Project CORE, e-Consults and my 1997 view “email should be part of an electronic record”

In 25 years, communication technologies have gone through several generations of change. Look back and see what I saw in 1997.

From Dall-E. Doctors at a computer, treating patients, optimistic



Throwing out old files from my office recently, I came across this blast from the past. In effect: “we should include an e-mail or electronic message function in the Electronic Health Record” or at least, “could you allow us to use our email program on the same computer as our electronic medical record? Then we could possibly cut and paste important questions and conversations between providers and cut down on full consults and referrals and improve coordination of care”

In 1997. At least 3 EHR implementations ago.

I hate to say “I told you so, but … I told you so.”

Here we are in 2020, and we have since studied patients having online portals and using online communication with providers and found these tools to be practical for providers and nurses and patients, and also shown to improve adherence to treatment and high satisfaction.

We have implemented Project CORE, a method for docs to request electronic consults from specialists on their patients; straightforward questions that come up regularly can be quickly and easily answered by colleagues WITHOUT having the patient physically go see the specialist. It is a win-win-win (speed of response for referring doc, no extra effort for patient, easy question/answer by specialist and decompressing packed schedules to make availability for more complex patients). Almost all our specialties now offer this to our primary care colleagues.

We have implemented Secure Chat within our EHR, an ability not only to send email-like messages (have had that since we implemented in 2011), but to send near-real-time text-like messages, securely within the mobile app (Haiku) associated with our EHR (Epic). Here’s an article from Providence Health System in Portland describing the features. Such interruptive alerting can be intrusive, but also when used well, can power highly-functioning teams.

Some observations: 

  • Email in 1997, at the time of this document, was a “new thing”. In fact, connecting computers to a “network” directly into the wall-jack was a new thing. I had purchased several generations of modems for home, where I could connect by phone line to the “Internet”. Of course, we WOULD NOT put patient charts on the computer, right? That’s just a ridiculous idea. 
  • Mobile phones in 1997 were increasingly common, but the number pads were a TERRIBLE way to type an SMS message. It would not be until the Blackberry in 1999 showed us that a ‘chicklet keyboard’ was a faster way to type what later became instant messages. 
  • And now, both of these communications technologies are embedded in EHR’s.  

This reminds me of something someone said to me when she was 5:

“That was back in the days of the dinosaurs, when you were alive, but I wasn’t.”

–baby daughter Lin, age 5

CMIO’s take? 1997 to 2023: electronic messaging in EHR’s? I told you so. I was just 25 years too early.

With Unwarranted Optimism like that … (personal reflection)

A Romantic Ocean-side Dinner Conversation. What could go wrong?

I love my wife.

She’s the one.

She’s the one who keeps me grounded.

CT: [One evening, over a couple of drinks, looking out over the Pacific during our romantic dinner out] “Hey, that surf is so calm, I bet I could go and swim a half mile along the beach right here.”

Wife: “And you’re exactly the kind of person with unwarranted optimism who would go out there, get pulled into a riptide and drown.”

CT: “…” o_o

Who is right here? Probably … both of us?

CMIO’s take? How about you? What contradictions do you embody in YOURself?

Footnote: the lovely Marine Room in San Diego, a few years ago.

The Nerd Family Camping Trip (a personal reflection)

Does your family camping trip look like this? Should it have to? What is wrong with this picture?

I am both grateful and horrified that our family camping trip to the Southwest of Colorado in large part is comprised of hauling books around the state in case someone has an urgent need to sit quietly and read. 

Here we have stacked the very different interests of of our 2 kids and my wife and myself. 

By Dall-E

I’ll go ahead and claim:

Measure What Matters, by John Doerr, who claims that OKR’s transformed Google into the powerhouse it is today.

The Gift of Therapy, Irvin Yalom, given to me by my daughter, who thinks I need some more grounding in the principles of psychotherapy and their application to working with colleagues in a high-pressure, high-stakes environment.

Designing Your Life, Bill Burnett, describing the foundations of Design Thinking, with applications to ones’ own life. 

Tribal Leadership, Dave Logan, about the 5 tribes and how our self-categorization is so poor, and how we all aspire to work on high-performance teams, and why we fall so short so often, and how to fix ourselves. 

Fresh off the Boat, Eddie Huang. An incredible, in-your-face, atypical Asian immigrant story. Wow.

CMIO’s take? All highly recommended. Or maybe I loved them because I was camping. What do YOU take camping?

Managing lab and radiology results, circa 1996. The nightmare is (mostly) over

Come with me in the way-back machine to 1996. Here’s a document from our “lost days” of paper process in healthcare =shiver=. I am grateful for the progress we have made.

From Dall-E: doctors at a presentation.


Amazing what you can find in old paper files. CT Lin MD

I was cleaning out an old file drawer today. Here’s what I found. In 1996 I was ‘medical director’ of ‘Care Center C: Internal Medicine practice’ at University of Colorado Hospital, on 9th avenue. As such, even 27 years (!) ago, I was focused on optimization. In this case, how to document and create a best practice, around handling paper files of patient records, and the associated chaos of receiving faxes and mailed results days or weeks after a patient visit.

As you can see, it was … a nightmare. There was no standard process back then. We tried to standardize, AND EVEN THIS workflow gives me chills today. Some highlights:

  • “If dictating!” (most notes were illegibly handwritten)
  • Manually clips “labs pending” flag to paper chart (inconsistent process requiring providers to ‘remember to do this’)
  • File in “holding area” alphabetically until labs return (unless of course the nurse needed it, or provider, or legal review, or quality review, or telephone call from patient pulled the file). We would have 3-4 staff members walking around the office, searching dozens of locations for an urgently needed single paper chart, instead of other important clinical work.
  • X-ray report comes by US Postal Mail to the provider’s office box; lab results are FAXED. Somehow these loose sheets have to be united with the right paper file patient chart. (Yikes!)
  • Most results do not accurately have the name of the provider or the resident ordering the test so someone has to look up who ordered the test to deliver to the right person. Mind you, there is only a rudimentary registration system, so one often had to look in paper scheduling notebooks to see which provider saw which patient.
  • “Decides method of notifying”; in many cases, usual practice was to tell the patient “hey, don’t worry, if you don’t hear anything, it was normal.” AND NOT NOTIFY AT ALL. It turns out, when we did an internal audit later that year, about 1/3 of all completed test results WERE NEVER DELIVERED BACK TO CLINIC. So then, we would have had to tell patients “don’t worry, if you hear nothing, it was EITHER NORMAL OR WE LOST IT.” Terrible, terrible.
  • “Postcard to be sent”, where the provider writes the name BUT NOT THE ADDRESS (because, clerical work) and then the clerk LOOKS UP THE ADDRESS for Mrs. John Smith. No potential error there, right? I would routinely have patients bring back postcards saying “I think you meant this for someone else.” And also postcards READABLE BY ANYONE are going through the mail with test results on them… hmmm.
  • There are potentially 9 handoffs in this ‘standard process’ Already much better than what went before (no system at all), but still gives me shivers.
  • NOT SHOWN: test results would often take 3-5 days to return from lab, 5-10 days to return from radiology, and our own dictated notes (if not just handwritten) took 7-14 days to return from the transcriptionist, by inter-office courier. We hoped the patient would not call us within 2 weeks of seeing them, because we might have NOTHING ON FILE during that time, in their chart.

Today, by contrast: we order the test in the EHR, it knows who the patient is, who the ordering provider is (resident and supervising faculty), it routes the order to the correct ancillary testing location, the bar code label goes on the specimen, or the radiology is digital, the result is electronically delivered right back to the provider and clinic care team, AND ALSO deliver the result directly to the patient (most results in real-time, as soon as the provider receives it, it is available to the patient online). And then, the provider and team have a standard way of communicating (online or letter) with the patient about the result and next steps. 1-2 handoffs, and much more seamless and rapid process

CMIO’s take? 1996 to 2023 is a long time. I know we have LOTS MORE to do and we are FAR from perfect. We can also be grateful for how far we have come. Do you have moments of gratitude for our collective progress? Let me know.

Stinky, smelly fish FTW (Harvard Health Publishing) and an origin story

Why Eat Lower on the Seafood Chain? Or, Lox and Bagels or Sardines and Bagels? A personal story of setback and triumph.

CT feeds stinky fish to his kids

I’m proud to say I introduced my kids, when they were growing up, to sardines and mackerel, foods that I loved when I was growing up a son of poor immigrant parents. They routinely gross our their friends as they pick up small smelly fish and consume them, while exclaiming: “Oooh, that’s the spine! That’s the guts! Yum, that’s good!”

When the world food supply collapses, and no one else will eat stinky smelly fish, my kids and I will be fine. We’ll be out back, consuming our Costco-brand mega-pack of canned sardines on top of bagels.

Lox and Bagels origin story

I thought everyone ate like this. Turns out the origin story comes from my mom.

We were invited to a weekend brunch with my father’s work colleague, and they were serving lox and bagels. Our family had never heard of such a thing, and 12-year-old me gobbled down numerous servings and loved it.

My mom took notice and went to the store to buy lox, which, she found out, was salmon.

However, she also found out, salmon was expensive beyond my dad’s assistant college professor budget.

So, shopping around, she found sardines in a can. She brought these home, with bagels, hoping that her son would not notice the difference.

Sardine and Bagel Switcheroo

How did it go? Sardines and Bagels? I was in heaven. “Mom, can we have this every week?” And a tradition was born. I don’t even remember that someone did a switcheroo.

CMIO’s take? OK, no informatics lessons here, you can move on.

Home from informatics extravaganza that is AMIA

Great entry from my Zen Calendar. And reflections on AMIA Spring Conference.

Had a fascinating trip to AMIA CIC 2023. It is always great to meet up with friends old and new, catch up in the current work, celebrate new Fellows of AMIA, watch the rapid rise of GPT. Even cooler to see the gradually dawning understanding of newer AMIA attendees that communication skill, storytelling, and relationship building is the key to success in informatics.

So cool. Our future is bright, not because of new tools, but because of the smart, eager, emotionally intelligent next generation of informatics leaders. I’m so grateful to be around them this week.

APSO Notes: what Machiavelli taught me

What does a book from the 15th century, my own pediatric record, and APSO notes have to do with modern informatics?

from wikipedia

It is the year 2009. We are 8 years into our EHR journey (Allscripts Touchworks, at that time). Physicians are dutifully recording progress notes by dictation, by typing, some using templates, to record their observations and thinking about patients in the longitudinal record. We scribble in paper charts (not every clinic is electronic yet: we have a 10 year plan to convert all the clinics).

The complaint: EVERYONE KNOWS that when the EHR team comes to town, we will put our notes into the (#$^@ computer and no one will be able to read them any more.

Exchanging illegibility for unreadability

SOAP format implies: Subjective, Objective, Assessment and Plan, and has been this way since Larry Weed proposed his organized way of tracking patient data. With brief notes, and prior to all the federal regulations on what NEEDS TO BE in the note (if you didn’t write it down, it didn’t happen), SOAP notes were terrific. Even today, surgeon notes, on a global surgical fee (eg surgeon’s can’t bill on length or complexity of notes in the perioperative period), SOAP notes can be pretty darn brief:

S: Postop day 2. No complaints. Pain improving. Not passing gas yet.
O: Vitals stable. Wound looks good
A/P: Healing well. Teaching dressing change. Anticipate DC in AM if eating.

Here’s an example of MY pediatrician’s medical record on me. 16 years of my life on one piece of paper. OK, maybe just a bit TOO succinct.

In contrast, our electronic progress notes at the time were reaching 5, 7, even 15 pages long, full of regulatory language and audit trail signatures and time stamps.

A terrible example of Emergency Department note, circa 2010. Notice the red circles around the crucial elements in this 15 page note. And that the last page is all signatures and time stamps

What is worse, these long notes are particularly hard to read on a screen. In an EHR, that means: Find Chart Review – the listing of all notes, find the note you want to read. Click to open the document, then scroll 12 pages down to find the A/P. It’s not on the Last page, because that is full of signatures and time stamps. It is about page 10 out of 12. Then, Click – scroll, scroll, scroll for the A/P of the second note.

After about 3-4 of these, you get tired and STOP LOOKING for more thinking from other doctors. IT IS TOO HARD.

What a sad state of affairs. What to do?

My solution: APSO notes!

Yes, that note is 12 pages long, yes, we need to work on shortening it. In the meantime, how hard would it be to teach docs to put their ACTUAL THINKING at the top of the note? Assessment and Plan AT THE TOP.

This way, you could write your note in the same sequence: Subjective, history, past history, etc, then Objective, exam findings, lab results, and then MOVE BACK TO THE TOP and complete your Assessment (I think this is what is going on with the patient) and Plan (This is what we’re going to do about it).

By doing so, as the patient’s history and number of visits with various specialists gets longer, it continues to be EASY to click – (no scrolling) read the A/P, Click – (no scrolling) read the next A/P. Many times easier to browse the chart and get a concentrated dose of physician/APP thinking.

In my mind, I’m a genius.

How hard could it be to change doctor behavior?

You know what is coming. I did not.

I built a new note template: APSO format, to sit alongside SOAP format. I user-tested it in 1:1 meetings with about 80 colleagues, who all agreed “This seems better, easier.”

I launched the note template, held my breath …

I got to a 70% adoption rate. Woo-woo.

Many folks (EVEN AMONG MY SELF-PROCLAIMED FRIENDS) did not change behavior. “Oh, I forgot.” “Oh, I am planning on trying that sometime.” “Oh, I was very busy and running behind. Not today.”


Another failure for the Failure Resume.

About this time, I was reading Kotter’s Leading Change and also Machiavelli’s the Prince. Between the 2 texts, I had some insights.

1. The Burning Platform (Leading Change)

I knew we were headed to adopting a new EHR platform in 2011, which was sure to cause significant disruption in many ways. Never waste a good crisis. Use the Burning Platform: when everyone jumps, give them a good place to land.

If you’re going to mandate APSO notes in the EHR, why not do it from the ground-zero of installing a new EHR? This is what I set out to do. The ground-work: the standard template for all progress notes would be APSO format: Assessment/Plan/Subjective/Objective.

I told the white lie: “Sorry, our new EHR only comes with APSO notes.”

I got the leadership to back me up (see below): APSO notes are much more readable than standard scrolling SOAP. This is the right moment to make this major change in policy. Don’t let individual complainants revert back without a thorough review with all leaders.

2. How to build meeting consensus  (Machiavelli)

Having re-read my Machiavelli text, I set up my next plan. I needed medical leadership consensus on making such a broad-ranging change.

By the way, for those of you who equate Machiavelli with self-serving, power-hungry, win-at-all-costs reprobates, well sure. HOWEVER, his text is ALSO full of practical advice for leaders.

He states: if you go into a meeting and you do not already know how everyone will vote, you have not done your job.

There are 40 members of the multi-disciplinary Ambulatory Medical Directors group; they are a rowdy, tough-to-wrangle group with strong egos, lots of opinions, and rare consensus across primary care, medical specialty and surgical specialties. If you have worked any amount of time in healthcare, perhaps this is familiar to you.

I determined to meet 1:1 with the majority of the group, including of the most influential members.

My tactic:

CT: “Don’t you hate it when it is hard to read the notes of [other specialty here]?”
CT’s targeted medical director: “Yes! Their notes are TERRIBLE. Ours are fine, by the way.”
CT: “Right! Well, I’m planning on enforcing APSO format for their notes so it is easier for us to read them.”
Target MD: “That sounds great. It is SO NEEDED.”
CT: “However, in order for me to get them to change to APSO, I need YOUR specialty to change to APSO. We need to be unified and apply pressure to THEM to change.”
Target MD: “But, our notes are fine. We don’t need to change.”
CT: “I can’t do this without you. The actual change for you is minimal. Just start part way down the note at Subjective (that is F2 key pressed 2 times), your patient visits and documentation sequence doesn’t change, just the final display of the note is different. For a minimal investment on YOUR part, we ALL benefit from THEIR NOTES being more readable. How about it?”
Target MD: “Hmm. I suppose it is worth it. You can get THEM to change though?”
CT: “Yup, you give me your approval for your specialty, and I will get THEM to change.”
Target MD: “Deal. Makes sense. Minimal change for us, big improvement on their part.”

CT repeats this conversation WITH EVERY OTHER MEDICAL DIRECTOR. Each of whom have the same thing to say about every other specialty. “We’re great, but those guys are terrible.”

As a result, the following Committee discussion was a non-discussion: “CT is proposing standard APSO format for all notes written in Epic. Any discussion?” “Nope. Makes sense to me.” “Sounds ok.” And then discussing some minor concerns, we were done.


Perhaps 20 hours of planning and 1:1 meetings for a 5 minute agenda item.

What’s that? This is unworkable for the majority of decisions? You are absolutely right. We pull out all these techniques ONLY for the BIG decisions. But it can and does work. To this day, Primary care notes (we write about 1 million a year), are 100% APSO format, and specialties are about 88% APSO.

CMIO’s take?

Years later, I gave this talk at Epic UGM and it has become an Epic Classic (link requires userweb login). In subsequent years, readability and note format continue to be debated, and at one point I was referred to in a UGM session as “unlike those Radical Extremists at UCHealth who standardized on APSO, we can’t get our people to adopt it like that.”

Thanks for the … compliment?

And now you know how this particular sausage was made. Thanks to Machiavelli and Kotter, and all the smart people before us.

Automation Complacency, The Stepladder of AI in EHR’s, “Writing a note is how I think”. WHAT NOW?

A navel-gazing reflection on GPT, human cognitive effort, and the stepladder to the future. Where do YOU stand?

The image above generated by DALL-E embedded in the new BING, with the prompt “Doctors using a computer to treat patients, optimistic futuristic impressionistic image”. Wow. Not sure what the VR doctor coming out of the screen is doing.

Thanks to Dr. Brian Montague for prompting this post with his quote during a recent Large PIG meeting:

I find that I do a lot of my thinking when I write my progress note. If/when ChatGPT starts to write my note, when will I do that thinking?  — Brian Montague MD

That stopped me in my tracks.

We are so hell-bent on simplifying our work, reducing our EHR burden, we sometimes forget that this work is MORE than just pointing, clicking and typing.

It is also about THINKING. It is about assembling the data, carefully coaxing information and patterns out of our patients through skillful interview, parsimonious lab testing, and careful physical examination. It is how we, as physicians and APP’s, use our bodies and minds to craft an image of the syndrome, the disease: our hidden opponent.

Just like inserting a PC into the exam room changed dynamics, inserting GPT assistants into the EHR causes us to rethink … everything.

Pause to reflect

First, I think we should recall the technology adoption curve.

I fully acknowledge that I am currently dancing on the VERY PEAK of the peak of over-inflated expectations. Yes. That’s me right at the top.

Of concern, viewing the announcements this week from Google, Microsoft, and many others gives me chills (sometimes good, sometimes not) of what is coming: automated, deep-fake videos? Deep-fake images? Patients able to use GPT to write “more convincing” requests for … benzodiazepines? opiates? other controlled meds?

AND YET, think of the great things coming: GPT writing a first draft of the unending Patient Advice Requests coming to doctors. GPT writing a discharge summary based on events in a hospital stay. GPT gathering data relating to a particular disease process out of the terabytes of available data.

And where do we think physician/APP thinking might be impacted by excessive automation?

Automation Complacency

I refer you back to my book review of the book “The Glass Cage” by Nicholas Carr. As I said before, although this was written to critique the aircraft industry, I took it very personally as an attack on my whole career. I encourage you to read it.

In particular, I found the term “automation complacency” a fascinating and terrifying concept: that a user, who benefits from automation, will start to attribute MORE SKILL to the automation tool than it actually possesses, a COMPLACENCY that “don’t worry, I’m sure the automation will catch me if I make a mistake.”

We have already seen this among our clinicians, one of whom complained: “Why didn’t you warn me about the interaction between birth control pills and muscle relaxants? I expected the system to warn me of all relevant interactions. My patient had an adverse reaction because you did not warn me.”

Now, we have this problem. We have for years been turning off and reducing the number of interaction alerts we show to prescribers precisely because of alert fatigue. And now, we have complaints that “I want what I want when I want it. And you don’t have it right.” Seems like an impossible task. It IS an impossible task.

Thank you to all my fellow informaticists out there trying to make it right.

GPT and automation: helping or making worse?

Inserting a Large Language Model like GPT, that understands NOTHING, but just seems really fluent and sounding like an expert, could be helpful, but could also lull us into worse “automation complacency.” Even though we are supposed to (for now) read everything the GPT engine drafts, and we take full ownership of the output, how long will that last? Even today, I admit, as do most docs, that I use Dragon speech recognition and don’t read the output as carefully as I might.

Debating the steps in clinician thinking

So, here is where Dr. Montague and I had a discussion. We both believe it is true that a thoughtful, effective physician/APP will, after interviewing the patient and examining them, sit with the (formerly paper) chart, inhale all the relevant data, assemble it in their head. In the old days, we would suffer paper cuts and inky fingertips in this process of flipping pages. Now we just get carpal tunnel and dry eyes from the clicking, scrolling, scanning and typing.

Then when we’ve hunted and gathered the data, we slowly, carefully write an H/P or SOAP note (ok, an APSO-formatted SOAP note). It will include the Subjective (including a timeline of events), Objective (including relevant exam, lab findings), Assessment (assembly of symptoms into syndromes or diseases) and Plan (next steps to take).

During this laborious note-writing, we often come up with new ideas, new linkages, new insights. It is THIS PIECE we worry most about. If GPT can automate many of these pieces, WHERE WILL THE THINKING GO!?! I do not trust that GPT is truly thinking. I worry that the physician will instead STOP THINKING.


Is this a race-to-the-bottom, or a competition to see who can speed us up so much that we are no longer healers, just fast documenters, since we are so burned out?

Who will we be?

Radio vs TV vs Internet

My optimistic thought is this. Instead of GPT coming to take our jobs, I’m hopeful GPT becomes a useful assistant, sorting through the chaff, sorting and highlighting the useful information in a data-rich, information-poor chart.

Just like the radio industry feared that TV would put them out of business (they didn’t), and TV feared that the Internet would put them out of business (they didn’t), the same, I think, goes for physicians, established healthcare teams, and GPT-automation tools.

Lines will be drawn (with luck, WE will draw them), and our jobs will change substantially. Just like emergent (unpredictable) properties like “GPT hallucinations” have arisen, we must re-invent our work as unexpected curves arise while deploying our new assistants.

Another Bing-Dall-E image of physicians at a computer. In the future, a doctor will apparently have more legs than before.

A possible step-ladder

I think physician thinking really occurs at the assembly of the Assessment and Plan. And that the early days of GPT assistance will begin in the Subjective and Objective sections of the note. GPT could for example:

  • Subjective: Assemble a patient’s full chart on-demand for a new physician/APP meeting a patient in clinic, or on admission to hospital, focusing on previous events in can find in the local EHR or across a Health information exchange network, into an easily digestible timeline. Include a progression of symptoms, past history, past medications.
  • Objective: Filter a patient’s chart data to assemble a disease-specific timeline and summary: “show me all medications, test results, symptoms related to chest infection in the past year”
  • Then leave the assessment and planning to physician/APP assembly and un-assisted writing. This would leave clinician thinking largely untouched.
  • Subjective and Objective: GPT could take the entire chart and propose major diseases and syndromes it detects by pattern matching and assemble a brief page summary with supporting evidence and timeline, with citations.
  • Assessment and Plan: Suggest a prioritized list of Problems, severity, current state of treatment, suggested next treatments, based on a patient’s previous treatments and experience, as well as national best practices and guidelines. Leave the details, treatment adjustments and counseling to physicians/APPs interacting with the patient. Like Google Bard, GPT may suggest ‘top 3 suggestions with citations from literature or citations from EHR aggregate data’ and have the physician choose.
  • Subjective and Objective: GPT could take the Moderate tools, add detection and surveillance for emerging diseases not yet described (the next Covid? the next Ebola? new-drug-associated-myocarditis? tryptophan eosinophilia-myalgia syndrome, not seen since 1989?) for public health monitoring. Step into the scanner for full body photography, CT, MRI, PET, with a comprehensive assessment in 1 simple step.
  • Assessment and Plan: GPT diagnoses common and also rare diseases via memorizing 1000’s clinical pathways and best-practice algorithms. GPT initiates treatment plans, needing just physician/APP cosignature.
  • A/P: Empowered by Eliza – like tools for empathy, takes on counseling the patient, discovering what conversational techniques engender the most patient behavior change. Recent studies already indicate that GPT can be considered more empathetic than doctors responding to online medical queries.

CMIO’s take? First things first. While we can wring our hands about “training our replacements”, there is lots yet to do and discover about our newest assistants. Shall we go on, eyes open?

Machiavelli, “The Spare” and Medical Informatics? A reflection

What does “The Prince”, Prince Harry’s new book, and Medical Informatics have in common?

It is a joy to have a son in college who is still interested in speaking to me, the old fuddy-duddy born in the Last Century. He is attending St. John’s College in Santa Fe, where they study the Great Books curriculum, or as his sister says, “Oh, so you read about ideas from old dead white men?”


It so happens that his class, which started with Aristotle, has worked their way up past Copernicus (my recent post on changing world-views), and now in the sophomore year, is now reading Machiavelli, perhaps my favorite of the classics, since it so much to say about the challenges of leadership.

Over dinner last week, my son and I discussed what I remembered from reading the Machiavelli’s “The Prince” in our Physician/APP Informatics Book Club (yes, we did), and the quotes that I use almost every week at work.

Why Change is Difficult to Lead

The reason that change in an organization is so difficult, is because at best, your proponents are lukewarm, and your detractors have ALL THE PASSION IN THE WORLD –CT’s recollection of quote

And it should be considered that nothing is more difficult to handle, more doubtful of success, nor more dangerous to manage, than to put oneself at the head of introducing new orders. For the introducer has all those who benefit from the old orders as enemies, and he has lukewarm defenders in all those who might benefit from the new orders… The lukewarmness comes from the incredulity of men, who do not truly believe in new things…  –Original text from Machiavelli

How to Manage Bad or Good News

If you have to manage change that people will like, be sure to do it a little at at time and take credit for every improvement, to sustain the atmosphere of good will. If you have to manage a change that people will NOT LIKE, do it all at once. In fact, hire someone to make that change, and, at the end, when they are very unpopular, BEHEAD THEM. Problem solved.
–CT’s recollection.

For injuries must be done all together, so that, being tasted less, they offend less; and benefits should be done little by little so that they may be tasted better.
–Original Text from Machiavelli

Application: we have a new committee, EMO (electronic medication optimization) where we are learning to remove low value medication warnings (eg: multiple stimulants in one med list – many patients have more than one Adderall pill strength needed for the right dose). Suppressing such alerts that are 90% overridden, is a benefit. Every time we reduce clicks, we Broadcast it. Take credit for every reduction, every improvement.

On the other hand, when there is something ‘bad’ we must change, we do it all at once. We have to wipe out physicians’ old radiology order preferences in order to install new radiology orders that incorporate secure chat buttons and more effective routing. DON’T get rid of them piecemeal (they will hate you every time you make a change) rip off the bandaid all at once and remove ALL the preference lists and start fresh instead. ONE painful change. But, the ONE event fades faster in memory than many smaller changes. (Yes, I know that CT Lin ruined healthcare, regardless of what he chooses).

Close readers of the blog will remember that our book club also read Leading Change and also Buy-In by John Kotter. Really practical advice on tackling the sticky issue of how to set up important changes for success.

How to Build Consensus

Back in 2009 when I invented APSO notes (a future post) I had difficulty convincing colleagues to switch to a different format of document. In brief, SOAP notes are how docs have written standard notes for 70 years. APSO puts the assessment and plan, the most important part, at the top for increased speed and readability.

However, I had failed. In our EHR (Allscripts Touchworks at that time) I made APSO a selectable option next to standard SOAP notes. Result? 16% adoption rate, even among my close friends and colleagues.

I had an opportunity in 2011 for a platform change (we were adopting Epic) and I had a committee meeting to see if I could get APSO as the default standard.

Machiavelli teaches us that, if you don’t already know how everyone will vote at an important meeting, you have not done your work.

In brief, I made 30 minute appointments with EVERY influential medical director in that 30-member meeting to discuss APSO, answer their questions and in some cases do some horse trading (this for that) to gain support. Took a couple weeks to do this ground work, for this crucial decision.

Result? I achieved consensus at the meeting. APSO notes were the default (and for a time the ONLY) format available in our new Epic EHR. Thanks, big M.


This brings us to Prince Harry. I recently listened to his book “Spare”. I had not followed the royal drama closely, and did not know that Spare was a disparaging name for himself, in contrast to “The Heir” Prince William, as in “there’s the Heir, and there is the Spare.” How awful. See last week’s blog post (below).

One presumes that the Royal education includes the reading of The Prince, for modern princes.

One also presumes that palace intrigue, public scrutiny, the fickleness of public opinion, all weigh heavily, magnified to searing intensity by social media and paparazzi (what would Machiavelli say about paparazzi?).

Similarly, those leading projects in large health systems must contend with large populations, difficulty communicating effectively, rumor, innuendo, opposing viewpoints, resistance to change (but perhaps, not paparazzi).

Medical Informatics

To bring these threads together, one sees ancient and modern examples of leadership, managing communication, remembering that smart humans lived many years ago and wrote down their ideas. It is up to us to learn history or be doomed to repeat it. Remembering my personal failures, my 16-year journey to Open Notes, my nearly-failed plan to implement APSO notes, and now our struggles to deploy, maintain, study and improve Open Results, these innovations have all been guided, in some way by Machiavelli.

CMIO’s take? Who is the historian in your leadership group? Who reads the literature, learns from the past, and gives your teams perspective? How do you ensure a diversity of opinion, of thought? How do you challenge and disrupt yourselves to avoid complacency? I worry about this all the time.