Politico (and HuffPo): The Doctor of the Future (with stuff about us, and Care Redesign at UCHealth!)

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Not only do Christal and Kathy play healthcare professionals on this website, they also do so in real life.

Thanks to Sophie Quinton at Stateline, published in Politico 10/25, for a nice feature article about Care Redesign at UCHealth:

http://www.politico.com/agenda/story/2017/10/25/role-of-physician-in-healthcare-000554

And 10/26, in HuffPo!

https://www.huffingtonpost.com/entry/team-approach-to-health-care-means-new-role-for-doctors_us_59f09780e4b02ace788ca8fb

DENVER — When patients go to see Dr. C.T. Lin for a checkup, they don’t see just Dr. Lin. They see Dr. Lin and Becky.

Becky Peterson, the medical assistant who works with Lin, sits down with patients first and asks them about their symptoms and medical history—questions Lin used to ask. When Lin comes in the room, she stays to take notes and cue up orders for tests and services such as physical therapy. When he leaves, she makes sure the patient understands his instructions.

The division of labor lets Lin stay focused on listening to patients and solving problems. “Now I’m just left with the assessment and the plan—the medical decisions—which is really my job,” Lin says in a quiet moment after seeing a patient at the Denver clinic where he works.

We’ve been trying lots of things in our clinics at UCHealth because there is a national crisis of physician burnout, a national imperative to improve patient satisfaction, a national push towards electronification of healthcare, and a national imperative to improve quality.

We are of course, continuing our work on EHR 2.0 Sprints: see past posts Epic Sprint! Or, how we learned to love the EHR (part 1)Patients come second (so that everyone does better)! Addressing Physician BurnoutEHR Sprint team: work hard, persevere, sometimes you get to build a dream team, and stay tuned for future posts to come.

This is, so far, a separate initiative of improving teamwork, team-based care, returning joy to healthcare work. In short, we:

  • Added Medical Assistants to a primary care clinic to invert the usual ratio of 1 MA to 2.5 MD’s, to 2 MA’s per 1 MD.
  • Created an MA academy to retrain MA’s to work at the top of their certification (about tripling the usual tasks they do in the care of a patient)
  • Added scheduled time BEFORE a physician visit for MA interview and documentation
  • Asked the MA to stay in the room and scribe the patient’s history, examination and some parts of the assessment and plan, pend any orders or referrals or prescriptions for the physician
  • Asked the MA to retrieve any equipment or education needed by physician
  • The MA then completes post-visit tasks, vaccinations, education, after-visit summary printing, reminders, phlebotomy, followup appointments.
  • Physicians then move room-to-room as MA’s stay 1 patient ahead

As a result,

  • Physician burnout falls from 55% to 13%,
  • MA satisfaction and engagement improves,
  • Patient satisfaction improves,
  • Cost-per-visit DOES NOT CHANGE,
  • Access to care improves (more new patients, shorter wait times)
  • Quality metrics improve (non-physicians pay more attention to consistent screening for vaccines, colonoscopy, PAP smears, foot exams, prescription renewals, standard monitoring for chronic illness).

I have to acknowledge the hard work of our Family Medicine colleagues at AF Williams Stapleton Family Medicine and the Snow Mesa Poudre Valley Internists clinics in the University of Colorado “UCHealth” system, who pioneered this work, based off of the Care by Design model from Utah. Thank you to those who blazed a trail.

CMIO’s Take? What’s not to like? Despite “who moved my cheese” change-management issues, we’re finding that we run out of qualified MA candidates, we are hiring so many. Is this the doctor of the future? Team-based Healthcare of the future? Was healthcare supposed to be a team-sport from the beginning? It is one vision, and a darned good one so far.

Book review: Lincoln in the Bardo

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Two stars.

Picked up this book because my online community of friends raved about it. I like trying new genres, stretching to see if my mind can appreciate new ideas, new styles.

I listened to this on audible.com (highly recommended, btw: all those morning commute blues evaporate in the listening). In reading books about how our minds work and how to build resilience, it seems that letting our minds wander results in predominantly negative thoughts, unlike a mind focused on a challenging task.

The blurb about the book was promising: fiction, told from many first person perspectives, about President Lincoln, grieving for his young son, who perished from pneumonia. The twist is that on the Audible version, over 30 narrators supply the many voices, some from accurate historical accounts, some from souls stuck in purgatorial-never-land, as they observe the President’s grief and glimpse his thoughts.

The first clue as to how much like liked the book was in how I gradually accelerated the playback, first at 1.0x speed, for books I enjoy, to 1.25 and eventually landing on 1.5, hoping to be done sooner.

I tried. The unmistakable voice and cadence of David Sedaris pops up, and is entertaining, but is insufficient to hold my interest. It IS an interesting perspective on an inflection point in our country’s history, told in a very personal (and somewhat zombified way?!). Lots of folks liked it, it just wasn’t for me.

CMIO’s take? The literary technique, when a purgatorial ghost can temporarily inhabit the body of a living person and hence hear his/her thoughts is a delightful and clever illustration of empathy. And empathy is how all informatics gets done.

2017 Becker’s review of CMIO’s (I made the list!)

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https://www.beckershospitalreview.com/lists/50-hospital-and-health-system-cmios-to-know-2017.html

This is interesting. Nice to be recognized by Becker’s. Seems like the “CMIO’s to know” list grows each year. And, as long as I’m on the list, I’d say this is an AMAZING, THOUGHTFUL list. If I were NOT on the list, I would of course call this a nonsense popularity contest.

CMIO’s take? A CMIO’s work is never done. We will soon be in a post-fee-for-service world. In this new world, it will be necessary to re-invent healthcare teams AND optimize the EHR AND stay ahead of the uncertainty and tumult to come.

“Fasten your seatbelts, it’s going to be a bumpy ride.” (Misquoted from Bette Davis in “All about Eve”)

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.

Article: Hot Button from the AMA community: How to make EHR’s better

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https://wire.ama-assn.org/practice-management/hot-button-topic-how-can-we-make-ehrs-better-more-usable

Thanks to the AMA for a “Running Your Practice” community discussion on “How can we make EHR’s better and more usable?”

I enjoyed being part of the panel discussion and hearing different perspectives on how health care organizations are tackling “optimization” “efficiency” “patient-centeredness” “vendor accountability” “customization” “team-based care” and “practice redesign” to improve satisfaction and reduce physician burnout.

CMIO’s take? Lets learn from each other. There are more smart people who DON’T work for you, than who do.

30 Second Trick for Learning and Memory

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http://www.huffingtonpost.com/robyn-scott/the-30-second-habit-that-_b_4808632.html

Something I learned while taking that Coursera course on Learning how to Learn. Turns out it is never too late to learn something new. Here’s an idea that you can LEARN IN 30 seconds, and could have lasting repercussions:

Summarize your last meeting, or discussion, or class, or event that you want to remember, in 30 seconds. Maybe even an entire book. The act of having to prioritize, to summarize, to choose what is important, to actively recall — this engages the frontal cortex just enough to help re-inforce memories. It is indeed a “mind-sprint” equivalent of an 100-yard dash.

This is not only backed by science (see that Coursera course!) but feels right. I currently use a little black book to write down minutes of my meetings. However, I DID NOT take the extra 30 seconds to summarize. I think I will begin doing this.

CMIO’s take? Just like one should never be “too sick to go to the doctor,” one is never too old to learn something new. Thirty seconds is all it takes. Do you do this? Let me know!

 

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?

How to write an Open Note for patients

Worried about how patients might be offended by physician progress notes? Use this reference tool.

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2017-0904OpenNotesDocuTipsCTLin.pdf

Having been asked a number of times: what is the best way to participate in open notes and sharing physician progress notes with patients? Attached is our one-page PDF guide. Feel free to use and share. Please do include attribution when you share.

In short:

  1. Don’t Panic! Despite physician fears, patients are not looking for a completely rewritten layperson-friendly note. Many patients find it useful just to have access and be able to show that note to their next healthcare provider. You DON’T have to change a thing.
  2. The handful of “gotcha” topics in physician progress notes are few, and not difficult to write in a way that is respectful and still accurate. For example, use “shortness of breath” instead of “SOB”; “BMI>30” or “overweight per medical criteria” instead of “morbidly obese”; and “patient is non-adherent” instead of “patient refuses”.
  3. It gets easier with practice.
  4. I love the quote from Cassandra Cook. To paraphrase: If we write things that might offend patients, consider if such writing affects our own attitudes and behavior.

Furthermore, the OpenNotes.org website has a great toolkit for organizations looking to make the leap: https://www.opennotes.org/tools-resources/for-health-care-providers/implementation-toolkit/

CMIO’s take? Lets push open notes until it is the default standard for Electronic Health Records and Personal Health Records everywhere. Is your organization on board with open notes? Let me know.

Releasing test results to ICU patients and their families? Surely a bad idea?!?

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https://participatorymedicine.org/journal/evidence/case-studies/2013/06/12/divergent-care-team-opinions-about-online-release-of-test-results-to-an-icu-patient/

I’m always thankful for great colleagues who do good work. One of our former residents, Jonathan Sprague co-authored a report called “Divergent Care Team Opinions about Online Release of Test Results to an ICU patient.”

At it’s root, was the issue that we routinely signed up outpatients for our patient portal called My Health Connection. We also release ALL laboratory test results immediately to the portal, with no time-delay. This means that physicians and nurses often saw the result AFTER a patient received it online. Despite the anxieties of such an approach, we had decided back in 2008 that all our lab results would be delivered this way; we have released over 2 million results with negligible problems and highly satisfied patients.

In fact, our urology practice, initially hesitant to adopt these “open results” policies, found that 1) likelihood of missing a prostate cancer recurrence was less, since patients were assiduous at checking their own results online and then checking in with their clinic team and 2) one third of their telephone volume DISAPPEARED because patients would routinely call and ask “what was my PSA result this time?” Now, they’re one of our biggest proponents of information transparency.

In this case, a patient in transplant clinic signed up for the portal, got used to viewing results online, and then shared his account with his wife. When he was admitted to ICU after transplant, she continued to check results and found that in-hospital and even in-ICU results showed up on her tablet even before the ICU nurse was aware.

You can imagine the surprise the nurse felt when she responded to the call button: “What are you going to do with this high potassium result? What about that low oxygen result on the blood gas?”

See write up for what we did with this. In the end we resolved this peacefully, and our organization took another step forward, formalizing that inpatient test results would follow our outpatient results release rules:

  1. All lab results are immediately released with no time delay, EXCEPT that qualitative HIV and broad genetics panels ordered by genetics clinic are never shown online.
  2. All radiology and ultrasound are released immediately EXCEPT CT, MRI, PET are delayed 7 days to allow for possible cancer diagnosis to be communicated by physician to patient
  3. All pathology is delayed 14 days to allow multidisciplinary tumor boards to develop a complex treatment plan before releasing the result

 

CMIO’s take?
1. Nothing ventured, nothing gained.
2. Open Results policies work well for patient satisfaction, patient engagement, and DO NOT adversely impact physicians and staff IF well-communicated and expectations and guidance put in place. We’ve done this for 10 years and have reaped the benefits.
3. Even inpatients can handle test results, it turns out.

Coursera MOOC: Learning how to learn

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Just started a new course on learning how to learn. Want to join me? Of course, there’s no time. It is like saying “I was too sick to go to the doctor” or as some physician colleagues tell me in regards to the always-despised EHR: “I don’t have time to learn how to be more efficient.”

My high-school son and I have taken MOOC (massive open online courses) classes; he is taking his second class on astro-biology (cool!). I have taken one on Machine Learning through Udacity.com and this will be my first on Coursera. These online learning platforms are revolutionizing education, and we need to pay attention. There are free versions (what we’re doing) and paid versions, for little cost, to receive a certificate, that require additional documented work for deeper learning.

I came across the “Learning about learning” on my social media feed. Knowing that what builds resilience for me, is feeding my voracious appetite for new ideas, new things to mull over and recombine. So, when reading dead-tree-based books at home (mostly sci-fi, admittedly, and sometimes non-fiction psychology) and listening to audible.com on my commute becomes insufficient, taking an online class seems to fit the bill. It is a multi-week course, with maybe an hour or so of video-based learning with associated transcript, and LOTS OF GREAT IDEAS.

Want to join me? It is a four week course, started last week. Or take the next cycle. The important thing is: keep learning something new. Juxtaposing unfamiliar ideas against your usual work often results in new recombinations, I find.

For example, some neat ideas from the course:  Salvador Dali used to hold a brush while falling asleep and when the brush hit the floor, he would awaken and write down any associations and ideas that came to him just as he was falling asleep. This is an example of unfocused (but likely more creative) thinking. The twilight of our consciousness taps into this free association mindset. Often that unfocused time allows ideas to recombine. This does NOT occur when focused on a particular task, as we so often do.

CMIO’s take?
1. Keep learning something new
2. Consider trying Udacity.com or Coursera.com for something you’ve always wanted to learn.

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