My code: “You cannot overestimate the unimportance of practically everything.” (NYTimes)

Wait, what?

www.nytimes.com/2021/04/17/opinion/letters/personal-philosophy.html

Happy weekend! I just saw this on the NYTimes.

Read this sentence a couple of times. Then read the 100-word “life philosophy” letters to the editor. This one, from David Pastore, Mountainside, N.J.  …  Wow. 

CMIO’s take: Do you have a life philosophy to share? Please comment below.

Your Colleagues Don’t Read Anything You Write (NYT)

TL;DR: Improve your email writing skills so that colleagues will read your stuff!

OK, this is distressing. Just like the statistic that 1/3 of prescriptions are never even filled by patients (what?!), turns out colleagues really don’t read your emails. Pause here, and just feel that surprise and disappointment seep in.

Take a breath. Ok?

Having read Bit Literacy a few years ago, a digital riff on Getting Things Done, I have always known there are better ways of handling the email deluge. For example: the Eisenhower box: Do it, Decide to Schedule it, Delegate it, Delete it.

from jamesclear.com

Also the idea that there are URGENT things, and NON URGENT things, and IMPORTANT things and NON IMPORTANT things. Email tends to be the URGENT and NON IMPORTANT and we all have long term strategies that are NON URGENT and IMPORTANT, and how do we move our daily work from one to the other. This is the story of my life.

However, in the service of improving email communication, Mr. Orendorff, of the New York Times updates the best-practices of WRITING emails to improve your chances of being read and being effective. My favorites:

  • Make the Subject Line useful: REPLY REQUESTED: thenyoursubjecthere or FYI ONLY: thenyoursubjecthere. Even better, if I can possibly ask my question or make my statement really short, I write it entirely in the subject line and end with my initials, signalling there is NOTHING in the email body.
  • Write a TL;DR. Cool internet slang for Too Long; Didn’t Read. As an internal medicine physician, I’m always guilty of being over-explanatory. Write the extra short summary at the end of your email AND THEN if you did well with that last part, you can DELETE your original email and ONLY SEND the TL;DR. Good job!

CMIO’s take? Read the article and change your life (and your colleagues lives) Today!

SpinLaunch will get to space with 1/10 the cost: the edge of what is possible

The inside of the SpinLaunch centrifuge. Image from Wired dot com

https://www.wired.com/story/inside-spinlaunch-the-space-industrys-best-kept-secret

I love these stories about entrepreneurs coloring outside the lines. “That can’t be done” or “There is a big gulf between theory and reality”. These are statements everyone faces when trying to change the status quo, including in healthcare.

The proposal in brief, use a massive centrifuge to speed a rocket up to 5000 mph and launch it like a slingshot so that it can coast up to the stratosphere and then a tiny rocket pushes it into orbit: it avoids the Tyranny of the Rocket Equation – that most of the mass of a rocket is dedicated to massive engine and the fuel it must burn to put a relatively tiny payload into space.

More power to folks like these. Yes, they might flame out as they get closer to a real trial, but imagine if they succeed:

  • Launch costs of $400k, instead of 10x as much
  • Being able to launch 5x month instead of 5x a year
  • Commoditizing access to space without massive rockets

CMIO’s take? Color outside the lines! I give it a 50:50 chance this is viable as a commercial enterprise after vaulting all the potential hurdles.

Clergy Preach Faith in the Covid Vaccine to Doubters (NYTimes)

Clergy embody the trust to heal our communities. They may be the boost the Covid Vaccine needs.

This article is an elegant discussion

of the importance of clergy in addressing vaccine hesitancy among those with doubts; they are the trusted community leaders we need right now. Click the image above to go to the article.

Bonus:

the article discusses UCHealth’s partnership with Shorter AME (African Methodist Episcopal) Church in Denver, with a photo of Yours Truly.

Even more amazing,

Shorter’s Fellowship Hall, where we gave vaccines, is named for Omar D. Blair, a Tuskegee Airman who went on to be a civil rights advocate. This is particularly poignant, as ALL clinical researchers at University of Colorado, and across the United States, must learn about the Tuskegee Syphilis Experiment, an unfortunate chapter in the early history of medical research in the US, and a source of great distrust on the part of the black community towards American medicine.

We are therefore so grateful to develop and grow a trusting partnership between UCHealth and black churches and community centers, to fight the pandemic with our best medical tools.

A Church-based Vaccine clinic

  • Some interesting ways vaccination at a Black Church is different from a vaccination on-site at a UCHealth facility.
  • Most people know each other; these are strong communities; folks getting shots spend more time waving and chatting than getting nervous about a vaccine.
  • Lots of church leaders guiding, comforting, coordinating a smooth vaccine clinic, alongside our UCHealth clinicians and leaders.
  • As a UCHealth worker, feeling like we are invited into the inner sanctum of a close-knit extended family

When I suggest to a vaccination recipient: “You can go be observed in the chapel for 15 minutes by our nurses and doctors. However, that observation time is optional and you can leave now if you like.” The response is: “Oh, I’m going in there! I haven’t seen these folks for a YEAR! I’m gonna talk to EVERYBODY.”

Some Churches UCHealth has been to in recent weeks

NYTimes and Shorter AME Church, Denver CO
New Hope Baptist, Denver, CO
Colorado Community Church, Aurora, CO

PBS and Black Churches

If you missed it, PBS recently ran a special on Black Churches in American History, that is a fascinating look at how the DNA of America runs deeply through these communities (from slavery, the Underground Railroad, Civil Rights, Women’s Suffrage, Martin Luther King, and the rise of black clergy in political life). Amazing and well-told.

CMIO’s take? It is a privilege (and also the right thing to do) to partner with strong community organizations to get minorities and medically under-served communities vaccinated. It is a privilege to be part of this effort.

COVID Vaccines at Colorado’s Epicenter from March 2020: JBS Greeley Beef meat packing plant.

Changing minds with Stories, not Data.

NEWS ARTICLE: https://www.greeleytribune.com/2021/03/05/jbs-workers-having-seen-the-largest-outbreaks-in-weld-county-receive-first-doses-of-covid-19-vaccine/

This was a remarkable event, and I’m glad I was there to see it.

For those who may not know or remember; Greeley’s JBS meatpacking plant was the center of Colorado’s first major outbreak of COVID illness, resulting in numerous deaths and hundreds of workers getting sick and hospitalized. Meatpacking requires close quarters, and one infection spread rapidly to many.

I watched on the news with horror as the disease spread, and Greeley, a small town in rural Colorado became national news. Greeley also led the state in COVID illness early in the pandemic.

Public Health Effort

The great news NOW, is that Colorado’s Public Health coordinated a multi-health-system effort to vaccinate the nearly 5000 employees there. When I heard of the opportunity, I dropped everything and headed up there last Friday to be part of the effort.

It would seem an insurmountable task: How do you coordinate nearly 100 volunteers who don’t know each other, in a noisy, unfamiliar plant? How do you incent workers who may have questions about the vaccine, to come discuss and be vaccinated? Will you have enough translators (at least 8 languages are spoken by employees)?

7 health systems coordinated

Soon, however, we got organized into 14 tables of 3 vaccinators, taught how to load vaccine syringes from defrosting Pfizer -70 degree vials, supplies distributed, and employees started rolling in, paper consents in hand.

Doctors, nurses, medical assistants, technicians, healthcare workers speak the same language. Despite the cold hallway, we buckled down and got to work.
Dr. Hoffenberg instructing each table on standard vaccine process.
Patients arriving by the hundreds

2500+ vaccinated

We vaccinated over 2500 employees on Friday, a great day and smooth operation. See above for the write-up by the Greeley Tribune, among many news organizations on site.

The “Education Room”: Stories NOT Data

Here is where it gets interesting. I found out that I was assigned to the “Education Room” upstairs. Management at JBS was serious about maximizing employee engagement with this big push for vaccination.

  • The plant was closed for 2 days.
  • All workers would be paid for 4 hours of shift work JUST TO SHOW UP.
  • All workers who got vaccinated would receive an additional $100.
  • All workers who declined vaccine could sign a paper … AFTER they went to the EDUCATION ROOM where Dr. Lin and other physicians and nurses were waiting
Image blurred intentionally

Hmm. I thought I had signed up to vaccinate today …

When I heard this, my life flashed before my eyes. Not really, but I had a rapid sequence of thoughts:

  • I hoped they had enough translators (turns out, yes: Somali, Spanish, Amharic/Ethiopian, many more)
  • I hoped I had heard most of the rumors and misinformation about the vaccine before and be ready to respond
  • I hoped that I could avoid STATISTICS and DATA, since most vaccine-decliners have (mostly misinformed) STORIES. Data never beat a compelling Story. Only Stories have a chance to fight Stories in the battle for feelings and changing minds.
  • I thought back to a book I read recently, The Righteous Mind, about values, moral thinking, and how those with liberal values, and those with conservative values see morality with very different lenses. Would I be able to speak a common language to connect with those who saw the world differently?

Reasons why NOT?!?

Yes, it turns out, we only had about 100 people come through for the 6 hours I spend there. Of the 100 we spoke with, I heard a dramatic range of reasons why people were declining the vaccine:

  • “Well, it’s not a real disease anyway.”
  • “I heard the vaccine kills people.”
  • “The vaccine is only 95% effective. So what is the point? Like, it doesn’t even work.”
  • “I heard it is made from dead babies.”
  • “Only old people have a problem with COVID.”
  • “I am healthy. I don’t live with old people. I don’t need it.”
  • “My roommates will make fun of me. We are not getting it.”
  • “My parents told me not to get it.”
  • “Why are WE the guinea pigs, before everyone else?”
  • “I’m going to wait and see.”
  • “I’m pregnant. I heard it is dangerous for my baby.”
  • “I already had COVID. So, I’m immune.”
  • “I never get ANY shots, flu, nothing. I don’t need it.” (and more)

This was a daunting task. However, we had a room full of translators for all languages, 3 tables set up with information sheets and 3 cultural ambassadors to explain the importance of the vaccine and WHY JBS managers and leaders thought this was important, and even Union Leaders who would show videos of themselves getting the shot themselves (thank you JBS; very organized!). THEN, if the participant was adamant about their decision, fine, go sign the paper and get paid.

Less Helpful Conversations?

IF they had a question, one of us would get called over, and we could chat. I heard a few discussions in the room. Some less effective approaches:

Employee: “I don’t want the shot. I already got COVID. I’m immune.”
JBS Supervisor: “I haven’t got COVID. I’m not immune. You don’t care about me?”
Employee: “Nah man, stop talking. Where do I sign the paper.”
(Confrontational)

Employee: “I don’t want the shot. I’m healthy.”
Medical advisor: “You know, the shot is 95% effective. Even though it doesn’t protect everybody, the data shows that almost everyone gets immunity. Even if you DO get the infection, it is likely milder and you won’t have symptoms.”
(Data-heavy, confusing, and not addressing the issue)

Employee: “It is not a real disease.”
Medical advisor: “Yes it is. People die all the time. Here are 5 reasons the shot is safe and the evidence that it works…”
(Not enough reflective listening, eliciting thoughts, trying to find common ground, and too much talking)

Whew. I could see myself falling into each one of these traps. I set myself a goal to find STORIES to match and counter their STORIES and to suppress temptation to exhibit my command of the DATA (sooo hard).

Better Conversations?

Here are some of the better ones we came up with. Importantly, ALWAYS begin with “What questions do you have?” and “Tell me more about what you understand.” and “Anything else?” and “I like that you are trying to get good information before making a decision. This can be very confusing and scary. I would like to help.”

Employee: “I’m pregnant. I’m afraid for my baby.”
Me: “Yes, there is less information from the vaccine tests about pregnant women. HOWEVER, MOST of the women doctors and nurses at University Hospital who are pregnant have gotten the shot. And we are confident it is safe for the mom and baby.” (result: agreed to shot)

Employee: “I heard the shot makes you sick.”
Me: “Well, most people do not get sick. If they do, some get a sore arm, or a headache or fever, like getting the flu. Tylenol helps. For me, I had a fever for about 3 hours overnight.” (result: agreed to consider it later)

Employee: “Why are we the guinea pigs and getting it early?”
Medical advisor: “Actually, the doctors and nurses were the guinea pigs; they got the shot back in December and January. We are all healthy and staying safe, with no major side effects. We want YOU to be protected too.”

Employee: “I just don’t want to do it.” (unable to state a clearer reason)
Me: “I hope you see all the doctors and nurses in this room. We are all volunteers, took a day off to come here, because we WORRY about you and your community. You are Essential workers. Last year, many of your co-workers got sick and died, and we did not protect you. We don’t want this to happen again.” (result: thanked us for volunteering, and promised to consider vaccination)

Motivational Interviewing?

Of 100 people, about 20 agreed to the shot during our session, about a 20% conversion rate. Is this normal? I have no idea. One of my colleagues noted:

“Compared to vaccinating, this is soul-crushing. To do your best explaining why a crucial vaccine would save lives IN THIS PLANT, and not to connect. So hard.”

Nurse Practitioner in the Education Room at JBS

At the same time, we all agreed that many of the decliners also said they would think about it some more, and would consider getting it later. In motivational interviewing lingo, perhaps they were moving from “pre-contemplative” to “contemplative.” Even a mild attitude shift like that, is a win.

Some of the more effective strategies:

  • Listening more than talking
  • Finding common values: “The Broncos!” or “Protecting elderly parents”
  • Telling a personal story of COVID or getting vaccinated and how it felt
  • Talking about “looking out for each other” “protecting our community” “making Colorado safe” “keeping Covid out of your family”
  • Using metaphors: “Which vaccine? Its like, Dodge, Ford, Chevy. Just get in the car. We will all get there.”

Dr. Steve Hoffenberg, Emergency Medicine Physician, coordinated the vaccine efforts at JBS. Thank you, Steve.

FINALLY: Will you look over this document with me? I wrote a ONE PAGE summary of what I thought were the BEST STORIES to fight misinformation about COVID Vaccine. What do you think?

Download the document here: https://www.dropbox.com/s/k94xra38b4tmmst/2021-0309%20Why%20Should%20I%20Get%20the%20COVID%20Vaccine%20CTL.pdf?dl=0

CMIO’s take? Wow, there is a lot more to vaccine work than “give shot, call next patient.” Coordinating a public health effort: massive. Focusing on high risk populations: important. Listening, connecting and changing minds: some of the hardest work of all. In the coming months, THIS will be the conversation.

Kevin Kelly: 68 bits of advice (Technecium)

From amazon.com and Kevin Kelly

https://kk.org/thetechnium/68-bits-of-unsolicited-advice/

Kevin Kelly: co-author of the defunct but world-changing Whole World Catalog, publisher of Cool Tools, author of What Technology Wants, and generally smart guy, is 68 (or was when he posted this). Brilliant observations. This is me Plus-one-ing his post. Some teasers:

  • Learn how to learn from those you disagree with, or even offend you. See if you can find the truth in what they believe.
  • Being enthusiastic is worth 25 IQ points.
  • Always demand a deadline. A deadline weeds out the extraneous and the ordinary. It prevents you from trying to make it perfect, so you have to make it different. Different is better.

CMIO’s take? Happy new year. Go read it, link above.

News: (WIRED) 30 lines of code blew up a generator

from wired.com

https://www.wired.com/story/how-30-lines-of-code-blew-up-27-ton-generator/

In what is an insider’s view of what our cyber warfare unit, and the cyber-criminals out there are working on, a view of the inner workings. I believe this may have been part of that the STUXNET attack on Iran’s nuclear facilities (and centrifuges) reported in 2010 (WIRED.com article).

CMIO’s take? The real world and the cyber-world are colliding in more intricate ways.

Oumuamua: the edge of reason?

from The New Yorker article

https://www.newyorker.com/magazine/2021/01/25/have-we-already-been-visited-by-aliens

A nicely written discussion by Elizabeth Kolbert at the New Yorker. In it she discusses the details of recent findings of the Oumuamua object that blasted through our solar system at 4x the speed of usual asteroids, did not move as expected, and must have been “an interstellar object”. Some are calling it an alien artifact, others are pooh-pooh’ing such a description as “unscientific.”

Farhad Manjoo at the NYTimes also comments. Fermi’s paradox talks about how to calculate the very large number of planets out there and the unknown fraction of those that might support life.

 In 1992, NASA spent $12 million on a project to listen for radio signals from other planets; the next year, Congress cut the funding, with one senator joking that “we have yet to bag a single little green fellow.”

In years since, scientific funding in this area has been paltry.

Here is the Fermi Paradox equation about the likelihood of extraterrestrials: https://www.space.com/25325-fermi-paradox.html

Why not consider alien life? Is it so ridiculous? As a scientific community, we pride ourselves on being open-minded, but our history sometimes indicates otherwise.

Is this is the edge of reason? Does our group-think ridicule those on the edge?

Some of what we do in healthcare is also at the edge of reason (see: Open Notes, APSO Notes). It is often ridiculed. Until it is not.

CMIO’s take? Perpend.

Covid Be-Gone. 10,000 Vaccines, One Weekend: UCHealth @ Coors Field.

Billie, Alex, and some crazy doctor, newly recruited Pit Crew. Biggest innovation? Billie’s smiling face on her button! Why haven’t we all done this!?

Our team is at it again!

The Rockies and Coors Field welcomed the UCHealth crew, this time for a 2-day, 10,000 vaccine event Jan 30 and 31. It was a smashing success, and tremendous fun, to boot.

Our fearless leader, Ali Hererra, giving last-minute tips to an eager 630am crew.

The new kid on the block

The new kid on the block: a neck-lanyard, battery-pack augmented iPhone with the EHR mobile app installed for on-the-fly vaccine documentation from QR bar-codes.

Gratitude!

Our vaccine clients show tremendous gratitude; we love the spontaneous cheering and applause that break out at times while the cars are moving through. One even handed us an unexpected gratitude card today!

What’s the count?

Here’s my tally for one day of vaccination: 150 for each day, 300 for the weekend. Unanticipated outcome? Donning and doffing gloves 150 times in quick succession causes some hand irritation and a need for heavy doses of vaseline petroleum jelly at the end of the day.

I proudly showed my clinical informatics colleague my collection of vaccine caps in my pocket (see how clever I was to keep track of my productivity?), and she promptly told me: Well, it is easier just to run a report (Thanks, Kristin). Um-hm. And I call myself a CMIO.

Efficiency tip?

Efficiency tip? Here’s the latest: Non-dominant hand: bandaid on the thumb, half peeled. Vaccine, ready to go. Pre-peeled alcohol swab. Dominant hand: Mobile device on a lanyard or in a coat-pocket, QR code scanner ready, some quick screening questions and screen-taps, vaccine documented in EHR, give vaccine, walk back to tent and re-supply while our student hands out the vaccine card and follow-up instructions. Rock-and-Roll.

First of all, our team CRUSHED the scheduled volume today. At our peak, we vaccinated more than 1000 people per hour, with average throughput times of 22.5 minutes (that’s INCLUDING the 15 minute observation).

To say that another way: we timed cars arriving at Check-in Registration at time ZERO, got screened, registered, consented, and vaccinated in about EIGHT MINUTES. And 15 minutes after that, they were rolling out of the observation area. WAT?!

We had numerous people exclaiming: “This is unreal, how smooth it is.” With masks on, we’re getting good at reading the smiling eyes. Wave after wave of grateful vaccine recipients.

Current Vaccine Tent workflow

The Tent 8 “A-team.” Billie Martinez, medical assistant, Brittney Poggiogalle, PA student, Alexander Jimenez, medical assistant (working hard). Thanks for making us all look good!

Turns out it is easy to “infect” colleagues with the enthusiasm I have for optimizing our workflow, which is now:

  1. Vaccinator sets up the non-dominant hand with vaccine, bandaid and swab (see above)
  2. Patient arrives with QR bar code ready on their phone (from My Health Connection or a printout). No Bar code? No problem, a last name search is only a few seconds more. Beep! 3 screening questions, done!
  3. Vaccinate! (previously described)
  4. Pivot our positions, and our student volunteer steps up and hands the vaccine card with followup instructions to proceed to observation area and to NOT MISS their next appointment (already booked for 3 weeks from now).
  5. DONE! our best cycle time: ABOUT 70 SECONDS INCLUDING DOCUMENTATION.
  6. Perhaps even more exciting, talking to each other about Lean process, discussing throughout the morning, how to stay safer: remember to tell drivers to put it in Park! Remind each other as we walk up and down, to stay out of the driving lane! When standing at your work table, prep your supplies with your body turned facing the line to be aware of your environment. Tell each other if you see something to improve.
  7. All 3 vaccinators have their own neck-lanyard mobile documentation tool, and we can give about a vaccine every 1.5 to 2 minutes including drive-up time, and one student keeps us supplied with peeled bandaids, filled-out vaccine cards, and explains next steps to the drivers, allowing the vaccinators time to re-set for the next care. It is a beautiful dance.

A Lean Lecture?

Talking with a colleague later, I reflected that I got so excited about our efficiency, that I gave a mini-lecture during the morning to our team and student volunteer on Lean process. My colleague then replied: “Oh no, Student! Wrong Tent! Wrong Tent!” implying that no student needs a lecture from an over-enthusiastic CMIO on a weekend. (Thanks for the commentary, Dr. Bajaj).

Our previous worries about backlog of paper charting needing later data entry?Gone!

The cool thing about this setup is: we did not pre-identify which cars had slow-down factors like: more than one scheduled vaccine recipient per car, no bar-code, occasional technical glitch, or lots of clinical questions. Occasionally, if one car took a little longer, the other 2 vaccinators would walk up the line and greet the next car. Once the line opened up, everyone slid forward easily. A handheld mobile and a one-hand vaccine supply made us nimble. None of us was waiting around, unless our line of cars emptied out entirely.

I enjoyed hearing the pharmacists on-site, who were mixing up batches in real-time (the Pfizer: needing to defrost and reconstitute from -70!), on the walkie-talkies discussing which tents needed more vaccine: “We’re almost out again at Tent 8.” “Okay, on the way with another batch of 25.” With our throughput (3 vaccinators, cycle time about 2 minutes simultaneously), that batch would only last us about 18 minutes. Loved every minute of it.

The CMIO in me wanted up-to-the-minute vaccine stats from the other tents. Not that I was feeling competitive. No. Not me.

The Pit Crew

Not being satisfied with even this, mid-morning we were asked to transition to a Pit-Crew method being piloted by our Clinical Informatics nurses. In our standard lanes, cars would pause at one of 6 Registration lines, drive down a lane and then be split into 16 vaccine tents. The Pit Crew were doing both Registration AND Vaccination in the Registration (big white) tent. Then, no second stop, straight to Observation. It was going so well, we recruited additional people to run a second line.

INSIDE the big tent. Four cars in a row. One stop to do it all. We don’t have all the timing numbers yet, but we believe this may take additional seconds or minutes out of our cycle time. There are some potential downsides to this configuration VERSUS our vaccine tent configuration; the registration workstations on wheels (WOWs) aren’t as nimble in traffic compared to our handhelds, so walking upstream when there is a delay is not practical, and if one car takes longer inside the tent, there is more potential delay. The upside: one stop could make the transit time much shorter per vehicle.

At the end of the weekend, ZERO DOSES WASTED. 10,000 given. ZERO significant complications in the observation area. Dr. Richard Zane calculates that the 10,000 vaccinated patients means that 157 fewer people will die of Covid as a result of our actions this weekend. Wow.

Stay tuned! We’re already performing at a high level, but we think there are yet improvements to make, while keeping patient and team safety our top priority. The work of our Incident Command structure has been a joy to watch, with team leads in constant communication with the Rockies, the Denver Police, the State, County and City.

Here’s a CBS Denver news article about us, with more photos from a drone.

CMIO’s take. Who knew that Toyota Lean Process could help vaccine administration? Furthermore, I’ll say it again: Get us more vaccine! We can handle it.

Xenobots are coming: Tiny Blobs of Programmable Tissue (WIRED)

From WIRED.com, the application of DNA engineering not only to the sequencing and reading the DNA and RNA of viruses and organisms, but now to CREATE “tiny blobs of programmable tissue.”

REALLY?

Watch it above, and read it yourself: https://www.wired.com/story/synthetic-biology-plan/