CMIO teahouse menu

How can tea improve clinical decision support? How does it help change organizations? Are you kidding?

Links to some of these teas:

CMIO’s take? Those of you who have worked with me know that one of my favorite things is to have 1:1 meetings in my office and serve tea. Taking inspiration from my spouse who enjoys throwing cocktail parties and creating a fanciful drink menu, I recently put together a CMIO’s teahouse menu. I hope you enjoy it.

“The useful part of a pot is where there is no pot” -Audrey Tang, Digital Minister of Taiwan

Hollowed out
clay makes a pot.
Where the pot’s not
Is where its useful.

Poem 11

Thirty spokes
meet in a hub.
Where the wheel isn’t
Is where it is useful.

Hollowed out
clay makes a pot.
Where the pot’s not
Is where its useful.

Cut doors and windows
to make a room.
Where the room isn’t,
there room for you.

So the profit in what is
is in the use of what isn’t.

Taken from Ursula LeGuin’s version of the Tao Te Ching

https://www.wired.com/video/watch/wired25-2020-audrey-tang-taiwan-covid-19-pandemic

Watch this video/ read the transcript. I love this for several reasons:

  • The Taiwanese are my people
  • “Digital Minister” is the best title of all time
  • Taiwan’s national response to COVID is a model for the world (Taiwan: fewer than 1 death per 100,000 vs USA: 66 deaths per 100,000)
  • The transparency of information and the building of trust: the government published its COVID and mask data with open API’s so private industry and nonprofits could build 100’s of apps to improve healthcare and the commonwealth
  • The POETRY of Taoism!

CMIO’s take? It is worth a watch. Informatics applied effectively at the national level. And, bonus: mindful Taoist philosophy applied to transparency of information. Zowie!

Epic EHR webinar with UCHealth: Inbasket Re-invention: did we really delete 12 million messages?

Yes. Yes, we did.

https://userweb.epic.com/Webinar/View/7968/Taming-the-In-Basket-with-UCHealth-Teaching-an-Old-Dog-New-T/

Are you and your organization struggling with:

  • How to tackle the hyperobject that is the EHR inbasket?
  • Does your legal/compliance team worry that deleting messages is bad idea?
  • Do you have users with tens of thousands of unread inbasket messages?
  • Are you having trouble getting starting on this ambiguous, massive effort?
  • Would you like to know some of the specific settings and decisions we made?
  • Are you concerned that it is difficult to measure improvement with inbasket?
  • Are you eager to see CT Lin and team fail at yet another ambitious but ill-fated project?

If so, you =might= find some answers in our recorded discussion above.

We touch on: leadership, governance, organizational change, legal concerns, specific Epic EHR inbasket settings and decisions, clinician burnout, high-performing teamwork, and human connection. Really.

Note: Hosted by Epic. Login to Epic Userweb required. Go watch it, then come back and tell me what you REALLY think.

Here’s your moment of zen – cactus images from Arizona

Here is the “burr in my sock” or “pebble in my shoe” that bad EHR design can become. In another context, this is can be beautiful.

Found this in my sock in the middle of my hike.

The only way to hike in Tucson in the fall is starting at 630am and being done before 9am.

CMIO’s take? Be present, get outside, take a breath.

Is the EHR Inbasket a Hyperobject? And what are you going to do about it?

Inbasket Hyperobject: hard to grasp, even harder to cut down in size.

https://www.wired.com/story/timothy-morton-hyperobjects-all-the-way-down/

This is a mind-blowing read. What is a hyper-object? It is a somewhat disturbing concept of something bigger than an object, something that transcends our understanding as a human. The concept’s inventor, Morton, defines it as: “phenomena too vast or fundamentally weird for humans to wrap their minds around.”

Okay. What?

Consider examples like “all the plastic in the world” or “climate change” or “a black hole” or “massive oil spills.”

Science fiction author Jeff VanderMeer has said “hyperobject” neatly describes the bizarre alien phenomenon he wrote about in Annihilation, his surreal novel turned 2018 movie.

Annihilation: Southern Reach Trilogy, Book 1 | Books, Novels, Audio books
from Jeff Vandermeer

OK, now that’s disturbing, as I read the book and felt chills during a summer evening. That guy can write. This is as close to a jump-scare that I’ve ever had, reading a book. Even had to put it down for awhile to calm down.  =shiver=

Now, I’m thinking: the Epic electronic health record’s INBASKET is a hyperobject.

EHR Inbasket as Hyperobject?

Now, we’re talking. Something that is weird, difficult for humans to grasp, and alas, vast. To the uninitiated, the Epic EHR inbasket is a message center where much of our internal communication takes place: incoming phone calls from patients can be sent to inbasket for nurses, docs, assistants to help manage the request; incoming patient portal messages come here; prescription renewals from pharmacies, from patients; consultation reports from specialists, hospital discharge summaries; notifications that “you did not finish writing this note for this patient visit”; test results from blood tests, radiology studies, biopsy reports; nurse-doctor communications; provider-provider communications. Lots of things.

And, for our busy clinicians, some inbaskets have dozens, hundreds, and sometimes THOUSANDS of unread messages that can be weeks, months, YEARS old. Yikes.

Hyperobject.

Solving the Rubik’s (hyper)cube?

First, improve teamwork, huddles

Ok, but that is a future post. Aside from the idea that we need to improve our internal teamwork and fundamentally redesign how we use our internal tools, there are some simple changes we can start with.

Time to cut our hyperobject down to size. We know that incoming inbasket messages from patients has tripled (see previous post). We know that our healthcare professionals are suffering from burnout (see previous post). We (I) have been guilty of delivering automated messages to our docs that we originally thought were helpful. Maybe it is time for a re-think.

Our plan to re-size our Hyperobject:

  • Pick a date (in December 2021), a one time PURGE of all messages 6 months or older in our Inbaskets. This is 7 million messages. Seriously. Rationale: If the provider hasn’t handled this by now, either the patient has called or messaged again (a more recent message), already come for a visit, or perhaps even left the practice to go elsewhere; there is NO VALUE in keeping these.
  • In December, begin a 90-day expiration clock on all new incoming messages. If you haven’t addressed a concern or responded or read a message by 3 months, it will disappear. Yes, there are theoretical risks of deleting reminders to complete a task or respond to a patient. But, here we are in mid November; is it still relevant that a patient called for advice in August, before school started? Also it is theoretically possible that a provider will stop someday and spend a weekend reading and replying to thousands of messages, but this is not likely at all. We are aware of some inbaskets with messages that number in the thousands. Yes, we are not proud of it. Our current setting where we NEVER delete old messages, I consider a personal failure of bad EHR design and configuration on my part. Behold: the man who ruined healthcare. :(. But, we’ll fix it now.
  • We are discontinuing the delivery of automatic CC (carbon-copy) messages from consulting specialists back to the referring provider and PCP (primary care provider). In 2011, CT Lin and his merry band thought we were doing everyone a favor by CRUSHING the BLACK HOLE (a DIFFERENT HYPEROBJECT!) of the University docs who never remembered to send a consultation letter back to the referring doc. “Hey, we sent you a patient for this clinical question, and WE NEVER HEARD BACK FROM YOU.” We created a technical solution to AUTOMATICALLY send a specialist’s clinic note back to the referring doc AND the primary care doc (if different). In the beginning, this was a great idea! However, this rule now sends several HUNDRED THOUSAND messages a year to our 6000 internal and innumerable community providers. I am personally burying my colleagues. Asking one of my full time internal medicine colleagues, he tells me “I receive about 100 to 150 auto-CC notes per week. Every couple of weeks I take a Saturday and read through 200-300 messages of which about 5 are useful to me. But I can’t NOT read them, what if I miss something?” What an excellent, OCD (obsessive compulsive) physician. But also the way to burn out on patient care. You work 40-60 hours a week and then spend evenings and weekends “catching up” on the blizzard of messages and tasks in the EHR. We need to do Today’s work Today. By the way, specialists can always manually send an important note back to the referring doc or PCP “hey, calling your attention to this” with a single click. And, our specialists ALREADY do this, so I often receive the automated note AND a manually sent note for specific concerns.

Thus, I feel pretty good about stopping the automation. How often do you read that sentence from a CMIO?

Clearly insane CMIO

To be clear, we have “internal” providers who use our Epic EHR and can look up the consultant specialist’s notes the next time they see the patient. These are the folks who will benefit. ON THE OTHER HAND, we have “external” providers in our communities who do NOT have access to our Epic EHR, they use a different EHR or perhaps are still using paper: We plan to continue to eFax or otherwise deliver these notes UNCHANGED. Thus, still addressing the community need for information and stopping the internal clogging of our own pipes.

Whew! That was a lot more long-winded than I intended, but this is a big deal, a big movement, that has already generated a lot of heat, a lot of concern about “why are you moving my cheese?” So far, in our internal provider discussions, we are hearing 90% support and 10% anxiety from our colleagues. We plan on moving forward and creating innovative solutions for those who do not see this as an improvement.

CMIO’s take? Hang on everybody. This Inbasket Hyperobject is getting resized. We have lots more plans for reducing the burden of inbasket messaging, this is just phase 1 of 4 major phases to come. Stay tuned!

The pandemic, patient messages and phone calls: Octopus or Starfish?

Here we are 19+ months into the pandemic. Time to look at our (unvalidated) trends within our 12 hospital, 1000 clinic health system in Colorado.

Top (blue) line indicates outpatient visit volume monthly from Sept 2019 through Sept 2021. Over 2 years, we saw that dramatic dip in volume in March. That was followed by a gradual recovery and a 10% sustained increase in volume since then. We have added some clinics to our system in the meantime.

Magenta line indicates online messages. We started at 58,000 monthly messages in September 2019, and have sustained 180,000 messages in the most recent 3 months of 2021, a 3 fold increase in patient messaging. OK to ignore that weird peak in Mar 2021, related to a one time system broadcast. This is a real concern for provider workload.

Orange: Surprisingly, we also see an increase in telephone messages (triage-type phone calls): from 23,000 to 35,000, a 1.5 x increase. This means that online messages have NOT replaced phone calls since the onset of the pandemic. This could be related to the growth in percentage of our patients who now have a portal account (growth from 70% to 85% of our patients enrolled in a portal account, over 1.6 million accounts), as well as existing portal-using patients sending more requests and messages, wanting to avoid in-person visits.

Red: Additionally, Scheduled Phone Calls (non-existent prior to pandemic) are now at 5000 monthly messages, and

Green: video (virtual) visits went from nearly zero, up to a peak of 70,000 a month, then stabilizing at 23,000 monthly.

It is an interesting, evolving picture. We have not formally changed staffing or workflow to accommodate this change in message and visit volume, and it has resulted in a massive increase in inbasket messages for providers and staff, with concerns of an unmanageable burden and real risks of burnout for providers and clinical staff.

We believe that, at its root, patients want care, are more anxious about their health during a pandemic, want to avoid in-person visits, have learned about our online tools, and are unclear as to the best way to interact with us.

We could: improve our “front door” experience “Here is how best to contact and work with us”. We could improve our triaging of incoming messages to find the right location/time/place (online message, eVisit by messaging, online chat, scheduled phone call, virtual visit, urgent care, emergency department, other innovative approach).

We could ensure our teams know the best practice for: handling patient questions, prescription renewals, referral requests, outreach programs, remote monitoring, when to suggest video or phone visits, huddling in-person to replace unending back-and-forth messaging.

OCTOPUS

As a result, we are kicking off a major Inbasket redesign initiative. Although our inbasket settings were carefully considered and modified over the years since 2011 (our original Epic go live) with careful feedback from our physicians and informaticists, we still have opportunities:

Inbasket TECHNICAL changes:

  • Eliminating “messages > 12 months old”
  • Reducing the “FYI” and not-actionable messages
  • Auto-deleting some categories of messages after some period of time
  • Creating smartphrase responses to improve thoughtful responses to team mates and to patients
  • Streamlining the ‘response buttons’

Inbasket WORKFLOW changes:

  • Creating best-practice teamwork for “top of license” work
  • Considering innovation tools to “auto-reply” to common questions
  • Moving complex conversations away from portal messages to scheduled phone calls, virtual visits, in-person visits, urgent care as appropriate
  • Considering billing for complex portal messages with patient consent

Just like with Physician Burnout and Wellness in general, there is plenty of work for everyone in Inbasket improvement: there are at least 8 arms to this octopus. Even if we can just “hack off” some of the arms (hmm, perhaps not the best metaphor for healthcare), we can certainly reshape the octopus into something more manageable (a starfish?).

STARFISH

CMIO’s take? Is your inbasket an octopus or starfish, or some other marine animal entirely? It is time for a wholesale re-imagining of our messaging and communications with patients and with each other. What are you and your teams doing in this area? Let me know.

Oxygen masks, John Hodgman, and a hotdog?

This was a good week. Like many of my medical colleagues who are plowing through our next surge of Covid patients, we have feelings of exhaustion, angst and sadness, or as one of my Twitter colleagues on #medtwitter calls it, a new emotion called ‘emptysad.’ So apt.

So it was great to get out of the house, and learn to occasionally ‘put my own oxygen mask on before assisting others’, as our airline colleagues would say. Today, I’d go for a 35 mile loop around Denver. Come along on my visual travelogue!

There’s lots of construction on the Highline canal, the Sand Creek trail, and the Cherry Creek path. I can’t wait to see what turns out. Meantime, we have detours upon detours. Here’s one near Northfield, an expanse of wild sunflowers illuminating the margins of I-70.

This is a 3.5 hour loop for me. The great thing is: very little bike or foot traffic even on a holiday weekend. The smoke is less noticeable today, the sky is blue, the Colorado zephyr winds still cool through the day.

Then, the Confluence of Sand Creek and Platte River, both the wild fowl that frequent the area, and also the industrial ‘aromas’ of Commerce City and the Purina Puppy Chow plant. Such a juxtaposition.

Then it’s a quick dash upstream along the Platte, to Confluence Park, where Cherry Creek meets the Platte. Here, see the crowds for REI and the splashy mess of shore that is kid and dog and kayak friendly.

The hot dog stand is reliably yummy.

On the way home, I found my informatics and physician colleague Steve Rotholz at his outdoor photography booth at the Cherry Creek Arts Festival. Further surprise: he’s reading our book club book for the month: You Look Like a Thing And I Love You. A great explanation of AI and the weirdness that ensues in the development of these tools.

On the quieter parts of the trail, I listen to my current audio book: Vacationland, by John Hodgman, read by the author. I have loved his previous stories on The Daily Show and on public radio. He doesn’t disappoint in this autobiography.

I hope you’re finding ways to have a restorative summer. Go out and do something you love.

How to Get Things Done When You Don’t Want to Do Anything (NYTimes)

How to Get Things Done When You Don’t Want to Do Anything – The New York Times (nytimes.com)

from nytimes.com, George Wylesol, article by Cameron Walker

This spoke to me. Maybe it speaks to you. This pairs well with another recent NYT article by Adam Grant on Languishing:

by Manshen Lo, NYTimes, article by Adam Grant

Feeling Blah During the Pandemic? It’s Called Languishing – The New York Times (nytimes.com)

It is okay to forgive ourselves this feeling, that we’re not 100% on our game, that we’re not giving 110%.

CMIO’s take? I’m taking more breaks, connecting more with friends outside work, disconnecting from work tasks more, finding small, enjoyable things, reading more books for fun. How about you?

The Narrows at Zion Canyon: a visual travelogue

In November of 2020, my son and I toured the Southwest US. One of our stops was at Zion Canyon National Park, where we were excited to experience the Narrows. It seemed a great way to escape the pandemic and get away. Spend a few minutes on the journey with us!

Driving, we arrived late in the day at Zion lodge, in darkness. We saw this improbable sight outside our cabin in the morning: canyon walls rising thousands of feet overhead, just outside our door.

We had rented dry suits from Zion Adventures, and laid out our clothing that evening for the hike ahead. In case you’re wondering about the hyperlinks, no this is not a paid post. Just a joyful recollection of an aging parent…

Double boot liners, grippy-soled rubberized river boots, an impervious suit with rubber-gasketed pants and sleeves, and a huge diagonal waterproof zipper across the chest. Hard to wrangle but exciting! We felt like spacemen. We wore several clothing layers underneath.

Normally the Narrows is a super-popular hike through the spring, summer and fall. We had thought that with the pandemic and with wintry November weather, we would have no trouble booking a shuttle ride from the Lodge in the park up to the entrance of the Narrows, 3 miles away. Suffice it to say, plan ahead. Fortunately, we found a last-minute shuttle option with seats remaining. Whew, disaster averted. Otherwise, the lodge had offered us “bikes to rent and ride up there, suits and all.” That would have been more adventure than I needed.

We walked the paved path for the 1st mile. Giddy and nervous, we passed a number of casual hikers who stared at our gear, our dry suits, our 6-foot wooden walking poles, our backpacks. Here, with the residual heat deep in the canyon, the last remnant of fall colors contrasted with the snowscapes outside the park.

And then: the pavement ends. Into the stream! I can feel the cold water sloshing around inside the boot. Hey! my feet stay dry! I don’t care about splashing because I’m sealed in up to my neck, and my backpack has a dry sack inside with food and water. The cyanobacteria poisoning warnings do not deter us. Upstream we went.

Did I mention the incredible geology? We feel puny in its presence.

I was surprised at the grip of these rubber soled river boots. Crunching upstream over large and small rocks was easier than expected. Where was all the slipperiness, the unstable rocks, the twisted ankles? The equipment smoothed that away. I grinned at my son; this was a blast. The water depth was up to a foot and the going was not hard. The current ran a couple of miles an hour.

As we saw fewer hikers, the enormity of the cavern became apparent. At one point, it appeared that the walls were maybe 3 football fields tall, 1000-feet-high sheer walls of stone. These walls plunged right down into the river with no shore or beach to speak of.

From there the river got deeper and faster. In about an hour and a half we arrived at the fork to observation point on the right, with photographers set up to catch the changing light in the canyon. Then we took the left fork to “Wall Street,” presumably named for the impressive sheer walls narrowing in.

At times, the water rises to the hips. Some hikers with only waterproof pants turn back. One couple raised their jackets, exposing bare midriffs to keep their clothes dry, and gamely walked through the first deep crossing. That must have been cold, with the water at 40 degrees. It is sunny, but also snowing.

At a rock outcropping, we paused for lunch. We find a few larger boulders, unpack and have our bagels. Suddenly ravenous, we savor the calories, noticing snowflakes drifting down 1000 feet into the canyon. The light is peculiar: in shadow, with sunlight bathing the Canyon just around the curve, blue sky overhead. It looks like indoor light because of all the bounce and reflection.

This is our turn around point. We rest, recharge, hear the stream burble, feel the snowflakes, our hunger sated, snug in our dry suits, we smell the fall giving way to winter.

It feels – cold, but I’m sweating from effort. The canyon appears unforgiving, but we have supplies and equipment up to the task. Flash floods and cyanobacteria poisoning are a risk, but we have mitigated them. Unlike more extreme adventure-seeking adrenaline junkies, this is the degree of risk and adventure I’m ready for.

It is time to head back. Downstream, like downhill, would be quicker. My main concern was balancing Seeing with Photography.

There is the disappointing idea that the more photos one takes, the less the brain experiences. Or maybe not. Yes, there’s more to show off when you get home, but were you really present? Or did you just line up and frame the shot? But, if you don’t take photos, how interesting is your blog post later? #FirstWorldProbs.

I tried to do both. Who knows.

Downstream was a pleasant splash. Yes, it was 1.5 times easier and slightly faster. There was little resistance to swinging the shins through the water as it flowed with you.

There are great speedway-sized curves to this river, as the millennia of water microscopically carry away molecules of rock every day. The views are magnificent.

It is a hike that promotes mindfulness. Your focus is required for not-stumbling, for pushing upstream, for awakening your senses. The constant, echoed river babble precludes idle chatter.

It is: exploration, sightseeing, photography, companionship, escape, reflection, effort, appreciation for dry-suit and photographic technology, wonder, mindfulness, pure sensation, focus, curiosity, pride of offspring, joy. All at once. Each in turn.

We emerge from the river, dripping and yet perfectly dry. We make our shuttle home.

A perfect day.