as “stupid, anyway.”

Austin unlocks the fun hidden deeply in your teenaged soul, suppressed by years of schooling and working. If you have 10 dollars and a free hour, read this book. Such an easy way to get a new perspective on creativity, enjoyment, and life. As a CMIO, my take is: many folks at my work desperately need to read this book.

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