Patient Knowledge and Experience is the largest untapped resource in healthcare

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Yes, I firmly believe this. We are starting to mine our EHR data. We can begin to see prescribing patterns, and how they affect patient vital signs (blood pressures, heart rates, pulse ox). We can look at aspirin prescriptions in patients with coronary disease. We can look at steroid inhaler prescriptions in patients with persistent asthma.

But what about patient experience? Those who have conducted Group Visits can begin to see patients educating each other, in ways that physicians, staff, educators don’t understand. “How do you manage your insulin dose when you work swing shifts or night shifts?” “When you catch yet another cold, how does that affect your liquids intake and medications for heart failure?”

Companies like “PatientsLikeMe” are beginning to look at this information as well. It is about time that our EHR vendors (or maybe startup companies) start helping us unlock the knowledge inside our own medical records for the benefit of other patients.

FOR EXAMPLE, in the screenshot above, in a presentation that I give, consider a 55 year old man with worsening knee arthritis. How hard would it be for us to find “patients like me” treated in the past few years with similar symptoms, similar age/sex/activity level/health status, who were faced with a similar decision about choosing an orthopedic operation and physical therapy?

We could say several really interesting things:
-See how many chose each option
-Compare the 3, 6 and 12 month outcomes of each choice, for pain and function
-Evaluate PROMIS (patient reported outcomes) of each option for: overall health, anxiety, depression, functional status.

Who would NOT want such information? Local, recent experience of other people like me, facing a similar challenging decision.

CMIO’s take? Time to disrupt ourselves.

Book review: The Better Angels of our Nature

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Whoo. Four stars. OK, 5 stars for philosophical arguments and hard science content, 3 stars because it is hard to listen to for hours on end.

This is an important book, and one that argues that over the time scale of humanity (decades, centuries and millennia), instead of at our puny scale of 24-hour news cycle CNN or short term memory of the last few days or weeks, violence as consistently declined. Pinker argues with compelling evidence that the background violence that used to be taken for granted (murder, rape, robbery, war) is much less prevalent as time goes on. Because our brains don’t carry the long view unless someone assembles the data and points it out, we are inclined to see what our nightly TV and news cycles bring us: episodes of violence across the globe.

Pinker argues that global communication technologies (the Gutenburg press and thus books, then radio, TV, internet) both enhance our ability to understand the other AND ALSO over-emphasizes the individual acts of violence, as those salacious details are “what sells” and what our hind-brains, wired for risk-assessment, remember most easily.

And yet the statistics speak loudly that the “truthiness” of what our gut tells us, is not true. In chapter after chapter, example after example, Pinker deconstructs our presumptions and shows us we are wrong. This is the best, least violent era yet for humanity.

CMIO’s take: Maybe it is less newsworthy, but voices like Pinker are sorely needed.

Gladwell writes about autonomous cars and digital music (must read!)

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from https://thebestschools.org/features/defending-malcolm-gladwell-intellectuals/ 

https://www.caranddriver.com/features/when-autonomous-cars-rule-what-will-happen-to-car-culture-feature

Malcolm Gladwell does it again. I picked up last year’s Car and Driver when at the barber this weekend. C/D created a 31 page spread on Autonomous vehicles, or as they cleverly put it “Auto: No ‘Mo Us.”

Gladwell edited the contributions of about a dozen authors, but his final essay was a stunner: how self-driving cars are to the passionate car lovers, as digital music is to passionate music lovers from the 60’s and 70’s. There is something about the ubiquity of a technology and service that strikes at the heart of what causes people to pursue hard-to-find, counter-culture and memorable music. And this translated, in decades past, to those who created long lasting memories.

CMIO’s take? Automation, convenience and digital tools become the enemy of personal memory and identity? A thoughtful read and critique of our age.

Ukulele parody: Everyone Knows its Becky

Thanks to the medical informatics division at UC San Diego Health for hosting me at their informatics seminar series. I gave a talk about our efforts on improving physician well-being and reducing burnout (see previous blog posts on Sprints and Practice Transformation).

Sometimes, I travel with my ukulele. Sometimes, I sing at the end of my presentations. Sometimes, I climb out of my meditative, introvert bubble and see what happens.

Thanks to the one guy in the seminar who clapped for me. Kidding. UCSD has a great crew of informaticists doing great work. Christopher Longhurst (CIO) and his team are implementing a team with the purpose of getting physicians “Home for dinner” among the many other good things they’re doing.

Anyway, my apologies to The Association, whose song “Everyone Knows It’s Windy” I ripped off and re-purposed.

And yes, since I’m binge-watching “Breaking Bad” right now, I know the song features prominently in one of the episodes (NSFW). Where do you think I got my inspiration?

CMIO’s take? Always keep ’em guessing.

GROK Board: how to instantly understand what’s important about a patient

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Thanks to my University of Colorado School of Medicine colleague Steve Ross MD who challenged me to think about how we improve the clinician experience in EHR’s.

Yes, we are all worried about Physician Burnout, and about the EHR Burden, and bemoan how difficult it is to assemble all the important pieces of data about a patient into a coherent whole, so that the physician can GROK the patient (instantly understand; thank you to Robert Heinlein’ Stranger in a Strange Land) and thus treat him/her effectively and humanely.

Let us not forget where we came from. Although paper was more familiar, and tactile, and you could SEE HOW HEAVY a patient’s past medical history was by how many volumes the clerk would deliver from the warehouse and slam down on your desk, it was NEVER a joy to approach the chart and begin to consume it, page by page.

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image from https://covtrustblog.com/2013/07/23/ctc-tips-record-retention/

AND YET we are still far away from the ideal state where a physician can walk up to an EHR, bring up the patient, and on ONE SCREEN have a pre-digested, specialty-specific, visit-specific, patient-centered, view of the patient. We have all dreamed of the ideal “chart-biopsy” tool that would allow us to see all the many pieces of a patient’s past history, gathered into one place. I have yet to see such a tool.

In my view, such an ideal GROK-board should pursue the following:

  • Be HUMANE and emphasize the patient’s goals, preferences, and identity
    • Thanks to Gregory Makoul for his fantastic work in patient-physician communication. We need to improve the visibility of patients as humans in the EHR so that physicians can more quickly connect as person to person; this results in improved patient outcomes and less physician burnout.
  • Increase SIGNAL to noise ratio of the information presented
  • Prioritize MOST IMPORTANT next actions
  • Make the RIGHT thing easy
  • Make it QUICK to grok and then act

CMIO’s take? I don’t pretend to have a monopoly on this vision. I challenge all of us to make something better than the GROK-board I threw together the other evening.

AAMC report on UCHealth Sprint (news)

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Team Spirit!

https://news.aamc.org/patient-care/article/reducing-stress-electronic-health-records/

More news about our EHR 2.0 Sprint efforts; we’re getting some attention from around the country and it is gratifying on several levels: 1) that organizations are taking Physician Burnout seriously and 2) that our efforts at concretely moving the needle on EHR burden and Physician Burnout are getting some attention nationally.

Certainly our internal clinics are benefitting from these efforts.

CMIO’s take? More is not always better, unless (work and burden) is better.

Cooling off physician burnout: a story in 5 pictures.

Yelling at the computer, patient on the exam table. Doc’s not happy, ain’t nobody happy.

This is of course the distillation of the frustrated physician at the computer in the corner (you may recognize the physician-actor), with dissatisfaction cascading to the patient. Why does it have to be this way? How did we get here? Well, we are often victims of ‘translational’ thinking, with insufficient ‘transformational’ thinking. What I mean is: just because the doctor carried the paper chart into the room and scribbled on it, doesn’t mean that putting a computer in the room is sufficient. Would we: ask an airline pilot to review the passenger manifest and take tickets? Would we ask the courtroom judge to take detailed notes in the courtroom?

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from JAMA: a child’s illustration of their doctor visit: doc at the computer in corner, thanks Elizabeth Toll!

Here, let’s just pile on, with a kids view of their doctor typing away in the corner. What a gut punch. Is this what children (and adults!) think of seeing the doctor now?

the Triangle of Trust: aligning doctor, patient and computer to SHOW, LISTEN, and TEACH

So here is an incremental improvement. Think about bringing the patient down from the exam table (so many stories of doctors calling questions over their shoulder at unseen patients on the exam table!) think about having them sit next to you and talk about what you’re doing on the computer and whether that looks right. Use it as a method of reflective listening.

“Medical Scribing,” “Advanced Rooming,” “Care Transformation,” or “Team Based Care”

Take it a step further with MA’s doing advanced rooming role and also scribing for the physician. This implies a doubling or quadrupling of the MA staff, but can dramatically reduce physician burnout, improve quality metrics and improve throughput resulting in cost neutral staffing in a fee-for-service model, and dramatic improvements in quality in the near-future Value-Based Care model.

Use Speech Rec for your assessment and plan! It is magical!

How about this? Use speech recognition for your assessment and plan IN THE ROOM with the patient. I find it to be magical, when trained and used properly! More on this in another blog post.

Others have talked about the Triangle of Trust and the HUMAN LEVEL (research article) and HUMAN LEVEL (powerpoint).

CMIO’s take? Five pictures — one way to cool off physician burnout. How are you and your organization approaching physician burnout? Let me know.