Forest bathing: what is it good for?

Sometimes it is good to get away. Mind you, this photo is more than a year old (before pandemic), but it makes a few points…

Exercise

Remember to get some exercise. Just … not with 3 super-fit members of your family. Notice everyone having a good time running, except Dad with the barely suppressed grimace of pain and facial mask of determination.

Family

Remember, family members are supposed to support each other. And not run too fast for old people to keep up.

Forest

This is the beautiful Forest of Nisene Marks. I have to say, those articles about Forest Bathing? Yup, they’re right on. That time spent in the woods? When I wasn’t gasping for air, it was a spectacular place, a place to recharge.

Leisurely Jog

As always, I had agreed to go for a “leisurely jog” with the kids and with my baby sis. We would run up the path for maybe a mile or 2, then “It’ll be easy, coming back down! Come on! It’ll be fun!”

Grasping my iPhone with a death grip, I set off. Because, if you’re going to go for a run, your iPhone HAS to track your exercise, doesn’t it? As quippy daughter always says:

“Dad, it’s NOT about the steps. IT’S ABOUT THE LIFE.”

I disagree. If my exercise app doesn’t track it, what’s the point?

Nevertheless, we get to the top (barely). I sprint to the turnaround sign (because, Dads have to make a point). This causes nausea with imminent vagal response.

After some time spent with arms tripod-ed on the knees, gasping for air, concerned looks from the sister (the kids are immune to these cries for sympathy) and an extended period of hands-on-hips walking back down the trail, we commence our downward leg.

I was promised an easier time headed down. This was a complete fabrication.

It was several hours later (or so it seemed) we got back to the car.

CMIO’s take: I do have to admit, the smells, the sights, the laughter were a wonderful respite. Yes, we did bathe in the forest (with our clothes on). And it did refresh my spirit. How do YOU recharge?

Fatal crashes, the Macintosh, and the Shallows

https://www.wired.com/story/how-dumb-design-wwii-plane-led-macintosh

Thanks to WIRED for this article on the design of planes, specifically the B-17 bomber in World War II and how fatal crashes led to better design and human/machine and human/computer interfaces, leading to the Macintosh.

Although thought provoking, I dislike and disagree with some of the discussions in this article:

  • Carnival Cruise’s idea that a “personal genome” should learn your preferences as you wander the ship, and show and encourage you to see more of the same. Where is serendipity, discovery, and being exposed to contrasting ideas?
  • Furthermore, what about The Shallows: what the internet is doing to our brains? Like what I’m doing to you here, reading my blog post, probably sent here from a link from your Twitter or Linkedin or Facebook streams. We are skimmers, not readers anymore. Can we even hold a complex thread of ideas in our head on one topic?
  • I’m reminded of the medical term “clang association” where patients with psychosis hear something which reminds them of an unrelated conversation. Distractable, are we.
  • Also, the pre-flight checklist, I think, comes from the B-17 bomber, the plane that was claimed to be “too complicated for humans to fly”.

CMIO’s take? See how I illustrated clang associations for you? AFAIK I don’t have psychosis or schizophrenia, but then maybe — SQUIRREL!

What clinical informatics is NOT. Also Nerd Glasses and Propeller Hats.

My offspring. An out-take from Go-Go, their K-pop dance routine. See hyperlink below.

I’m reading a book called Mindfulness in Plain English: another book my daughter left laying around the house with her annotations in it. I love the underlining and ‘YES!’ marks and also the ‘is it though? You shouldn’t wait to be perfect…’ comments. Just a few short years ago, she was in the playpen, and now I love to see her mind at work.

Anyhow, mindfulness meditation is something that I aspire to: I have had months where I meditate daily, and there are times when I forget and lose the habit. I have found it calming and centering and have found clarity through the practice.

You can refer to my blog series ‘CT Meditates, a comedy’ from 2017.

What I love about this current book is the chapter on what Meditation is Not. I love it. It helps define the thing by talking about what it is NOT. For example an annotated list:

WHAT MEDITATION IS NOT

  • Misconception 1: meditation is just relaxation
  • Misconception 2: meditation means going into a trance
  • Misconception 3: meditation is mysterious and cannot be understood
  • Misconception 4: meditation is for saints. Not regular people.
  • Misconception 5: meditation is running away from reality

I love this idea. Writing about the negative space helps clarify what something IS. So, here goes.

There are lots of misconceptions about what Clinical Informatics is.

It can be defined as the science and practice of managing information by capturing, storing, analyzing, retrieving, and using data to improve the care of patients and populations.

Sure, whatever. Perhaps it is more meaningful to talk about misconceptions.

WHAT CLINICAL INFORMATICS IS NOT

  • Misconception: informatics people are the secret Star Chamber of the Electronic Health Record. They wear propeller hats or nerd glasses. <– Yes, these are my nerd kids wearing propeller hats and nerd glasses. And yes, I am proud of them.
  • Misconception: informatics helps you set up your computer. (That’s Information Technology)
  • Misconception: informatics has to do with servers, network cables, wifi problems. (still, IT)
  • Misconception: informatics is a way to force people to do things they don’t want to do. (no, no, no)
  • Misconception: informatics is only about designing things, we leave training to others. (ok, partly right, but we all fail if we don’t train adequately)
  • Misconception: informatics is for people who prefer computers and don’t like talking with humans. (no. please do not send us “the doctor who is our resident computer nerd.”)
  • Misconception: informatics is quick and easy, just put a hard stop there, and DONE! (no. we do not “force those other doctors to do this thing because it makes it more convenient for me and my project” UNLESS it is also good for patient care and clinical leaders all agree)
  • Misconception: informatics has no need of customer/user (patient or clinician) feedback. (just no)
  • Misconception: informatics is a special and arcane field that only computer geeks will understand. (sigh. we fail if this happens)
  • Misconception: informatics is a field of medicine where most people tell you, NO we can’t do that.
  • Misconception: informatics always takes months to achieve the goal or complete a project. (when we do Sprints, we can amaze our docs)
  • Misconception: informatics is unnecessary: an EHR project only needs a subject matter expert and a computer analyst (sorry, without an informaticist to translate, such a project is likely to fail)

Informatics is NOT “Hard stop, and Done!” Instead it is building relationships, understanding the pressures and desires of patients, providers, staff, and understanding the ultimate goal of health care.

Indeed, it is perhaps, one of the major advances of modern healthcare. I would argue, the field of “clinical informatics” should eventually become standard curriculum for ALL physicians.

CMIO’s take: Health care is about using our best science, our best work-flow, our best teamwork. We use this information to heal individual patients and improve the health of our communities. We need great, up-to-date information to do that. Only by capturing, storing, analyzing data, creating new knowledge, and delivering that seamlessly to the provider at the bedside (or directly to the patient) can we grow, improve and evolve as a learning health system.

The Quandary 14’er. Observations of an aging human.

Coming out of the tree-line, noticing the bright moonlight, we shut off our headlamps, casting the trail in an eerie black-and-white moonscape. We hiked by moonlight!

Quandary Peak, left, dominating the Breckenridge valley.

Quandary, for many Coloradoans, is just another one of those 53 peaks in Colorado over 14,000 feet in elevation. For me, however, it was a daunting collection of challenges posed by my college-aged kids. Would I get up at 2:45am to attempt to summit at sunrise? Would I know how to hike in darkness with a headlamp and not trip and fall? Would I keep the pace? Would I tumble off the wind-blown trail on the way up?

Quandary Peak is apparently one of the easier Colorado 14’ers to hike; only 3 miles from the trailhead to summit. How hard could it be?

Yup. Pretty hard.

Those of you who have followed The Undiscovered Country know that I will try anything … once. For example, a 7 mile cross-country ski-in trip to Uncle Bud’s Hut.

Some quick observations:

  • At 2:45am, not a lot of cars on the road to the Quandary trailhead, up near Breckenridge, about 2 hours from Denver.
  • Hiking in the middle of the night, with disappearing trails, steep rocky steps and tree roots galore, is … trippy? exhilarating? disorienting? All of the above.
  • Hiking with a headlamp is surprisingly do-able (especially with the adrenaline of: am-I-going-to-survive-this energy).
  • Hiking with a headlamp is also highly claustrophobic, in that your entire world is the stomp of your boot, the clatter of your hiking poles, the next visible tree, the next rock, the next chance to trip in your faint circle of light.
  • About 4am, coming out of the tree-line, noticing the bright moonlight, we shut off our headlamps, casting the trail in an eerie black-and-white moonscape. We hiked by moonlight! This distracted me from the gusting, bone-chilling winds and the constant scramble over the rock fields. Nope, don’t have a camera that can capture this. But, next best thing (below):
Stars, the son, and the hint of sunrise.
Pre-dawn scramble. Before the madding crowds.
Pre-dawn gloam in solitude, then blazing sun on descent, increasingly crowded.

About 530am, a purple, then green, then orange glimmer of sunrise to the east. Interestingly, the rocks started to glow orange UNDERNEATH, while faintly white on top. Is this what sunrise hiking is like? Never, have I ever…

Imagine: much darker, and somehow, the rocks glow orange underneath…

About 630am, after some shifting clouds, orange crepuscular rays burst through and the entire rocky ascent turned brilliant orange, moonlight banished. 4 liters of water disappears fast on a constant upward climb at 11,000 then 12,000 then 13,000 feet. So do snack bars and ham and cheese sandwiches.

Summit! about 7am. How could 3 miles take 4 hours? In hindsight: donning and doffing gear. Frequent gasping-for-air breaks (disguised as water breaks). I have no idea how Everest climbers have base camp far above 14,000 feet. Even acclimated to 5000 ft altitude in Denver, the additional elevation is tough on the lungs, heart, brain.

The US Geological Survey marker, 14,200 ft. Quandary Peak.

The timing of our climb, on a Saturday morning starting around 3am, was good; few people on the trail, and at our summit, we were among the first 10 people there, taking pictures. The descent, however… Well, lets just say, the photo below was about 8am. Within the hour, we saw hundreds of other peak-aspiring hikers on the narrow trail.

Rocks, and a cool ridgeline hike.

I’m thankful of active offspring who invite me along on such adventures. I’ve summitted 3 peaks that were 14’ers: Gray’s and Torrey’s, and now Quandary. Today I vow that this is my last 14’er: no need to punish this body any further.

On the other hand, I said the same after Gray’s and Torrey’s, two peaks side-by-side and commonly done on the same hike. I made the mistake that day of not bringing hiking poles. The descent, not the uphill, was my undoing: near the end of the hike, my right knee was so swollen and painful that I ended up keeping the knee straight and just swinging it outwards to take a step forward. In our family, we call that the “Pinocchio leg” for somewhat unclear reasons.

Quandary summit with daughter. The Rockies go on forever, it appears.

My main goal this trip: 1. Survive. 2. Use hiking poles to aid descent and avoid Pinocchio leg. 3. Blog about it. Success!

CMIO’s take? What are you doing to recharge?

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!

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