Ghost Kitchens and their meaning

image from the NYTimes article

https://www.newyorker.com/news/letter-from-silicon-valley/our-ghost-kitchen-future

This is a great thinking piece from the New York Times. A ghost kitchen is a trailer set up in a parking lot, with chefs cooking dishes from restaurants, sometimes from 3-4 different restaurants. This can result in serving meals in the parking lot, or setting up for local delivery AS IF delivered from the main restaurant. This solves the problem of underemployed chefs at restaurants with inadequate social distancing seating, or restaurants that have had to remain closed for some reason.

Observations:

  • Placing ghost kitchens in parking lots leverages old spaces
  • Ghost kitchens emphasize hyperlocal location
  • Ghost kitchens are thriving during the pandemic
  • Ghost kitchens leverage internet tools: apps, A/B testing, analytics, and allows nimble innovation, recombination, creativity, disruption

Read the article, and come back here to think with me. What could healthcare learn from Ghost Kitchens? We are already seeing the beginning of disruption in healthcare: the use of telehealth visits with patients has increased the flexibility of patients and providers by removing geography as a constraint (in some cases). What could A/B testing, or analytics do to further serve our patients in a high-quality, personalized, lower cost way?

CMIO’s take? Sometimes, you have to look outside your usual work-sphere to get the best ideas. Sometimes you have to be willing to disrupt yourself before someone else gets there first.

All y’all EHR-using folks don’t know how good you have it.

The author, Chief Medical Information Officer of 3 million paper medical records.

For fun, I’ve set my Zoom background with an actual vintage 1997 photo I took of the medical records room in the basement of University of Colorado Hospital on Ninth Avenue in Denver (back when giants walked the earth). This aisle featured 6 stacked rows of medical record charts AND piles of paper record folders ON TOP since we were out of room (not shown). This was one of 29 aisles of records in the Records Room, holding ONLY the latest 3 years of records: the rest were retained (for 27 years) in a downtown warehouse.

Fun fact: we turned down lots of innovation partnerships and offers of free services because the medical information locked in those paper records was too difficult to pull out:

  • We have a Pulmonary Function mobile van parked out front: send us all your patients who currently smoke and we will screen their lung function for free!
  • Hey, our insurance company will pay you a bonus payment if you can prove all of the patients who have had a previous heart attack are taking aspirin! (true story, a clinic trying to prove this using paper medical records and clerical staff paid more gathering the data than they received in bonus money)
  • Quick: the mobile mammogram bus is coming next week: let’s call all our patients who are due for mammography screening!
  • We have a new diabetes educator visiting for a couple weeks! Can we contact all our patients with diabetes to come for a free visit?
  • Uh, oh! The medication Bextra is being recalled by the manufacturer; quick: call all our patients taking that medication! (True story: 1/2 of our clinics were able to run a report on our EHR at the time and call affected patients immediately; the other half, still relying on paper records, had to say… “well, when the patient calls for a prescription refill in a few months, THEN we’ll tell them…”)

Fortunately, it is simple in our current EHR to run ad-hoc reports to do all this now. Whew! And, we can do predictive analytics on this data to save lives that would have blown my mind back then.

Here’s another flashback:

Don’t tell the post office; this is where all their bins went

THIS is the Medical Records intake room, back when we were ONE hospital, 40 clinics (we’re now 12 hospitals, 800 clinics). On average, 6 vertical feet of paper, received EVERY DAY. Fifty medical records staff, filing, sorting, pulling, sending, receiving, creating new charts. And, still, we were 2 WEEKS behind on filing.

We had over 20 transcription services, all local, receiving tiny tape-recorder dictaphone tapes, transported by COURIER from the doctors dictating. As an aside, some of us remember hearing doctors mumbling their ultra-fast, only partly understandable dictations walking the halls between patients. On average, outpatient transcriptions took about 2 weeks to complete and print out, mail, and file back into the record. Inpatient daily transcriptions were ordered STAT for 3x the cost and typed same day, arrived by urgent courier in the late evening and taped into the paper chart.

I am proud of my doctor handwriting

For the record, here’s a paper progress note I wrote in 1999 on “non-carbon paper” sending the original copy to Hospital Medical Records, and then keeping the yellow copy in a “shadow chart”: a duplicate set of medical records kept in our “off-site clinic” because … we could not count on Hospital Medical Records to pull the relevant charts for clinic patients scheduled each day.

Don’t even get me started on our appointment scheduling system. “Oh yes, thanks for calling! So you’re looking for Dr. Lin’s next available appointment? Sorry, nothing for the next 3 weeks. Oh, you’d like to see the next available doctor? =sigh= OK I’ll pull down the other twelve 3-ring binders, one for each doctor, and see who might have an open spot.”

Are you keeping track? 50 medical records staff at the hospital to maintain Main Medical Records, and 1-2 additional medical records staff at EVERY clinic (about 40 clinics) to keep a shadow chart. Because we don’t trust each other to keep track and deliver records on time!

Hello, dolly

Oh, and meet this guy. In 1997, our medical information (see: x-ray films, paper medical records, dictaphone tapes) moved at the speed of rush-hour traffic on Colfax Avenue. Seven miles each way, 12 leased buildings throughout metro Denver. Two round trips every day.

With all this person-power and effort, the result? On a typical clinic day, I would see about 18 internal medicine patients. Main medical records would successfully deliver charts for about 9 patients. Our clinic’s shadow chart system would deliver charts to my exam room for about 6 additional patients, leaving, on average THREE patients with NO CHART. Just a piece of non-carbon paper, with handwritten vital signs and a list of patient-reported allergies that day. Mind you, there was no such thing as a clinical computer system at the time. As a result:

“Hi Doc! It is great to see you! What did my cardiologist tell you about me when he saw me 2 weeks ago and did all those tests? He said that I should come talk to you about his report.”

Um. I don’t have any of your records today. I see your blood pressure looks good and that you report no allergies to medicines though.”

“What?! I made this appointment to go over his report! That visit was 2 weeks ago!”

“Yes. Um. What condition, exactly, do you have? Why did we send you to my cardiology colleague? What do you remember that he told YOU? Can you help me out here?”

“This is disappointing. You mean you really have nothing on me? Do you at least have the blood test results or the echo result?”

“Um, no. I’m really sorry about this. Okay, tell you what, no charge for today, my apologies for wasting your time and I will call you later this week after I call and yell at my medical records people and maybe get your chart and see what it says.”

“Whatever. You guys should really get your act together. Okay, can you at least go ahead and refill those 3 medicines that you prescribed for me from last year? I’m about out.”

(Excitedly taking out prescription pad) “Sure, I’m happy to! Do you happen to remember the names of the medications and the doses and what they’re for?”

Let’s not even talk about loading up a 2-foot-tall stack of medical records in our arms, walking out to the car, throwing them in the trunk, driving home and dictating late into the night, and hopefully remembering to bring them back into the office the next day.

And, if there was an urgent need for a particular medical record? We would routinely have a couple staff members wandering the clinic, from office to office, desk to desk asking: “Do you have the chart for Peterson, Mary, or Smith, Joseph, or Samuels, Jane?” and thus not answering the phone, or rooming patients…

Of course, by contrast, with our current EHR, tap-tap-tap: instant access to any patient record.

Yesterday, for example, my patient met her oncologist to discuss a new diagnosis of metastatic cancer. Today, I was able to read her consulting note, review the pathology from a recent biopsy, refresh my education about peritoneal carcinomatosis in an EHR-linked online textbook, secure-chat and then phone call with the oncologist about prognosis and treatment options, set up a video visit with the patient and her family, and have a have a well-informed, thoughtful conversation about her next steps.

This speed and coordination would not have been possible in the era of paper charts.

Not as cool as Jimmy Fallon’s Thank you Notes

Wait! One more thing! Remember the good old days when we received faxed blood test results and then had to notify patients by writing a STACK of folded post cards? I faced a stack of these EVERY EVENING at the end of clinic. Please don’t ask me how many times a patient brought back a post card saying: “Um, this looks pretty important, but, I think you meant to send this to a different Peter Smith. I haven’t had a blood test in awhile.”

Yikes.

Our patient Portal, we call My Health Connection: we release test results to the patient online, and then send comments with our interpretations, arriving to the patient’s inbox instantly. Comment from my patient? “It feels like I have my doctor in my pocket. So cool.”

CMIO’s take? All y’all don’t know how good you have it.

On the other hand, are you old, like me? Do you remember those days?

On the third hand, in another decade, I hope folks will look back to TODAY and marvel how much better the future is.

Moment of Zen for Mother’s Day

If you’re not getting away enough from all things Pandemic, here’s a nice long-exposure photo from my iPhone 7. Yes, a CMIO with an iPhone 7. And I still love it. At least I have a smartphone, unlike one of my informaticist colleagues.

Forest bathing is a thing in Japan and increasingly worldwide, and perhaps we could learn a thing or two. OR, try Norway’s Slow TV (YouTube, almost 10 hours! Surprising how compelling it is, try it full screen), as highlighted by CBS Sunday Morning (8 minutes, YouTube). Don’t miss it!

Hope you all have a great Mothers’ day.

Miso soup v COVID-19.

Miso soup. One of my late nite superpowers.

Here’s a Sunday post: Musing about miso soup and it’s role in my battle with the pandemic. If you’re here for data, clinical informatics, and health system thinking, you can leave now.

FLASHBACK, mid-1970’s.

When I was the age of my youngest niece (okay, my only niece), I remember telling my mother who had just served me a bowl of home-made soup, with a sprinkling of goldfish crackers:

THIS SOUP IS SO YUMMY. I think it must be the goldfish I put in there. Goldfish are the perfect food, and I think I’m going to make a soup just from goldfish crackers and hot water. Mom, can I have some hot water?

Of course I wasn’t watching my mother’s face at the time, I was so sure of my world-shattering upcoming invention: Delicious hot water-and-goldfish soup.

I stood by, as she boiled some hot water for me on the stove. I had carefully selected a big handful of goldfish, and was cautiously resisting eating them, KNOWING that the soup was going to be TOTALLY WORTH THE WAIT. I was bouncing with excitement.

At last, hot water, in a cup on the kitchen table. =Plt-phtl-tlthtpl-plthth-ppth!= I slid all my goldfish from my sweaty palm into the cup, gave it a big stir,

…paused for a drawn-out moment to let the flavors swirl…

And took a big sip.

What did I think? It gradually dawned on me, as my face twisted into a surprised grimace, that the soup was not good … AT ALL. Just a bunch of semi-soggy flavor-less crackers and hot water.

I tried to fix it: added salt and pepper. Even some “Accent” (packaged MSG salt; hey it was the 1970’s! anything goes). Nope. Nope. And Nope.

I finally looked at my mom, who was silently watching, smiling and shaking her head at me. It was a lesson, I suppose, that her son had to learn for himself. Good soup was just not going to be that easy.

FLASH-FORWARD, present day.

I have always been obsessed with soup. Almost every restaurant we go to (or, used to go to), I would scour the soup offerings for candidates. I did let go of my soup-inventing dreams, but have lately been punching out Instant Pot – powered soups like Rosemary Cauliflower and Ginger Carrot, to some pretty good family reviews. But of course, they realize it’s Dad cooking, so the critic-grading-scale is set pretty low and forgiving to start.

Night-times are for miso soup, though. I’m a night owl and do some of my best thinking and working at night, and give me 1 teaspoon of Marukame Boy brand Miso paste, a cup from the hot-water pot, a sprinkling of scallions (pre-sliced and saved in a container in the fridge), and maybe some … GOLDFISH CRACKERS from a huge Costco bag. Heaven.

And, what do you know? Miso soup, consumed daily is supposed to have ability to FIGHT INFECTIONS! Hey! Who needs vaccines or treatments? Daily miso soup for EVERYONE, that’s the ticket. Okay, whatever, no.

Turns out, if my pre-teen self had just known SOMETHING about miso paste, I might have been a chef instead. Happy Sunday, everyone. Hi, Natalie!

Laocoön, The Aeneid and Captain Picard

https://en.wikipedia.org/wiki/Laoco%C3%B6n_and_His_Sons

My high-school aged son is avidly devouring classic literature, and the echoes of those epic struggles from my own education, float back to me. On our winter break one evening, he had left the Norton Anthology of Western Literature out on the coffee table. Soon I was in the midst of battle at Troy, at Carthage, in Rome.

Aeneas of Troy, in the classic by Virgil, faces a long journey with many trials. Even in 20 BC, storytellers mastered Story. Sometimes the smallest moments are the best parts of a story:

  • Laocoön runs out from the city to warn his fellow citizens of Troy, that the large wooden horse left behind by hastily departed Greeks, was a trick: ‘beware of Greeks, even bearing gifts.’ To punish him, the gods send a pair of serpents to devour his sons and then kill him. The image above of Laocoön dying defending his sons is such a moment. The city elders, seeing him killed by the gods, are then convinced that he is wrong, and bring the Trojan Horse inside the gates. Of course, you know the rest: the city of Troy falls that night as hidden Greek solders pour out, open the gates and ransack the city.
  • Aeneas initially resolves to stay and defend his city to the death. His touching moment with his father and their resolve to stay together and flee is a pivotal moment of change for both of them.
  • Aeneas meets Dido, queen of Carthage, in his storm-tossed journey, and falls madly in love. Soon after, the gods send him a message that he and his lineage are to become the founders of Rome. He leaves immediately. Dido kills herself in despair.
  • With supernatural help, Aeneas journeys to the underworld to see the future: that his descendants establish Rome and create the Roman Empire.

These moments, to which I’ve summarized so prosaically, are told in verse and with rich detail and sensory imagery.

Interestingly, the Norton Anthology also included the ancient translation of Gilgamesh, perhaps the oldest recorded epic story. Being a science fiction geek, perhaps I should not have been surprised that my first exposure to this classic, written in antiquity, circa 1700 BC, first reached my ears via Captain Picard, on the all-time most popular episode of Star Trek, The Next Generation TV show called Darmok (no, not the new, apparently amazing show, that is behind the CBS paywall). Careful, don’t read the links unless you have time; you won’t come out for awhile.

CMIO’s take? Great storytelling captivating, and timeless. Smart people lived thousands of years ago. Sometimes Captain Picard teaches you ancient literature.

Unified Theory of Design Thinking for Social Systems (thanks to d_school at Stanford)

I recently attended a 6-day course Designing for Social Systems at the Hasso Plattner d_school at Stanford University. We sent at team from our Wellness initiative at the University of Colorado Department of Medicine, cutely named “WellDOM” (more on this in a future post). It was … a mind blower.

What is design thinking and why is it so cool?

  • It is a system of thinking that both expands and focuses creative thought.
  • It encourages curiosity and diving into the ethnography of individuals
  • It also encourages thinking about positive and negative influences at many levels of social systems
  • It actively encourages play, physical manipulation of prototypes and sticky notes to build a joint vision
  • It uses storytelling, rapid cycle development, ‘what if’ and ‘how might we’ statements to spark ideas.
  • It is FUN.

I’ve been thinking and digesting what I learned over the past few months and came up with the graphic above. I’m a visual thinker, and although it is quite cluttered, I think it finally encapsulates the scope of what I now appreciate to be Design Thinking for Social Systems:

  • It is Human-Centered (focused on emotion, story, experience), the inner yellow circle
  • It is Systems-Aware (complex social systems impact your success), the outer blue circle
  • It is Strategy-Focused (keep your end-goals in mind)
  • The inner and outer circles interact, and the strategy lane underlies the whole group of activities.
  • There are perhaps 4 dozen specific activities that allow you dive deeply into every part of this diagram, in your pursuit of a creative, lateral-thinking solution to complex, ambiguous problems.

Don’t wait! Take one of these courses! And start applying it today!

CMIO’s take? Creativity, and NOT Computing Horsepower, is the next frontier.

Five healthcare schools on one campus! Innovation on the Anschutz Medical Campus.

img_1451
Weird spirochetal sculpture at Education Quadrangle, Anschutz Medical Campus

It is amazing that 5 major health schools are in shared buildings with shared resources on one campus: medical, dental, nursing, pharmacy, public health. I believe we may be the ONLY campus with such shared facilities and schools in one place! The cross-pollination of ideas between these schools, their faculty and students and projects is fertile and exciting. Add the CU Innovations unit that pulls in the healthy startup community in Colorado, and see what sprouts up! (Watch this space for some outcomes of this work.)

The history of Anschutz Medical Campus (named after Phil Anschutz, tycoon with history in oil, railroads, telecom) goes back to Fitzsimons Army Hospital from 1927, a World War I recuperation hospital. Back then Building 500 was the main hospital (see center of this interactive map).

We’ve come a long way from a square mile of military marching fields with a solo hospital in the midst, to being Eisenhower’s recuperation hospital in 1995, and now we are a square mile of a medical campus with over 30,000 employees and 3 major medical centers (UCHealth, Childrens Hospital Colorado, and Denver VA Medical Center).

Exact Instructions on making a PBJ sandwich. OMG

http://laughingsquid.com/father-follows-childrens-exact-instructions-for-making-peanut-butter-jelly-sandwich/

Oh, this is precious. This reminds me of my intern days at University of California Davis Medical Center, when I was learning to write orders in paper charts for nurses and others to carry out on my patients. I very quickly learned:

  1. Even if you have bad handwriting, strive to write legibly. What, don’t like getting paged at midnight for an illegible order? Oh.
  2. Think through what you’re going to write so that your order doesn’t read like a Jane Austen novel. RN’s have to manually transcribe your order verbatim into their records. Be nice.
  3. Pretend that nurses and other staff are MALICIOUS ROBOTS THAT ARE TRYING TO MISINTERPRET YOUR ORDERS IN ANY WAY POSSIBLE. Making that assumption forces you to write as clearly as possible. Nobody can see inside your head. This perhaps has been the best life lesson, not only for writing orders in patient charts, but for life in general. We won’t go into details.

CMIO’s take? Lesson 3 for me was brought back in full force by the above video. Thank you, Internet.