The ongoing remote vs return-to-work debate (nytimes)

What is your organization doing? We (as of early June) seeing a “test positivity rate” as high as 28% for COVID in our region (it was as low as 3% a couple months ago just before Omicron variant), but a low hospitalization rate.

The informatics team (my Large PIGs) are still exclusively meeting remotely.

We are actually writing this COVID pandemic textbook paragraph-by-paragraph together, my friends. There is no “playbook” for how to behave now.

Dr. Glaucomflecken’s graduation speech to University of Colorado School of Medicine 2022

Of course the entire 90 minutes is worth watching, AND Dr. Glaucomflecken starts at minute 24. His speech is only about 13 minutes long. You won’t regret hearing what he has to say. He has survived 2 cancers, and a cardiac arrest (really? wow)

I’m so grateful to amazing folks like Dr. Will Flannery (Glaucomflecken’s real name), his humility, his insight, his humor, his TikTok channel. He’s a shining example of what a humanist physician aspires to be.

A Woman’s guide to Toxic Trolls (wired.com)

I have lost the ability to even … #hcldr #whyinformatics #hitsm

Image from Getty, via Wired.com

https://www.wired.com/story/womans-guide-toxic-trolls-internet/

Sometimes a well-written piece allows one to step outside of one’s identity and perceive what it is like to be someone else. This is one.

This is a “wow” read, in support of my colleagues out there using social media for good, and how about 50% of our colleagues suffer through nearly unimaginable interactions in a largely unregulated space. AND one way to fight back.

Blowing apart EHR classroom training, TikTok, Microlearning (and a uke song)

What does TikTok have to do with Classroom Training? And what is “so last year” with EHR onboarding? And which uke song is up next?

We discuss: uPerform (self-paced EHR online training), Amplifire (adult learning theory and what we call “pot-hole” training for difficult EHR workflows), no-more-classroom, and 1:1 coaching sessions based on “cognitive struggle” and EHR Signal data. And of course, TikTok.

CMIO 3.0, according to Healthcare Innovation (and quotes from me)

Hear from Drs. Pageler, Hanson, DePuy (and me) about how the CMIO role has evolved and where we think this role is headed.

https://www.hcinnovationgroup.com/clinical-it/electronic-health-record-electronic-medical-record-ehr-emr/article/21250442/cmio-30

I’ll remind folks that I have an “About” page that speaks to the role of CMIO, here: https://ctlin.blog/about/.

An excerpt:

…being a CMIO

A good CMIO installs an electronic health record (EHR).
A great CMIO sees the EHR as a building block for excellent clinical care.

A good CMIO teaches physicians to use the EHR.
A great CMIO listens, learns, and removes barriers to inspire creative and collaborative use of the EHR.

A good CMIO hires people for informatics / EHR work.
A great CMIO builds teams that perform better than any individual could.

A good CMIO communicates well.
A great CMIO builds trust so that constant change & improvement is not scary.

We believe that a high-functioning EHR is the central nervous system of a group of dedicated physicians, nurses, staff and patients, who work together to improve the health of individuals and communities.

I think Centaur teams are the only way forward in healthcare. In chess competitions now, hybrid human/computer teams regularly outperform both humans alone, and computers alone. These so-called Centaur teams (in Greek mythology, half human, half horse) are all the rage.

“We improve physician and team wellness and effectiveness by building extraordinary relationships and innovative tools.”

Vision Statement of our Physician Informatics Group (the Large PIGs)

Parkview Epic go live 3/9: Monkey Brains, a Haiku, and Physician Technology Adoption

Day 4

End of day 4 of and EHR go live. Are we getting punchy? No, this is a real sushi roll from a real restaurant here in Pueblo.

How can we not order Monkey Brains from the menu?

A pretty good day overall. Our physician informatics team is doing the rounds on 6 floors of the hospital, about 8 physical buildings and about 30 clinics. Here we are ‘debriefing’ over beers.

The vast majority of the clinics are doing really well, physicians and providers learning the note writer tools, order sets, pre-op process, secure chat communications, inbasket messaging, 2 factor authentication for controlled substance prescribing, and dragon speech recognition. And, seeing patients (and in one case, treating a mass casualty from a freeway pileup!).

Parkview Rocks

We are so impressed with the dedication of the clinicians and the hospital and clinic staff.

Makes me think of that song from Fiddler on the Roof:
‘Tra-DI-tion, tra-DI-tion!’

Instead we would sing it ‘Dis-RUP-tion, Dis-RUP-tion!’

Oh, that’s a uke song candidate you say? Hmm.

Musings about tech adoption

During a major go live like this, we see all sorts of interesting things. For example, we actually experience and can see the bell curve of technology adoption exhibited among clinicians.

Early adopters

Some clinicians are flexible, see the EHR as a new set of tools, and appreciate our help as we suggest best practices using the new tools. Within 2-3 days they are discovering innovations and pushing themselves to see ‘what this new thing can do.’

These are early adopters and digital natives. They need no ‘push’ from the informatics team, instead sometimes we judiciously apply the brakes on their wild flights of ideas. ‘Why don’t we survive this go live first before investing in your proposed next set of tools.’

Silent majority

Some clinicians are circumspect. Although they come in all age groups, most are older, less comfortable with computers and smartphones, think of EHRs as glorified paper charts, but valiantly spend time to learn, adapt, and willingly accept help and advice as they find their way in a new land. They are willing to consider that this might be better than the old paper process.

These are digital immigrants with open minds, and the largest group in the middle of the bell curve. Establishing trust and nudging are the best informatics tools. ‘Hey, good to see you again. How is it going? How can I help? Can I suggest trying another new thing today?’ Or, expressed as a haiku:

Come, see what I learned!
No, not that trick, but this trick.
It’s tricky but cool.

Late adopters

Some clinicians are doubting Thomases. They’ve heard that Epic is coming and have looked for jobs elsewhere, surprised to learn there are no new positions open that don’t also require EHR use. They are often senior clinicians with deep expertise, have established practices, large patient panels, finely tuned paper-based workflows honed over years. They are used to generating high volume and providing high quality care, and now everything has changed.

For these clinicians, their clinical expertise and years of experience are drowned under the heavy mantle of technology inexperience. They may perceive a loss of respect, a loss of autonomy, a loss of mastery. These are digital immigrants who were forced to relocate to this unfamiliar and hostile land, and wish to return to a home that no longer exists.

It behooves us in informatics to be humble and remember their value, their deep history and their expertise.

Extremes

Some clinicians are super early adopters: ‘Hey, I want a bluetooth speech recognition mic to go with my mobile tablet.’ ‘Show me your predictive algorithms for sepsis and how we are going to do surveillance.’ ‘I hear there is a way that the EHR can write your whole note for you.’

In the other direction, conversations can boil over into emotion and outbursts at staff, at colleagues, and at our informatics and IT teams. I’m told that a clinician did throw a trash bin in frustration this week.

However, we are proud to say that our primary metric is ‘Days since last chair-throwing’ and that is an unbroken streak of 2500 days, back to 2014, since a trash bin is clearly not a chair.

Kidding.

Hence my cryptic quote from yesterday, as we philosophically debriefed our team over beers:

The bell curve is made up of the entire bell curve.

Every medical staff has members in all these groups, including the extremes.

(from wikimedia.org)

Choose your own adventure!

Want to try out the CMIO / physician informatics role during a go live? Here are some challenging questions. How would YOU respond? Answer honestly before reading our approach.

Q: SO. What’s allowed as a Verbal Order? (meaning, I intend to use YOUR computer system as little as possible)

A: Actually, UCHealth policy is “verbal orders only in clinically urgent situations, or when the clinician is scrubbed in, or in transit and unable to enter their own orders.” However, the EHR only reflects your hospital’s medical staff policy. Let’s work with your leadership to clarify this.

Q: That “F2” key doesn’t work right in the note. It doesn’t even go where it is supposed to.

A: Let’s sit down and you can show me what you mean

Q: Why do I have to cosign all these orders and notes that my resident/fellow wrote? I trust them. Can’t I just “shift-click” and get rid of all of them?

A: Sounds great that you trust your team and that you’ve developed a great team workflow. At this time, the system does insist you glance at the work as your signing them one at a time. If there are standard protocols or policies that allow clinical colleagues to do their work, let’s develop them, document them, and we might be able to eliminate these co-sign tasks.

Q: I haven’t seen a thing that is quicker in this new system compared to our existing system. It is an expensive waste of time.

A: I’m sorry to hear this. However, you are only in the first week of a major go live and disruption in your work. Nothing is the same. The tools are flexible, and I’m convinced that our team and your team can work together to build new workflows to match or exceed your previous methods. It usually takes 1-2 months to fine tune your team’s new process.

Empathy. Trust. Respect.

Regardless of my artificially applied categories, there is a universal approach to clinician adoption of technology. We treat everyone with empathy and respect, honesty and transparency. We tell them why. We tell them where we are going, that the technology-empowered medical team performs better than the unassisted medical team. We open a dialogue, build trust, set behavior boundaries (when it comes up), and get through the transition together.

When we do this right, every clinician we work with will look back and say, ‘I can’t believe we used to do this any other way.’

CMIO’s take? Our ideal: no physician left behind.

Parkview Epic go live 3/6 pm. The helpful hardware man.

Walking the hospital, it is easy to see the Epic helpers: we are wearing red shirts, red lanyards, red vests (mine makes me look like the that old advertisement: ‘ACE is the place with the helpful hardware man!’).

Our command center, with 100% vaccinated uchealth team, is unmasked in non clinical areas, per our state public health guidance as well as internal leadership guidance. It is amazing to see people in person whom we have not seen (other than as Flat-land 2D entities: geek book alert!) in 2.5+ years.

Our team venture out to the floors, the ICU, the ED, the labor deck, all the nooks and crannies where doctors and nurses work. We are calming influences. The adoption of an EHR is always more than just changing documentation practices, it is transforming everything about how we care for patients. We repeat throughout the day: “it will be okay. We are teammates and we will get through this.” When the partnership between organizations goes well, like this, it is a pleasure to build on that colleagiality.

‘This is only our second day on Epic, and it is going great: it is already better than the BEST DAY we ever had on our old system.’

Parkview Health System Inpatient Rehab team

Our go live has had few hiccups this weekend. We even had a mass-casualty event triggered today: 22 car pile up on I-25 this morning in the snowstorm. Fortunately, result from the Emergency department was only 8 patients treated and released with minor injuries.

Step count yesterday: 11,700. Today, 4500. I recall our first Epic go live at the University of Colorado Hospital, I hit 27,000. So, we’re getting better at this. We know the big test is tomorrow with all the clinic going live in 3 campus locations miles apart. The ACE Hardware Man will be there. Wish us luck.

Parkview Epic Go-Live #3

Breakfast of champions. Banana, yogurt, OJ, some sliced bread. Back to the wards for more bedside support! Saturdays are a great go-live day since there are few surgeries and endoscopies.

ICU, med-surg floors and OB floor is active as usual. Weekend rounding allows docs to come if a little layers, so early morning is quieter for the nurses getting used to chatting in flowsheets on cut-over day.

Pretty cool items of hospital art. Spotted on our rounds.

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