Solve your problems, with a Ladder at work (what?)!

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He’s at it again.

There is a risk, in a large and growing IT organization in a large and growing health system (we’re up to 9 hospitals, 400 clinics) is getting disconnected among the hundreds of employees and colleagues within this unit. We certainly don’t have all of it figured out, but there are proud moments when we do something good…

(like untalented folks playing ukulele – see https://youtu.be/EC6yXXYl1vY) (as an aside, did you know that YouTube now AUTOMATICALLY generates closed caption content?) (although bad singing apparently still stumps it!) (and, there is a tool for humans to correct the computer-generated text) (hey, everybody, just like transcriptionists everywhere, who are employed by companies applying Speech Recognition to incoming physician dictations BEFORE having a human correct the computer generated text, I’m now also officially a Correctionist! the new title, apparently, for transcriptionists doing this new work).

Whew! I’ve always wanted to create a parenthetical aside that took on a life of its own (see my previous review of the book Mezzanine for the most artful and entertaining example of massively meandering asides).

Nevertheless, after some initial hesitance, gradual persuasion, and some non-standard funding, we’ve had a ping-pong table ensconced in the midst of our IT building for several years.

IMG_3589Okay, so we haven’t always been as quiet as we should be, to avoid disturbing those unfortunate enough to have a cubicle near the Ping Pong room. And, yes there is always the persistent business pressure of converting that conference room back into more offices, but we have held on (so far).

Use of the table is sporadic, and I feel, insufficient to deliver the quantity and quality of potential joy and human connection that comes with such an unexpected resource. In other words: HEY PEOPLE WHERE IS EVERYBODY.

I know, West Coast start-up companies all have ping pong tables and foosball, and the perks to attract millennials and them younger folks who, I’m told, are constantly joining the workforce. Sure. I’m just an aging boomer trying to keep up.

WHICH brings me finally to my point. After years of inertia, I put the finishing touches on my Ping Pong Ladder last night, and mounted it with some help (and, an IT colleague’s pen that has a built-in Level!)

This is a flashback to my heady days, in college, of being the Athletic Director in my dorm, and trying to convince my classmates that playing an intramural sport actually helps reduce stress and improve academic performance. In those days, I built and posted a ping-pong ladder in the basement of our dorm and had an active cadre of about a dozen classmates with more enthusiasm than skill, and had a grand time.

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Heady days of college
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OK, actually, heady days of college. The “athletic director.” Uh-huh.

 

However, the contrast here, is (okay, you can stop laughing now).

The contrast here is, nobody knows what a ping pong ladder is! Really?! “Hey,  when is the tournament?” “How does this thing work?” There’s a bigger social commentary here, too much FaceTime and not enough face time. Too much texting and not enough bowling. If you haven’t heard about or read Putnam’s amazing critique of the modern age, Bowling Alone, (TL;DR) at least read the synopsis, like I did.

I had to explain the underpinnings of the Ladder to several colleagues; that you challenge up to 3 spots up the ladder, and if you win, you take their spot and everyone else moves down, and that fundamentally, it is about social connections, finding someone to play ping-pong with, and having a social construct, an excuse to blow off some steam, have a chat, get some blood flowing, and then get back to work. No need to even break a sweat if you don’t want to. The good news is, everyone has either played ping pong or is willing to try. At least that is my hope.

Did you know, by the way, that official ping pong rules changed decades ago? Seriously? I learned that a game was first to 21, that you served 5 times in a row then switched, etc. Now, games are to 11, and you switch EVERY 2 SERVES. Apparently, nobody has time anymore. But, games do move more quickly, and more folks do get to play. So there’s that.

And of course, thanks to the first followers; it would be a sad day if my tile was the only one on the ladder. We had 19 colleagues put up a tile on our first day. Hooray!

CMIO’s take? Do you have a ping-pong ladder? or have you had to explain some ancient social norm recently to a younger colleague? Do we even think Ping Pong Ladders can survive in this modern age? Or is it time for the Boomer and his sad Ladder to walk into the sunset? Let me know.

Food trucks, Marble, Eisenhower, World War I, and walking through history at Anschutz

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The end of Summer, and of the line up of Food Trucks throughout the every-Wednesday summer extravagance.

Until the brief fall and onset of winter, that means flowers, blue skies, a chance to get out of our own heads, our stuffy offices, our walled-off Ivory Tower, and look around.

For example, how many of my colleagues know the history of that building in the background? The poetically-named “Building 500” was originally the Army Recuperation Hospital, built in 1927 for veterans from the first World War.

Its entryway is comprised of amazing, art-deco white marble, mined from Marble, Colorado, the same marble that was used to build the Lincoln Memorial.


If you look carefully at the steps going up from Ground to First Floor, you can see where decades of soldier’s boots wore a rut into both the upgoing and downgoing marble stairs.


Building 500 is also the site of a tiny by-appointment-only museum of President Eisenhower’s hospital room. Eisenhower suffered a heart attack while playing golf on the Fitzsimons Army base, initially treated as indigestion by his Presidential physician. Subsequently recognized as a heart attack, he was promptly put to bedrest, and treated with oxygen and morphine, the state-of-the-art care in 1955. Eventually the White House Cabinet members traveled by train to Colorado, and buildings at Fitzsimons Army Base and the Lowry Air Force base became the “Western White House” for a month during Eisenhower’s recuperation.

The University’s chapter on this campus began in 1999, with the agreement that the Feds would “sell” this square mile to the University for the price of $1, transitioning this land to a non-profit organization essentially for free. As one of my colleagues so aptly said: “Free is great, if you can afford it.” Think about it.

Since then, the entirety of University of Colorado Hospital and its 60 clinics have arrived, as has Children’s Hospital of Colorado, and soon the Veteran’s Affairs Hospital for Colorado. The Anschutz Medical Campus contains these three organizations, as well as 5 healthcare schools in the education quadrangle including the University of Colorado “CU” School of Medicine. It also contains all the CU research labs in the Research Quadrangle. This land has since attracted the Well Simulation Center, a housing quadrangle, and a Bioscience Research Park, hosting innovative companies developing partnerships with the scientists on this campus. It is a great place to work.

CMIO’s take? There’s a lot to be said about institutional memory, our roots, and how we got to where we are.

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

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

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

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

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

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

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

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

Keep your eyes on your goal, not your obstacle

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Some years ago, I was a post-call intern at UC Davis Medical Center. I had been up for about 30 hours in a row, but was hoping to get out for a quick bike ride on the American River bike trail in downtown Sacramento, near where I lived. I called up a fellow intern, and headed out for a quick training ride on a lovely bike trail by the river.

I was proud of myself for getting out, getting some exercise, connecting with a friend, even though I was post-call. In those heady days, I often followed the bike racing events like the Tour de France. My friend and I were learning to “paceline” or draft off each other as we rode through the early afternoon glades.

On our way back, there was a large lawn in between two bike paths, one that goes up to the bridge toward home, and one that continues underneath the bridge, heading towards downtown Sacramento. Due to a miscommunication, I nearly tangled with my riding partner, and swerving slightly to miss him, ended up splitting the difference of both paths and riding into the smooth green lawn.

No, problem, you say?

I immediately spotted a trash can about 30 yards away, sitting by itself, no obstructions around it on this nice green lawn. I was headed straight for it, at about 20 miles per hour, a good clip.

My post-call brain went into emergency mode. My eyes locked on the obstruction as it grew rapidly larger, my hands locked onto the brakes, and I began to skid across the grass.

It became clear that I was slowing down, but not enough to miss the trash can. Now, keep in mind that the trash can was about 3 feet wide, in a large grassy lawn that is about 1/2 acre in size, and no other hazards nearby. I was making a beeline for the can.

The next thing I notice is that the trash can is starting to elevate into the air. Up … up … up; I puzzled over this for some moments until I realized that I was GOING OVER THE HANDLEBARS. This resulted in a flipping movement, my bike tumbling gently to one side, unscratched, and I … did a complete flip, landed on my back, knocked the wind out of myself, and my cycling-shoe’d feet CLANGED violently against the empty green monster.

I lay there, chagrined. Maybe post-call and hence cognitively-impaired, high speed pacelining wasn’t the best idea.

Furthermore, my friend comes over, holds me on the ground to stabilize my neck (he had just learned about cervical spine precautions in his ER rotation that month) and says: “Don’t move! I’ll call 911!” In a fit of inconsiderate and impaired judgement, I swiveled my neck, looked up at him and said, “Nah, I feel fine.” He yells: “I can’t believe you just cleared your own C-spine!” After some recriminations and an apology on my part, we rode home.

This is just a long winded way of saying that our brains work in mysterious ways. You will very likely  hit what you’re looking at. SO DON’T LOOK AT YOUR OBSTACLES. LOOK AT THE CLEAR PATH AHEAD. On subsequent bike rides, some across very technical terrain strewn with boulders and sand traps, this really worked.

In my years of practice, this is one of my favorite personal stories I use as a cautionary tale to my patients. Don’t think about how bad smoking is, think of how you’re going to feel great when you haven’t smoked for a week. Don’ t think about your weight, think about how good exercise feels when you get home. Don’t think about the difficult conversation you just had; think about the ideas to craft a win-win outcome from your next discussion. My patients always get a chuckle out of my personal failures.

CMIO’s take? A lesson from cycling: I can still see that trash can. Sure, acknowledge your obstacles, but don’t stare at them. There’s a path. Stare at that. Your body and mind will help you steer you through.

Clear. Clean. Rested.


I’m spending the week away. No email, no meetings, virtual or otherwise, phone in airplane mode, escaping the trappings of life on the grid.

We are out camping, scrounging for firewood, burning our food on camp stoves or in the fire ring, canoeing up meandering rivers, and hiking Colorado’s spectacular wilderness.

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This is so fun, who cares about catching actual fish?

I’m perfectly happy to have others in the family gear up to fly fish. What I have under-appreciated is that fly fishing is also a spectator sport. To me, catching the fish is incidental: we catch and release anyway. The draw, for me, is watching the sublime curve of the line and the meditative ‘ssshhh’ as it undulates back and forth and then settles silently into the lake.

We are just car camping, but it is just out of my comfort zone, so this is enough of a stretch for me. Found a perfect hike near Vail: 6 miles up to and back from the cascading falls near Lower Piney Lake.

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My favorite thing: picking a sunny boulder at the edge of a mountain stream at the turnaround of our hike, slipping the hiking boots and socks off, anticipating the bracingly-cold water. Then, easing the aching feet into the stream: the first Yelp of surprise (every time!) the almost-painful cool, the feeling of ice-cold veins rising up, developing an internal minty feeling. Clear. Clean. Rested.

Nothing like it.

Gets me recharged for the hike back.

CMIO’s take? Seek rest and moments of peace. Resilience stems from recovery in the face of change. There has been so much changed in recent months and years, and too often I see physicians not taking the hiking boots off, no time for the mountain stream refresh.

Let me know how YOU recharge.

This Sh*t is Real! Sculptures, from Education to Science at Anschutz campus

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What is this round thing? 
Fun sculpture around campus.

We walk past these structures every day. When I ask my colleagues, none of them know the history of these objects.


The Art Walk / Globe Sculpture represents the connection between healthcare education side of the campus, and the research / clinical side of the campus. Beginning on the education side, a solid sphere is positioned adjacent to the Education quadrangle, 5 buildings where five schools share classrooms and resources (see link to walkabout blog). Down the long, uninterrupted sidewalk, you can see that the sculptures all line up, through various archways, to the final sculpture on the research and clinical side of the campus, represented by the wireframe sphere. 
A nice metaphor: the undifferentiated form of a sphere could represent an the raw idea, the unsophisticated view of healthcare, where the underlying principles are unseen. On the other end, traveling through time and space, and the years of a healthcare education, the wireframe represents the discovery and use of hard-won knowledge of the underlying structure of the sphere, to be employed in the discovery of new knowledge and the use of this knowledge in the care of patients and populations.

For me, it is reminiscent of the metaphysical Fuzzy/Techie line at Stanford University, represented by an imaginary line dividing the scientific side of campus and the arts side of the campus. Ours is better, methinks.

Little known fact: All these sculptures have power outlets and free wi-fi!

CMIO’s take? Cool things abound, all around us.

Unintended Consequences or Not everything works out as planned …

Coors Field. Reds at the Rockies
So the planning went great. A day at the Rockies game with the inimitable Epic ambulatory team, a cool, hardworking group of young, fast-learning folks.

Word comes that UCHealth is a Rockies corporate sponsor and we have tickets for the team to sit in the Rockpile, centerfield, nonshaded bleachers in 92 degrees. Sign me up!

So, I came in to work early, cranked out some awesome spreadsheets, knocked off early and headed to the game.

Bonus: I planned to park near home and take the new University of Colorado RTD A-train to and from Coors Field.

University of Colorado A train

Rockpile!
Here we are! Time for some hot links and beans!

I wear this polo shirt every 10 years or so, whenever the opportunity arises.

Union Station: downtown reinvented.
Get up to the famous Rockpile…

Find my seat, settle in for a fun afternoon…

Hey, where is everybody? I’m only a few minutes late for the 3:10pm start …

Empty bleachers
Hmm, they’re announcing the 7th inning stretch. Something wrong with this picture. Look at the ticket again. 1:10pm start. Seems that the website was citing Eastern time. 😦

AND, 90 degrees for 2 hours had most folks wilting and ready to head home. Rockies down 2-6 anyway… I had just missed them.

Not everything works out as planned.

Hot tip: do not add insult to injury by missing your train stop on the way home, whilst writing your self-pitying blog post. It could happen.

Wrong station on the way home.

CMIO’s take? just like in informatics, ‘The best laid plans of mice and men go oft awry.’ Several examples come to mind:

Issue: University specialist physicians often forget to write referral letters back to referring physicians and patient’s primary care physicians. Idea: why don’t we automatically route a copy of their note to the referring physician and PCP? Unintended Consequence: nicely formatted, custom-built sub-specialty letters with names and contact info are replaced with the generic letter necessary for the automatic process. After some scrambling, things are getting better.

Issue: physicians often do not record ‘exercise as a vital sign’ in the patient’s medical record despite exhortations by experts that this could help prompt Americans to exercise more, and track healthy habits. Idea: One of our cardiologists helped build a module to remind docs to do so: type of exercise, days exercised per week, minutes exercised per session. Simple! Elegant! (He wanted to set this as required for all outpatient visits across our system: all 2 million of them per year). Unintended Consequence avoided: our physician informatics team informed him that, until he gets agreement from physician leadership representing the many physicians who would be affected by this one change, we would NOT turn this module ‘on’ as a required element. Whew!

Any recent unintended consequences come to mind? Leave a comment. Happy July!

Sunrise (and lessons for Dad)

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If you’re a parent, think of putting aside your own harried life and occasionally accepting the random invitations that come your way. In my case, that’s an invite from my teenager: “Hey, Dad, lets head over to Red Rocks and see the sun come up this weekend!”

Suppressing my instant “Are you KIDDING?!” response, I thought about it, rolled my eyes, and eventually said “yes.” Sure, the getting up at 4:30am, the inevitable LONG midday nap that follows, the exhaustion… it is worth the look of joy on the face, the teaching of the life lesson, that it can be more important to say yes, to be the ‘first follower‘ (don’t miss this video!) can be powerful, life-affirming, and a way to create a stronger bond with those soon to leave the household.

 

And, just maybe, the sights are spectacular. Leaving aside the gas-powered air blowers and the leftover “aromas” of excessive alcohol and perhaps other substance use of the night before, its good to appreciate how beautiful a life surrounds us.

CMIO’s take? Despite the grumbling from teenagers about “life lessons from Dad … again,” sometimes, “life lesson” come from following your teens, being open and being willing to be surprised by them. Maybe even substitute the phrase “team members at work” for the word “teens.”

Pneumothorax, Dawn Patrol, and re-introducing the story of the patient

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NOT the patient of this story.

Our EHR’s are often way too antiseptic, full of words, graphs, numbers, and not enough about the person of the patient. We’re working on fixing this in a number of ways, but one way we can ALL do something immediately is to re-introduce the Social History, not just as a tool to detect genetic pre-dispositions, behavioral risk factors and social determinants of health, but also as a simple tool to connect us with our patients.

In my sordid past, I was the subject of some ridicule from my Chief of Service, as well as my fellow residents. You see, in 1990, I was on-call during my internship year at UC Davis medical center. The Department Chair routinely rounded each morning at 6am with the post-call team, and the intern would gamely present a patient he/she had “worked up” from being on call overnight. “Dawn Patrol” with the Chief was a uniformly feared, but nevertheless educational experience with the Chief, and it was to be my turn.

So, I was excited to find that one of my newly admitted patients in the Emergency Room that night had a pneumothorax, from injecting a needle into his neck! In my interview, I asked how this happened, and he explained to me: “So, you know how, when you bite your own thumb and blow, you can look in the mirror and see that one of your neck veins pops up, right? It’s a great place to put your needle if you have run out of spots in your elbows and such.”

What could I say? “Yeah, I know how that is.”

So, he showed me how he did it. It worked pretty well most of the time. But, this time, it seemed, his needle went a bit too far and … he developed shortness of breath. Seemed like his needle poked into the top of his lung and he “dropped his lung.” While driving. He was pulled over by some astute cops, and brought to the ER to be treated, handcuffed to his ER gurney.

Great case, I thought to myself. I got to put in a chest tube, and learned lots of interesting pathophysiology. Perfect for Dawn Patrol. My resident encouraged me to go back and take a very thorough history and detailed exam for the inevitable grilling from the Chief. I did so, and I was ready.

6 AM, and Dr. Silva walks up. “Good morning! Who’s got a case this morning?” I smiled brightly and launched into my polished presentation:

“This is a 39 year old prisoner and IV drug user, brought from jail for a chief complaint of shortness of breath, and admitted for pneumothorax. He was previously healthy until the morning of admission when he …”

“Stop there. What’s his educational level?” said the Chief.

“What?” I was taken aback. I had memorized my presentation and was on a roll, but…

“Education level?”

“He’s a prisoner.”

“I see. So he could be a medical student and you wouldn’t know. Perhaps that’s how he has access to needles.”

“No, sir. But…”

“So, has he recently purchased a truck from the Forest Service?

“Um, he’s a prisoner.”

“Because, those trucks commonly carry loads of dirt and scraps from the Central Valley, and he could have Coccidiomycosis, Valley Fever, that sometimes results in spontaneous pneumothorax.”

“Um…”

“Any travel to the Ohio river valley? Histoplasmosis? Exposure to Tuberculosis in an immigration center?”

“…”

“Is he a rose gardener?”

“Um. I don’t know”

“Because sporotrichosis is a disease commonly acquired by rose gardeners, and THAT is associated with spontaneous pneumothorax. Okay, what DO you know about his social history?”

“He’s a prisoner, sir.”

“I see. Okay, C.J., lets do this. I’m tired of interns presenting cases and not obtaining an adequate social history, either for diagnosis or for communicating and connecting with patients. From now on, Dawn Patrol will begin with a presentation of the patient BEGINNING with a detailed social history. Are we clear?”

“…. Yes, sir.” I was too flustered even to correct my own name “No, not C.J., I’m C.T.”

Over the following months, every single other intern at UC Davis personally THANKED me for my performance that morning. “Thanks C.J. Really appreciate it. Social History starts EVERY Dawn Patrol. Great.”

Just to pile-on, turns out the New York Times recently wrote about a medical mystery, wherein the SOCIAL HISTORY is the hero.

CMIO’s take? CJ sez: It is time to re-emphasize Social History in our record-keeping. It has the potential to generate helpful clues about patient illness, transform patients in to PEOPLE in front of our eyes, and improve our connection, our communication, and our own joy in the practice of medicine.

As of last week, I created a one page handout for my Medical Assistant to hand out to every patient she rooms for me:

Where did you grow up? Are you married? have kids? What do you do? What are your hobbies?

And, it is quite astounding what kind of responses I get. I’ve heard:

Well, back in the day, I used to box with Joe Louis!

I flew with the Flying Tigers over China.

I’m a reporter for National Public Radio.

I played with the jazz great Cannonball Adderley.

Now, I will use my Speech Rec tool and place this into the Social Documentation section of the chart, and using a smart-link, ALWAYS display this prominently in my progress note, to humanize the patient, to avoid the risk of my thinking of “the gallbladder in room 3.” These random and often amazing connections are some of my favorite moments in medicine.

Perhaps this has some impact on resilience, burnout, the joy of medicine, the human connection, the ability to distinguish patients on their human stories.

Have you done this? Let me know.

Robot parade

 

Robot Rail

Robot Parade, from “They Might be Giants” (Youtube link, 1.5min song)
The robotic revolution is upon us.

At UCHealth, our multi-million dollar robot train allows us to run the top 50 types of test results as “stat.” This means when the blood arrives in the lab,  it takes about 10-15 minutes, tops to run the blood test and report it into the Electronic Health Record so that doctors and nurses can act on that information.

This robot combines with a fancy multi-channel pneumatic tube system that spans across multiple buildings, and transports blood samples drawn from patients in our Cancer Center, about a quarter mile away. Furthermore, our nurses print pre-barcoded labels specific to the patient and the request lab order, so there’s no mix up during transport.

The 3 technologies together make it so that from lab draw to test result is typically less than 30 minutes. Compare this to the “old way” of human transporters who walk around between buildings every few hours collecting specimens, and lab technicians who run tests in batches, by hand, with lots of err0r-prone human transcription. You’d be lucky to see an 8am blood test return a result by mid-afternoon.

This is amazing on many levels, and so few people know about it. I bring students, residents and colleague down for a show-and-tell tour any time that I can.

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Our lab technicians simply transfer the pre-barcoded tubes from the pneumatic transport canister to the robot intake rack. An articulated arm with camera spots the tube, grabs it, scans the barcode, puts the tube in a carrier slot on the railroad, and sends it down the track to the right machine in real time.

Once at the machine, the centrifuge has 6 slots. At busy times, all slots fill up quickly and the spin begins. If there’s a backlog, additional tubes are re-routed to an alternate machine to start a new load in-parallel. If there aren’t enough samples to run a full load after 5 minutes, water-filled tubes are selected automatically to fill empty slots and the centrifuge runs. Brilliant!

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Sometimes tubes are needed in separate machines with different processing needed. The robot is smart enough to split off and label “daughter tubes,” pipette out the right quantity, and send each one to the right destination.

At the end of the line, lab tubes are stored in the automated Stockyard for 3 days in case of needed “add-on labs.” The seamless interface between the EHR and the lab system allows ordering physicians to be reminded “Do you want to add your new order to the existing specimen?” If yes, the robot retrieves the blood, runs it back up the railroad, processes the new order, with no human intervention.

This ONE IDEA has saved 30,000 repeat lab draws on patients, in ONE MONTH, at our University hospital. Astounding. Faster for doctors receiving important results, cheaper for the lab, one less “stick” for patients.

A true win-win-win.

CMIO’s take?  So cool. I wish =I= could ride the railroad. Or maybe it is time to retire and take up model trains. Does your organization have one of these? Or maybe you were a model train enthusiast? Let me know.

 

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