One of our book club books, for the ‘clinical decision support’ team for the electronic health record at our institution. We have now read it in our Large PIG book club meeting (the Physician Informatics Group: we try hard not to take ourselves too seriously). Some of us were depressed after reading. The initial optimism of the ‘glass cockpit’, the fancy new computerized design of the complex Airbus aircraft, are instead proving to be a ‘glass cage’, which isolates us and anesthetizes us from the real world. The author provides riveting examples of glass cages: the Inuit who lose their cultural skills of navigating brutally inhospitable landscapes because of GPS and snowmobiles, also, the pilots who make error because of automation, leading to automation bias and automation complacency: thinking the computer must be right, and the computer will know, so I don’t have to. Further, our attention wanders as we cede responsibility for moment to moment control of the task. How do we fight such a trend and temptation, as designers?
Yet the author speaks about ‘adaptive automation’ where a computer could detect the cognitive load or stress in a human partner, and share the cognitive work appropriately. He speaks of Charles Lindbergh, describing his plane as an extension of himself, as a ‘we.’ Can we aspire to improving the design of our current electronic systems to such a partnership that avoids the anesthetic effect and instead becomes more than the sum of the partners? Chess is now played best by human-computer partners; could health care and other industries be the same? And what could that look like? The Glass Cage gives us an evidence-based view into that future (and hopeful) world.
UPDATE: We had a great discussion during our recent book club. As an indicator, several of my colleagues told me: “I don’t like this book.” Perfect! It made for a juicy, spirited conversation about the benefits and risks of automation and how the stories in the book did or did not apply to healthcare and what we were building. Maybe we can consider “adaptive automation” so that the computer scales up and down its assistance as the clinician comes under crisis so that the human can focus on problem solving and the computer can increasingly assist with routine tasks. And then, we need to take care that “automation complacency” does not increase. We already have heard of clinicians saying “Well, EHR did not pop up an alert for a drug interaction, so that means it must be safe to prescribe this new med for this patient.” Whoa, are we giving away the primacy of our own training and experience to an algorithm already?
CMIO’s take: keep reading, keep learning. It is only through extensive experience from reading and books that we can learn from others in healthcare, and from others in other industries divergent from our own. There are more smart people who DON’T work for you, than who do.
UCHealth, like many other health systems, are extending their EHR network to affiliate hospitals and facilities. Whether a hospital is coming from a paper charting system or from a different EHR, there is dramatic culture change for independent physicians as they get ready to adopt the system-wide EHR. Here are some challenges presented by physicians working at these hospitals joining the system:
Independent physicians were loosely affiliated with the hospital previously. Some surgeons were used to handwriting their H&P or faxing in a preoperative H&P they dictated via their office chart. They did the same with paper preoperative orders. Will they be allowed to continue?
Independent hospitals have had paper-based or electronic order sets developed over decades of tradition which are often customized for each of the providers even though they address the same clinical condition. Will they be allowed to keep the many physician-specific versions of these local, non-standardized order sets in the system EHR? How about if they have no-longer-standard-of-care medications and care instructions?
Independent hospitals have medical staff committees, often with committee attendance paid by hospital. When assembling leadership committees, will the system pay for physician attendance at EHR committee meetings preparing for go-live?
Inevitably, some services and specialties are more engaged than others. In the worst case, physicians will ignore the calls to attend mandatory training and readiness evaluations. As a result, these same physicians and specialties will disproportionately think that “your EHR is a piece of #(&$.” How will you work with these physicians?
Similarly, some services will need more support after go live than others. These are typically the least-engaged physicians in the hospital. How will you develop relationships with these physicians to help them be successful?
Our solution (after several trial-and-error experiences…) is to create ONE Physician Champion for that hospital, and to pay for 0.2 FTE (20% of a full time equivalent, or about 8 hours a week) to serve as THE Physician Champion for that hospital for 6 months prior, 2 weeks intensively during go live, and about 3-4 months after.
We anticipate this Champion would spend less than 8 hours a week in months leading up, and spend quite a bit MORE than 8 hours a week just before and during go live, as long as the total engagement over the 9 months, averages out.
Here are the relationships that will make this Champion successful (see graphic):
Senior (system-level) Physician Informaticist with hospital go-live experience to be a partner and coach (model of “see one, do one, teach one” from residency training)
Project Manager who represents the IT analyst team that builds the EHR tools and infrastructure and tracks deliverables and deadlines, and Nurse Informaticist who represents clinical staff roles and shared workflows.
Physician Readiness Leaders working group to create consensus and disseminate knowledge back to front-line clinicians
To extend the reach and influence of the Champion, we establish a working group of pre-go-live Physician Readiness Leaders. The specialties represent a majority of patients admitted to that hospital. We emphasize the inclusion of particular specialties like surgery, obgyn, emergency medicine, hospitalists, AND infrequent consultants and primary care referring physicians.
This committee is co-chaired by the senior Physician Informaticist and the hospital Physician Champion, comprises about 6-9 Physician Readiness Leaders. The nurse informaticist and project manager also are crucial (see above). This whole group meets monthly in the 6 months prior to Go Live, then twice a month in 2 months after Go Live.
Physician Readiness Leads are required to: attendearly EHR training, and attendextra EHR training sessions to reinforce collegial discussions and problem-solving during training, and make rounds in the hospital in the first couple weeks of go live to commiserate chat with colleagues. Depending on the hospital and local culture, these Leaders may continue to meet sporadically after go live for ongoing maintenance concerns and EHR updates. The hospital Physician Champion is contracted for about a year, and is expected to step down several months after the go live is completed. In some cases, that person or an alternate Physician Champion is selected for ongoing participation in the system-level Large PIG to help with ongoing EHR improvements and be the bi-directional relationship for that region/hospital with the larger informatics and physician community.
HERE IS OUR INTERNAL DOCUMENT FOR Benefits and Responsibilities of Physician Champion
IMPORTANT: Strong Physician Relationships are directly proportional to effective clinical care and the successful implementation of electronic health records. It is even more important than the configuration of the actual EHR technology.
Benefits of the role:
Develop a global perspective of the IT provider plan and how the unified integrated EHR system (Epic) can benefit your group.
Hit the ground running in regards to workflow efficiency at go-live and staying ahead of the curve after go live
Opportunity to be operational and clinical leaders in the hospital configuration decisions
Decrease patient safety risk when providers’ groups are involved in order set build, training engagement and attendance at pre-flight sessions
In the absence of provider participation in EHR meetings, nursing and administrator decisions may have unintended impact on provider workflow.
Help to shape physician go-live support which can be focused for your providers that will have their first shifts and procedures after go-live
Attend meetings where your feedback is highly valued and affects change rather than informational only meetings
Start to develop partnerships, communication lines, and understanding of workflows that affect your day-to-day job
Nurses want to know that the providers are on board with the change. Participating in the decisions of this committee allows you are to be seen as the leaders.
Opportunities to visit and collaborate with same-specialty providers at other system Epic hospitals
Develop relationships with colleagues to help improve the system prior to and after go-live
Responsibilities of the role:
Attend 1 hour monthly physician readiness meetings for the 6 months prior to Epic go-live
Review specialty-specific order sets to assure appropriate content is available for go-live
Communicate with colleagues in your specialty at your hospital and inform the working group about your colleague’s readiness or participation in training, order set review, and pre-flight readiness.
Bring specialty-specific concerns to the readiness group, particularly around multi-disciplinary workflows (e.g. is faxing/scanning of paper H/P’s allowed? Who will enter order set orders if/when verbal orders are permitted?)
Communicate concerns to the Physician Champion
Communicate information discussed during readiness meetings to your respective specialty colleagues
Participate in early Epic training and at least one additional training session with specialty colleagues
Participate in Clinical Informatics Journal Club as part of monthly physician readiness meetings
Some sample books included in our Journal Club:
Leading Change (Kotter)
Managing Transitions (Bridges)
Design of Everyday Things (Norman)
Nudge (Thaler)
Crucial Conversations (Grenny)
Getting To Yes (Ury)
Jonathan Pell MD
CMIO’s (and guest’s) take? Create a clear set of expectations and responsibilities and a small multi-disciplinary team with STRONG relationships. Success in informatics is about relationships. (Thanks, Jon!)
I have never been a Twilight fan (and proud to say it). But Stephanie Meyer is on to a new heroine now, the Chemist. How interesting that it interleaves with my current TV series obsession “Breaking Bad.” My wife and I are powering through season 4, maybe 5 by the time I post this (We have a tradition of only discovering years-old dramas long after everyone else has forgotten about them).
Hey, its trashy, fun, life-and-death, good-guy-bad-guy action, with some romance thrown in. And laced with chemistry. It could have been a bit more detailed on the science-y chemistry side, instead of the drama side, but who’s complaining? A fast, fun read.
By the way, if you’re a reader and looking for a community of readers who like discussing books they like, consider Goodreads.com. I used to post my reviews there, as I could automatically cross-post them to WordPress, but no longer. With the Goodreads website redesign, the API no longer works. 🙁
I still like tracking my TO READ, CURRENTLY READING and READ books there, and visit with friends (bookworms?) of similar interests.
CMIO’s take? Sometimes reading a lot does NOT mean reading for work. And, reading a lot always makes you and your perspective more interesting. And, non-work reading often makes you more useful at work. Even, dare I say, sci-fi.
Trevor is someone I only know from his hosting the Daily Show on Comedy Central. He is hilarious, insightful and holds up an incisive mirror to America by being from another culture, by being from South Africa. Now he brings us along through his hilarious and also terrible childhood and growth into adulthood.
One memory of his childhood stands out: a childhood friend named Hitler (long story) ends up in a DJ and dance contest. It is important to note that the education of blacks in South Africa about the Holocaust has been limited, at best. Also, blacks are required to have an English name in addition to a name in their native tongue (of which there are apparently dozens). As they’re taught history, “Hitler” and “Mussolini” are names of folks, who, apparently are “strong” and “fearsome” but whose names do not carry any further cultural significance. SO, why NOT name your kid “Hitler?” Trevor and his friend end up as a hip hop DJ and dance act with local color at a celebration in a Jewish community center. The chapter titled: “Go Hitler!” is even more hilarious and mortifying than you can imagine. Can that boy tell a story!
I am grateful for the journey and his inviting us along into his home, his fears, his joys, his schemes, his failures; his successes. It is a roller coaster. It is as if de Tocqueville, who commented on American life as a British outsider in the 1800’s was funnier and lived in the modern era. Finally, the voices that Trevor uses to evoke his grandmother, his mother, his best friends, and all the many languages he spoke in Soith Africa… they are indescribable. Don’t read this book. Listen to Trevor tell it like he’s telling a Daily show story, except it is Real Life and he survived it.
CMIO’s take? Audible names this among the top 100 audio books of all time. I agree.
I have wanted to read this book for decades. Now, with my emphasis on reading consistently (both via Audible.com and in print, but alas only rarely on my Kindle app or Kindle device that my son discarded), I’m finally making progress on that enormous mountain of backlogged titles.
I love coming home, seeing the stack of tantalizing covers on the coffee table (apologies to my spouse, who is forever trying to keep the house tidy), and picking one up to spend hours lost in the worlds within.
Yes, I loved the recent Blade Runner 2049, yes, I watched the online shorts that led up to it. Yes, I re-watched the original, including the directors cut (and the hilarious back-story to the poorly-performed Harrison Ford voice over in the actual released movie: look it up yourself). And yet.
(side note: Amazon Originals now has a one season series: Electric Dreams, that is a fantastic collection of video interpretations of Dick’s short stories. Don’t miss ‘Autofac.’)
The book blows all the movies away. Philip K. Dick was not only decades ahead of his time, even now, his writing and thinking are too complex, too interweaved, too subtle for the movie screen. Electric sheep, artificial owls, animals figure prominently in the book, and are only briefly referenced in the movie. And the title finally makes sense. I really enjoyed this.
East Tennessee State University: Professor Hannah B Harvey
This is the first Great course that I have listened to. Yes, I’m like all of you. I’m proudest of those ‘important books’ on my bookshelf that I read during high school and college, and always aspire to buy and read more, but … there never seems to be enough time to CATCH UP ON THE LAST EPISODE OF BREAKING BAD or THE EXPANSE or THE MARVELOUS MRS. MAISEL (yes guilty as charged, your honor), much less break away to read a book (hello, audible.com for the commute) much less read the CLASSICS (unless of course your high school children start leaving their English lit or Russian lit or Holocaust books around and you pick them up an devour them, just to be annoying to the kids—try it, it’s fun).
So, it was with a mix of apprehension (will this be boring?) and pride (look at me! Taking another class for real! Kind of.) that I bought this and began listening. Thanks, ‘half-off audible.com sale.’ Turns out “on sale” Nudges do actually work (a future book review: I’m sitting here on the plane typing this review on my phone while the book Nudge presses against my knee in the seat-back pocket of this Economy seat).
Yes, yes I know. My wife often says: ‘it must be difficult to be you.’ Yes. Yes it is, honey. Thanks for noticing.
I’m listening to this first course. Professor Harvey has a bit of a southern accent, pleasant, well-spoken. A promising start. She’s explaining principles of good story telling, sure. Then she launches her first story, and I’M RIVETED. And then she dissects what just happened. AND I’M RIVETED. A big part of my job is: presentations, pitches for new ideas, new projects, talks to others about our successful work, speaking to laypersons, to programmers, doctors, students to convince them of something or another. I think I tell a pretty good story: some humor, some funny illustrative quotes, some quick lessons related to the story, and then a quick close.
But the professional storyteller? Watch this…
Wow.
Later in the course, the professor reveals that Little Red Riding Hood has hundreds of local culturally diverse versions. And many were not intended for children. In the version she tells, the wolf is a MAN. A handsome, vaguely dangerous, very attractive man. And darkness and blood and meat and ?string and ?white sheets in the river come into play. It only vaguely resembles the children’s story we all know. And the telling of the story is … transporting.
We learn about point of view, about developing characters and slight variations in voices, using head swivels, facial expressions, tone of voice, stepping around the stage to more clearly represent various characters.
We learn about accelerating time, expanding time to bring attention and create a short story from a longer narrative. We learn about the official role of the narrator, who, different from the heroine, or villain, or bystander, can be unreliable, or unlikeable, or have a complex and different point of view from you playing yourself. Hmm.
We learn about reading your audience, changing the story and presentation, engaging your audience in movements and shout-outs to bring them in.
And we learn about bringing it home. Remembering to tell a story THEY need and want to hear, not just a story YOU want to tell.
CMIO’s take? Give it a chance. I’m giving a thumbs up to Great Courses and to this Storytelling series in particular. I’m going to work on being a better storyteller in the service of improving patient lives. I’m also going to work on being a better storyteller to entertain friends and family and myself.
This is perfectly aligned with what I’ve been thinking recently. This combines ideas from a couple of books we’ve been reading: Nudge by Richard Thaler (a future book review), and another book on my to-read shelf: Connected, by Nicholas Christakis.
Nudge talks about how small changes in our environment, often something we can design or control, can subtly shift our behavior in either desirable or unintended directions, eg: a public school cafeteria can dramatically influence student food choices by the positioning of the food (eye level? early in the line, or late?).
Connected discusses in more detail, the idea that not only direct relationships (immediate family members, close friends), but friends of friends, AND EVEN friends of friends of friends, have some influence over our own health, eg: the NEJM research study that showed that YOUR likelihood of obesity is related to the obesity of those who are THREE relationships away from you. Wow.
And now, positive friend relationships (described as MOAI in this article, from Okinawa, Japan, with the longest-lived women, expectancy of about 90) have everything to do with long term health. I’ll leave you to read.
CMIO’s take? There are SO MANY THINGS outside of direct-healthcare that influence our health, our lives, and we are just beginning to explore them. How are you thinking about this in your healthcare organization?
I’m surprised of never hearing about this book, now in a 25th Anniversary edition. By Paulo Coelho, it is a well-told parable of the journey of a young man who loves to travel, and seeks his treasure, based on a recurring dream, at the pyramids of Egypt, a continent away.
I’m not an adherent of mysticism, and also not a scholar of the Koran. I did however enjoy the themes from these traditions that percolate up through the writing, the parables told as the boy undertook his adventures.
Each episode of his adventure: selling his flock of sheep and deciding to set out to pursue his Dream, meeting an old King who gives him two precious stones named Umim and Thummim, meeting an aging Merchant who himself realizes that striving for his goal was more important than reaching it, meeting the titular Alchemist, all become swirling threads, and messages of insight and hope.
CMIO’s take? ‘The world conspires to help those pursuing their Personal Legend.’ Perhaps I would not have said it in this way, but yes, I agree. In the world of human affairs, even in large academic medical centers and health systems, it is so easy to get caught up in ‘governance’ and too-rigidly respecting lines of authority and influence. As a result, it ‘makes us rather bear those ills we have than fly to others we know not of.’ (Shakespeares’ Macbeth) Sometimes we are too fearful to take a chance on our ideas. Worse yet, we don’t help encourage others to try new things and support them in their nascent efforts, especially when a kind word or slight nudge of support could make a world of difference. A good parable teaches us about ourselves. A great one entertains us as well, as this does.
Who could YOU support and encourage today? Let me know.
Mike (his NASA colleagues call him ‘Mass’ and so will I) is an amazing storyteller. If you read this book, maybe consider getting it on Audible.com, as ‘Mass’ narrates his own words and journey.
Mass’s New York accent is working class-cool and fits right in with ‘The Right Stuff.’ But, instead of death-defying Air Force test pilots, we have PhD-wielding engineers and physicists competing to be the one-in-ten-thousand astronaut candidate.
I remember having watched Neil Armstrong in 1969. I was a 6-year old, and remembered some fuzzy black-and-white images, a big party of adults in our apartment, and being allowed to stay up late. I had been fascinated with space Science over the years.
I remember getting my own elementary-aged kids excited over watching the NASA channel during the landing of Spirit and Opportunity on Mars. Nothing visual interesting to see, just listening and watching the Command Center wait in hushed tones for the signal of a successful landing and the entire room of scientists and engineers erupting into tears of relief and shouts of joy. We raised our arms and hopped up and down in our own celebration. Mom walked in on us and shook her head in bemused consternation. Whew. We were such nerds. And so proud.
Mass’s story is riveting. He’s a kid from the Bronx, with childhood astronaut dreams, never straying far from home. But then a mentor suggests that if he was really passionate about Space, he would find a way. Spoiler alert: he does.
He brings as along as he barely survives a PhD at MIT, difficult post doctoral work on a Robot arm with improved human-factors feedback, vision so poor it would disqualify him, getting to fly on the Shuttle, losing close friends in both shuttle disasters, getting to work on the Hubble repair (don’t miss THAT story, OMG) doing many hours of space walks, Tweeting from space, getting to be on Big Bang Theory…
Whew! I feel like I was along for the whole ride. Mass tells us of action stories, cliffhangers, scientific breakthroughs, comedy routines, insurmountable engineering design problems, interpersonal conflicts, lifelong friendships and jaw-dropping space walks. And he is such a guy-next-door.
CMIO’s take? Lessons on how high powered individuals and teams work. And the stories are unforgettable. Get this book today. Give it a listen. You won’t regret it.
Thanks to @ToddMeier, one of my IT colleagues at UCHealth. He explained to me the benefits of periodic modified fasting. This discussion put me on to watching a documentary about the Science of Fasting on YouTube, and then of course reading the book “Master Cleanser“.
Of course, I do not subscribe to non-medical claims about cayenne pepper boosting the blood circulation or “the only thing you lose during this, is mucus and clogged lymphatics”. But, look past all that.
If you know me and my writing, I like trying new things. This certainly falls into the category of “something new.” Perhaps the most powerful vision from my reading, is the idea that our Mastodon-hunting ancestors would have enormous protein meals and then perhaps not eat for weeks while the tribe looked for additional prey. Fasting and starvation are a normal, expected physiology for our human bodies. We know that the human body can go weeks without nutrition. Modern life, with 3 meals per day, and easy access to sugar and fat, and our tendency for overeating based on stress, eliminated the possibility of activating our fasting metabolism. Various reports of improved energy, cognition, reduced inflammation and joint pain, and perhaps a resetting of our sugar cravings, were all attractive aspects of trying this. My colleague at University of Colorado has written extensively on this (The Fat Switch and The Sugar Fix).
This sounds somewhat reminiscent of the Paleo diet and perhaps pseudo-scientific hocus-pocus. Nevertheless, with my underlying gout, and this desire to try something new, I broke through several weeks of ambivalence and decided to prepare the lemon drink proposed by this “master cleanse.”
The drink comprises half of a squeezed lemon, 2 tablespoons of pure maple syrup (200 cal), and a pinch of cayenne pepper. This is added to an 8 ounce cup of water, and preferably consumed hot. It is surprisingly tasty for what I considered a “deprivation” diet.
I am now on day 3 of my master cleanse and feeling good. I am experiencing no hunger, I went to my usual 90 minute karate workout, I did 4 hours of yard work, cutting down innumerable branches to appease my home-owners association “warning letter”, and now I have done a couple 5-mile bike-to-work rides.
Despite my wife’s misgivings, I did not “bonk” or hit the wall on my rides. Maybe my ketogenic diet was actually promoting my fat cells to convert stored fat into ketone bodies for nutrition (the normal non-glucose pathway, I vaguely recall, as I clear the cobwebs from my medical school physiology days). My sustenance has been about 3-4 cups of master cleanse lemonade. I could not convince my wife to smell me to check if my breath was actually fruity (as patients with diabetes who are in severe ketoacidosis exhibit).
Some observations:
Within about 2 or 3 minutes of consuming a master cleanse glass, the hunger disappears rapidly. Hunger is suppressed for 4-6 hours. Then taking another glass rapidly suppresses appetite again. I find no decrease in energy. I find that the hour spent preparing for a regular meal, eating the meal, and cleaning up from the meal becomes just 2 minutes of drinking my lemonade and cleaning a glass (… and then an hour writing a blog about it). I no longer experience post-meal fatigue and drowsiness. I think that my mental clarity is actually better throughout the day, and I am forgetting to drink tea as an energy boost because I find I do not need it.
Unlike my perception that fasting would be a miserable starvation experience, this method, that does provide 200 cal in maple syrup 3-4 times per day, is a comfortable, minimal impact to my day. I am finding that it does not impair my exercise or activity at all. In fact I am somewhat motivated to stay physically active to prevent any muscle breakdown during this “cleanse.”
It is unclear to me how many days I will persist in this trial. Each day I find there are challenges as I either smell my wife’s aromatic cooking or observe various family members crunching their way through a delicious meal. I find interesting moments when I crave a bagel or a piece of cheese, or some takeout Chinese food.
One time, I did consume a ginger candy midway through this cleanse and about 30 minutes after felt somewhat drowsy. I am wondering if this is a burst of insulin in response to an oral glucose load, causing post-meal sleepiness (see: Post-prandial somnolence on Wikipedia). Hard to say if it was a coincidence.
Last night in a moment of weakness I rationalized having a bowl of miso soup from a concentrate that I bought at a local Japanese store. Reading the label carefully, I find that it is only an additional 30 cal of protein and a little bit of carbohydrate. This was perhaps the most delicious bowl of miso I have ever had in my life. There is no umami flavor in lemonade. https://en.wikipedia.org/wiki/Umami
UPDATE end of day 4. Having braved 4 days of “cleanse”, my cravings betrayed me at last: chips, salsa, miso soup and some cheese and crackers. Oh well, not the end of the world. After four days of consuming only 600-800 calories by way of lemon drink, I figure that’s about 1200 calories net negative each day. My scale did show a drop of 5 pounds over this period of time, with really very little effort. Not sure I noticed any difference in my knee pain (probably a non-inflammatory degenerative arthritis anyway), and my gout is so stable, can’t tell the difference. I did my usual activities, sipped 3-4 glasses of “cleanser” each day, found a surprisingly peaceful, evenly-balanced energy day, felt clear-headed and at least somewhat virtuous. If I was a data geek (ok, I am) I would ask my doc for some lab tests on my uric acid (breakdown product from muscle) and a serum creatinine and electrolytes, to see what is going on inside. Maybe another time, if I end up doing a more extended version someday.
Surprisingly, I found that the first meal after 4 days of a liquid-only diet was an incredible sensory experience. The luxury of just CHEWING and using my tongue and tasting flavors is a surprising joy when it is no longer a routine. Maybe that is one good reason to do a periodic fast, the ability to re-discover such simple joys. Oh, the crunch, the flavor, the aroma…
CMIO’s take? A little bit of fasting may do you good.
Have you fasted before? Let me know!
