What is a Yottabyte, and How Do You Treat It? (a talk)

I gave a keynote speech late last year at Technology Awareness Day, hosted by the University of Colorado, Anschutz Medical Campus about Big Data, Tech acceleration, and Artificial Intelligence, as applied to healthcare.

I enjoy making my colleagues uncomfortable. How long will doctors have jobs? Will the AI eliminate internal medicine doctors? If Watson can beat humans at Jeopardy, can it beat me at reading medical literature? Can it be dermatologists at diagnosing skin cancer? Can it beat radiologists at interpreting CT scan images?

It is true that the most complex object known to us is the human brain, with its trillions of neurons and extensive interconnections. From this physical matter, something called “general adaptive intelligence” and “consciousness” arises, neither of which we understand or know how to construct or deconstruct. On the other hand, fundamentally though, isn’t a neuron a collection of physical and chemical processes that we DO understand? And then extrapolating upward then, is it not conceivable that we could eventually figure out how to construct a human brain in all its complexity? Hmm.

Reading books like “Life 3.0” and “Superintelligence” gets me thinking about stuff like this. It is both humbling and exciting at the same time.

CMIO’s take? Decide for yourself. I know, it is almost an hour long, and who has an hour anymore, especially if TED speakers can get their point across in 10 minutes? Well, consider my talk a series of 4-5 TED talks. Yeah, that’s it.

Dept of Medicine Innovation talk (video) on EHR Sprints

I play a doctor in this blog, and sometimes in real life. 


Recently I gave a talk for the Department of Medicine Innovation and Research seminars at the Anschutz Medical Campus for University of Colorado’s School of Medicine. I spoke about one of my favorite topics, some of which I have discussed in these blog pages: Reducing the EHR burden and improving physician burnout with EHR Sprints.

CMIO’s take: what is YOUR organization doing to address physician burnout? Something similar? Let me know!

We are Physician Builders (ukulele EHR parody)

Here we are at #ugm2018 Epic’s annual User Group Meeting. We’re at our first Directors’ Advisory Council session with over 600 attendees, and we discussed our governance approach to Physician Builders and how we overcame internal resistance to the idea that Physicians could do a good job creating new designs, templates, smart tools, and other content (and some actual programming) in the Electronic Health Record (they can!). In fact, our 19 Physicians who are now certified builders have made substantial improvements to our EHR environment on behalf of numerous medical and surgical specialties, as well as our physician users in general.

The point being, that although IT analysts are terrific for creating most of the content of the EHR, having physician builders with deep knowledge of the EHR technology leads to some interesting capabilities:

  1. Physician informaticists, with clinical knowledge, strong communication skills, and now technical know-how, can help other physicians reduce the EHR burden by matching tools to the clinical scenario, and reduce cognitive burden. For example, it is difficult to order the right cardiac arrhythmia monitoring tool (Holter? Event Monitor? Zio? Some other device?). Instead of building what a cardiologist physician was requesting, our physician builder thought about it, and suggested some the creation of a cascading order panel that gently guides the ordering physician to the right order WITHOUT building an exhaustive long checklist with difficult-to-follow paragraphs of instructions. Having a foot in both worlds is beneficial in this case.
  2. It is delicate and important do develop EXCELLENT relationships, CLEAR communication and strong guidelines so that the IT analyst team and the physician builders know what to expect from each other. When done poorly, turf battles erupt: “don’t touch those tools that I built!” But, done well, we become a synergistic team: “wow, thanks for taking on those Express Lanes; we would not have achieved our Honor Roll status (and helped all those urgent care centers) without your help.”

Really proud of our high functioning team.

And to ensure our audience got the point, we sang them our song. Lyrics below, YouTube link above.

We’re Physician Builders (Champions, Queen)

I’m a frustrated doc. Am Em
Passed my builder test
I wanna build
But she says: ‘You jest!’

And bad mistakes. C F
I’ve made a few
I’ve had my share of bad code kicked in my face C G Am
But I’ve come through! D7 G A

We’re physician builders, my friend D F#m Bm G A
And we’ll keep on buildin’ ’til the end D F#m G A
We’re physician builders, we are the builders Em A7 Gm A7
Those are happy users, cause we are the builders D C F G7
Of an Epic world. G7 D

I’ve set up smartlists. Am Em
And CER rules
You sent us Foundation and everything that GOES w it
I love those smart tools.

And maybe with time C F
Create a team goal,
We’ll share build in Text and Hyperspace
And make Honor Roll! C G Am D7 G A

We’re physician builders, my friend. D F#m Bm G A
And we’ll keep on buildin’ ’til the end. D F#m G A
We’re physician builders, we are the builders Em A7 Gm A7
Those are happy users, cause we are the builders
Of an Epic world.  D C Bb G7 D

CMIO’s take? What are YOU doing to ensure that you don’t take yourself too seriously? Are you here at Epic #ugm2018? Let me know!

How can the Triple Aim help patients? Here’s how.

Three amigos, with very different approaches to Aneurysm repair

My father (hi Dad!) recently was diagnosed with an incidentaloma. In medical speak, that is an “incidental” (or, unintended) finding on an imaging study conducted for an entirely different reason. His physician found an ascending aortic aneurysm of a certain size, on CT scan of the chest.

Dad was interested in finding a vascular surgeon in the Los Angeles area who was experienced in evaluating and if necessary, performing surgery for this condition. “So,” he asks me, “who’s good at vascular surgery in Los Angeles?”

I was completely stumped.

I went online, as all good internet-enabled adult children do, and found several dozen websites that purport to show and rate surgeons in the Los Angeles area. NONE of them were useful. Angie’s list, HealthGrades, lots of commercial and informal sites trying to meet an important need. Either there were no surgeons listed, or maybe there is a fragment of a listing and no data, or maybe there is a marketing blurb associated with that surgeon, or maybe someone ranting about a surgeon with whom they were unhappy. Nothing in terms of quality of care, operation case volumes, patient outcomes, very little of patient satisfaction…

And yet, we now are collecting such data in our massive EHR’s. WHAT IF we took the Triple Aim of improving healthcare:
-Improving health of populations
-Enhancing the experience of care
-Reducing costs

And gave a such tool to our patients? What if we could apply Amazon.com principles to searching for physicians and showed the screen above: how many operations of this type per year, the re-hospitalization rates; the complication rates, the patient satisfaction, the cost of that care, wrapped up with an overall star rating?

Yes, I can hear the outcry now. There are SO MANY REASONS that we can’t do this. As a former hospital CEO (Dennis Brimhall) said to me decades ago:

NO PATIENT SHALL WAIT. This is our vision. I know there are 300 reasons why patients HAVE to wait in our hospital. And yet, we ALL know that waiting is one thing patients hate about our care. So, NO PATIENT SHALL WAIT. And it will be ALL OF US working to solve the 300 things so that this can come true.

So it is, with this vision. It is hard, and nearly impossible with the sociopolitical structures we have now. The technology is just about able to do this, but the much harder work is convincing all the stakeholders in the healthcare industry (and in my own organization!) that this is valuable, this is important, and we must do it.

It is also possible, that by the time we achieve this, the 2 “surgeons” pictured above will have grown up and helped solve this problem. And that clearly irrelevant, untrustworthy guy on the right will have retired.

And, Dad’s fine, by the way. Thanks for asking.

CMIO’s take? If you don’t like change, you’ll like irrelevance even less.

Ukulele parody: Everyone Knows its Becky

Thanks to the medical informatics division at UC San Diego Health for hosting me at their informatics seminar series. I gave a talk about our efforts on improving physician well-being and reducing burnout (see previous blog posts on Sprints and Practice Transformation).

Sometimes, I travel with my ukulele. Sometimes, I sing at the end of my presentations. Sometimes, I climb out of my meditative, introvert bubble and see what happens.

Thanks to the one guy in the seminar who clapped for me. Kidding. UCSD has a great crew of informaticists doing great work. Christopher Longhurst (CIO) and his team are implementing a team with the purpose of getting physicians “Home for dinner” among the many other good things they’re doing.

Anyway, my apologies to The Association, whose song “Everyone Knows It’s Windy” I ripped off and re-purposed.

And yes, since I’m binge-watching “Breaking Bad” right now, I know the song features prominently in one of the episodes (NSFW). Where do you think I got my inspiration?

CMIO’s take? Always keep ’em guessing.

CT meditates: a comedy (14) Stanford wellness, military mindfulness, and Death Sticks


I like Stanford’s relatively new Physician Wellness site; something we can all aspire to. It includes links to self-assessments (see “Test yourself” link on the far left of that page.


What highly-competitive health care provider doesn’t want to test themselves against others? Maybe I can score the highest! Wait, maybe not the highest on a burnout scale…

It is a good conversation to have, with yourself about your own elements of burnout, and internal resources of resilience. How do you stack up? Is it time to “go home and rethink my life?”  (link: youtube video on the guy who tries to sell Star Wars’ Obiwan “Death Sticks”).

Remember, if you’re coming on the 3-minute daily journey with me:  eyes closed, with just the simple goal of spending 3 minutes in a comfortable pose, and focusing on breath. Then to watch the inevitable stream of thoughts floating by, observing each one as a puffy cloud, letting it just drift by without diving into it, and returning to breath.

Teaching our Communication workshop recently, I was reminded that the US military now has soldiers undergoing Mindfulness training with quantitative improvements in focus and performance. Hmm! Maybe this IS more than just mumbo-jumbo.

CMIO’s take? Mumbo-jumbo sometimes is good.

Compose a talk (a blog, a paper) with sticky notes


This is my favorite way of constructing new talks now. Stickies that you can move around, just like manipulatives from grade school.

I came across an interesting idea in my recent reading, that your office should have 2 desks: one that has NO COMPUTER and only lots of paper, pens, stickies, glue, and other manipulatives. This is your CREATIVITY desk, where ideas come together, and the joy of using your hands, your mind, your physical space helps build connections, thoughtfulness, foster good ideas. Thanks to Austin Kleon and Steal Like an Artist.

Then, across the room, you set up a second desk. This is your PUBLISHING desk, and has a computer, a printer, and all the tools you need to electronify a finished set of ideas into a Presentation, a Blog post, a Manuscript.

And, never the ‘twain should meet! For computers, although great at publishing and formatting, can be DEATH to idea creation. Yes, I type faster and more legibly than I can write. Yes, pictures drawn in Powerpoint can be sharper and with straighter lines. But, can any tablet, laptop, desktop equal the ease with which we can sketch, scratch out, tape over, scribble, dog-ear, lay out a dozen books, cut out pictures from magazines, mash-up ideas quickly, reshuffle?

And, isn’t an idea “under the glass” (see book review: The Glass Cage) an anesthetizing soporific?

Don’t we want to “feel” something in our fingers? Run our fingers through the dirt? the sand? the snow? OK, I don’t miss paper cuts, sure. But, scribbling, taping, retaping, scribbling, drawing connecting lines, scribbling, erasing and blowing away the eraser-crud, isn’t that the stuff of imagination?

CMIO’s Take? When I say all this, I’m not sure if I’m a digital immigrant losing ground to digital natives (Mark Prensky, thanks), or if I’m rediscovering a general principle that the younger Boomers, the Millenials, Gen Y, Gen Z have all lost. What do you think?

How to write an Open Note for patients

Worried about how patients might be offended by physician progress notes? Use this reference tool.



Having been asked a number of times: what is the best way to participate in open notes and sharing physician progress notes with patients? Attached is our one-page PDF guide. Feel free to use and share. Please do include attribution when you share.

In short:

  1. Don’t Panic! Despite physician fears, patients are not looking for a completely rewritten layperson-friendly note. Many patients find it useful just to have access and be able to show that note to their next healthcare provider. You DON’T have to change a thing.
  2. The handful of “gotcha” topics in physician progress notes are few, and not difficult to write in a way that is respectful and still accurate. For example, use “shortness of breath” instead of “SOB”; “BMI>30” or “overweight per medical criteria” instead of “morbidly obese”; and “patient is non-adherent” instead of “patient refuses”.
  3. It gets easier with practice.
  4. I love the quote from Cassandra Cook. To paraphrase: If we write things that might offend patients, consider if such writing affects our own attitudes and behavior.

Furthermore, the OpenNotes.org website has a great toolkit for organizations looking to make the leap: https://www.opennotes.org/tools-resources/for-health-care-providers/implementation-toolkit/

CMIO’s take? Lets push open notes until it is the default standard for Electronic Health Records and Personal Health Records everywhere. Is your organization on board with open notes? Let me know.

Review: Show and Tell: How Everybody Can Make Extraordinary Presentations

Show and Tell: How Everybody Can Make Extraordinary Presentations
Show and Tell: How Everybody Can Make Extraordinary Presentations by Dan Roam

My rating: 5 of 5 stars

Turns out there are several types of stories to tell in presentations. Dan speaks to the idea of understanding your audience, understanding your purpose for a presentation, understanding what goal you wish to achieve: informative report, imparting a skill, overcoming an obstacle, etc.

Dan writes (and I love this):
“When we tell the truth, we connect with our audience, we become passionate, and we find self-confidence. When we tell a story, we make complex concepts clear, we make ideas unforgettable, and we include everyone. When we use pictures, people see exactly what we mean, we captivate our audience’s mind, and we banish boredom.”

CMIO’s take? There are a number of good books on presentations, like Presentation Zen, Death by Powerpoint, and anything by Ed Tufte (starting with Visual Display of Quantitative Information). This book is a quick read. Powerpoint is DEATH unless we use it with skill. Most have no skill. This is a tiny book, a quick read. Get skills here.

View all my reviews


Doodling. I recently gave a talk at the Health Evolution Summit conference in Dana point California. It was a humbling experience, as I was expecting to give the standard PowerPoint presentation, and was told: “no,” that instead, I would be out on the lawn in front of the wind and surf and be giving a talk on a flip-chart.

This provoked a great deal of anxiety, and prompted ego- and personality-rebuilding. Then I thought of my sister’s book recommendation “The Doodle Revolution.” And so I took my story, boiled it down into symbols, and give a talk, which was not unsuccessful.

Turns out, googling any concept attached to the word “symbol” allows you to see what other people have used for symbols, such as for “strategy” or “manager” or “project manager” or “consensus”. Try, for example, googling “consensus symbol.” Well, at least it starts the creative juices flowing.

I challenge any of you to understand my chicken scratch doodles and interpret them into a coherent narrative. The good news is, I’m no longer afraid that my terrible chicken scratch will be criticized. I know that it will, and it’s still helpful to me and to my audience. I’m learning to get over myself.

For those of you interested:

  • The “upside down spaceship” in the corner is really a handshake symbolizing “partnership”
  • “…and…but…therefore” comes from a previous blog post on storytelling*
  • The elephant is a reference to slow moving, large academic medical centers
  • The drowning man refers to Healthcare organizations in the age of acceleration
  • The USB symbol refers to technology companies


CMIO’s take:  What are you waiting for? Get out and doodle! OR, if you’ve doodled successfully (or even unsuccessfully), let me know in your comments!


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