Thanks to Joshua Liu and Alan Sardana for a great chat spanning decades of my informatics career. We cover:
Covid-19 threatens to hospitalize an exponentially increasing number of patients in the coming weeks. In addition to building more physical space and finding more equipment, what happens when we run out of hospitalists to manage their care? What if, instead of our usual 10 teams of hospitalists, we need 20 teams? Thirty simultaneous teams?
Thanks to CT for the guest-blogging spot. I’m a physician / programmer working at the University of Colorado and UCHealth, helping our system prepare for the Covid-19 crisis.
Seeing the the massive surges in patient volume related to the Covid-19 pandemic that befell our colleagues in China, Europe and New York, we knew that we would have to find “surge capacity” among providers in our area.
We guessed that outpatient docs (like CT and me) would be needed to support the inpatient service, where neither of us have been for a long time.
I for one, was relatively panicked by the thought of serving on the inpatient service. Not only is it a different branch of medicine at this point, more than a decade from my training years, but from an informatics perspective, the workflow is completely different. I figured that if someone with my (relatively high-level) of comfort with the Epic EHR was feeling stress, others would be as well.
So roughly four weeks ago, I reached out to my informatics colleague on the inpatient service and suggested that we leverage our existing training videos to quickly produce a comprehensive written and video guide to the inpatient service, targeted at these likely recruits.
He and I, together with three other hospitalists, another outpatient internist and an informatics neurologist, quickly compiled a comprehensive document of workflow and tips.
We were gratified to find that a large number of internists practicing outpatient (clinic) medicine were willing to serve as part of the Surge teams and were interested in this just-in-time training.
There was so much interest in our training tools (document plus embedded videos) that the University of Colorado General Medicine division re-arranged the Grand Rounds schedule, and we presented this material to 150 interested outpatient internists at this week’s Grand Rounds, held by Zoom meeting.
We are so grateful that our cross-specialty relationships and shared technical expertise that are unique to informatics allowed us to create and present this material in a matter of days. Our wish:
I hope that you can benefit from these documents. However, the longer view and greater message is the value of a strong informatics team which is uniquely positioned to rapidly mobilize and meet unforeseen needs.
Richard Altman, MD
Is the integration of an individual’s narrative into the Electronic Health Record FEASIBLE to Improve Person-Centered Care? (CT Lin: I’m excited to welcome Guest Blogger: Heather Coats PhD)
Person-Centered Care, a buzz word to refocus our Western (US) healthcare system on the user of the system, the person who has a health need. We as clinicians, use the word “patient” but they are a human, just like us the clinician. We all have past, present and future stories that make up “who we are” However, this whole self sometimes is seen as parts in our western medicine culture…the cancer patient in room 202, instead of Jon, the person…who is a grandpa, a dad, and businessman whose illness is impacting his ability to be all of these things.
In recent years, the shift in Western Medicine to incorporate the person’s experience has been moving upstream. The IHI (Institute for Health Improvement) “Person- and Family-Centered Care” domain–Putting the patient and the family at the heart of every decision and empowering them to be genuine partners in their care, goal is to develop “partnerships between clinicians and individuals where the values, needs, and preferences of the individual are honored; the best evidence is applied; and the shared goal is optimal functional health and quality of life” http://www.ihi.org/Topics/PFCC/Pages/default.aspx
Since 2015, the IHI helped share the practice of asking the individual receiving health care: a simple question…“What matters to you?” in addition to “What’s the matter?” This reframing of the clinician-person interaction orients the care being provided more to the whole person, to give a much different light to a plan of care that opens the door for opportunities to involve the person’s whole self. http://www.ihi.org/about/Documents/IHI_Timeline_2018.pdf.
Now, I do not want to diminish the physiological as an important component in the delivery of care. As clinicians, our expertise (life experiences, training) are grounded in knowledge of the physiological, but I would dare to ask, we are not the experts in the whole person who is sitting across from us. Second, when a person is facing an illness…cure of the illness may not be a reality, but healing of the self is still possible.
A recent NPR Morning Edition aired on their Morning Edition program (June 8, 2019): “Storytelling Helps Hospital Staff Discover the person within the Patient aired on June 8, 2019 on Morning Edition on National Public Radio.
Person-centered narratives are one proposed way to have dedicated tools to shift to more person-centered care.
An exemplar of this narrative shift, is the MyLife/MyStory program at the William S. Middleton Memorial Veterans Hospital in Madison, WI. https://www.youtube.com/watch?v=_Wy1aMXQCTk. This program has included over 2,000 person centered co-created narratives into the electronic health record since 2013. Their program has trained an additional 50 sites to implement programs similar to theirs.
This is where my “story” comes in, I had the pleasure to attend MyLife/MyStory training back in 2015, which allowed me to think about this type of program could be implemented outside the VA, and have a program of research that tested person centered narratives interventions to improve communication between clinician and persons receiving healthcare. My NIH/NINR funded research focuses on the implementation of a person centered narrative intervention that co-creates a first person narrative that is approved by the person, then uploaded into the person’s electronic health record for their healthcare team to learn more about “What matters to them?” The first phase of the program did prove to be feasible and acceptable by the individual- the person hospitalized for serious illness, their family, and their clinicians. Through this work, perhaps, there is just one more way to help shift Western healthcare to “truly” be person and family centered.
—Heather Coats, PhD, APRN-BC
Assistant Professor of Research
Office of Research and Scholarship
University of Colorado, College of Nursing
Nurse Practitioner, University of Colorado Hospital Palliative Care Consult Service (PCCS), Department of Medicine, Division of General Internal Medicine, University of Colorado, School of Medicine
We are incredibly honored and humbled to be awarded Most Wired level 10 by CHIME: the College of Healthcare Information Management Executives.
We were one of the three organizations, out of thousands applying, to be awarded level 10, indicating the highest achievement in superior performance and process for information technology used to improve clinical care. This is the first year that CHIME separated out the awardees into levels 7, 8, 9, and 10.
See my last blog post for some of the details of our presentation at CHIME and some of the projects contributing to our success.
It was humbling to stand by the CIOs from Cedar Sinai and Avera Health to receive the honor. Link to article from CHIME below.
CHIME Posts 2019 Most Wired’s Awards and Recognition List
What I said in my acceptance comments, and I stand by them:
At UCHealth, Clinical and IT excellence arises from Partnerships:
1. Partnership between the CIO and CMIO and our teams. We make each other better than we could be alone.
2. Partnerships between UCHealth and our vendor partners: we know that there are more smart people who DON’T work for us, than who do.
3. Partnerships between UCHealth and the CHIME community. Healthcare CIO’s are a brilliant lot. We know we stand on the shoulders of giants.
Lastly, we want to pay it forward. More than 3 health systems deserve to be level 10. ALL patients deserve to be treated by a health system performing at its best and we want to see MANY MORE health systems on stage next year.
Thanks to all our EHR colleagues; I’m returning from Epic’s UGM (User Group Meeting: check out the twitter-verse at #UGM19) and learned a ton from other customer presentations and from Epic’s future vision as a company. Here is our contribution: a successful integration of RTBC (real time benefits check) of prescription co-pay, prior authorization data, and “payer suggested alternative” meds, right in the prescriber’s workflow, right inside the EHR. Simple, works fast (pharmacy- and patient’s insurance-specific real-time check within about 1 second) for every prescription written. Now, you can tell the patient “This prescription has a $4 co-pay at Target pharmacy”. What a difference.
This was the difference between my patient NOT paying $291 for doxycycline tablets vs $90 for doxycyline capsules. Really?
See my blog post on RxRevu previously. This is working well, and we’ve scaled up to all 3000 prescribers at UCHealth with excellent results.
TO celebrate, we’ve come to discuss our success at UGM … and (of course) to sing a song. Thanks to Terri Couts, VP of Epic Applications at Guthrie Clinic, co-presenting the topic, and for agreeing to sing with me!
CMIO’s take? Enjoy the song.
https://www.acmimimi.org/2018/10/InformatimukulelogicalOfferingsfromCTLin.html
Ross Martin is a physician informatician extraordinaire. Among his many talents, he is a singer-songwriter with his own musical show, and he publishes a blog at at ACMIMIMI: the American College of Medical InformatiMusicology. Turns out there is a small community of physician informaticians who cross the line between work-a-day informatics and the arcane arts of … music?
For example, a fellow Fellow of ACMIMIMI is Dr. Francis Collins, founding member of the Human Genome Project, and Director of the National Institutes of Health. August company.
CMIO’s take? I’m sure all you health IT geeks out there have hidden talents. Let me know what they are!
This is my Failure Resume. I got the idea from several sources, and thought: this will be fun and humbling for me, and perhaps encouraging to my junior colleagues facing a tough uphill climb through academia or in their organizations. In hindsight, it is easy to cherry-pick my best successes (ignoring my many failures) and construct a narrative that makes it sound like I have always been successful.
This is FAR from the truth.
Reality is much messier, and often, much more interesting. Sharing this with my colleagues has been fun and eye-opening for everyone. Here are links to my one page Failure RESUME and by comparison, my one page Regular RESUME.
CMIO’s take? I think it would be a wonderful world if more of our senior Professors and respected clinical leaders (in informatics or not) posted their Failure Resume’s. It makes us more human and gives hope to our next generation of rising leaders.
Yes! I am an internist. Yes! I have practiced for many years. Yes! I know about CHA2DS2-VASc and HAS-BLED*. Yes! I vaguely recalled that we installed built-in calculators right into our EHR to reduce the barriers for our docs to use these calculators while seeing patients.
No, until today, I had not actually used them in the service of a patient. I had been able to skate by with awesome colleagues doing these calculations at hospital discharge, or seeing them prior to me, and I would follow the recommendations generated by these discussions.
UNTIL TODAY! So, I typed in dot phrases to invoke CHADS and here come both calculators, fill in some quick data and see above; really awesome automatically generated displays that can be placed in patient charts (and shared with patients!), and now I can have a thoughtful discussion.
I am amazed, and humbled. In a high-functioning physician informatics organization, the CMIO should NEVER be the bottleneck. We should be innovating, improving our EHR, and balancing “good governence” (hey! don’t put all those interruptive alerts in here UNLESS those being alerted agree that this is a valuable use of their time!) with “rapid cycle innovation” (well, if the nurse leaders on that unit REALLY want to have a pop-up alert every 30 minutes, every time a heparin blood test returns, as long as the nurse leadership wants to try it…)
The innovation here is, lowering the barrier for docs to use it IN THEIR WORKFLOW within the EHR. Furthermore, to have it DISCOVERABLE! So many innovations are “hidden” (Oh, you didn’t read our monthly newsletter with 20 items? It was number 12. Oh, our newsletter went to your spam folder? Sorry about that). So, being able to type a search for CHADS or HASBLED into our search field actually teaches the doc how to use the tool. Amazing, being a customer of my own informatics team’s development. Sometimes, stuff just works.
*CHA2DS2-VASc and HAS-BLED are fantastic medical calculators that, based on scads of high quality evidence, that we can now effectively calculate the future stroke risk score of atrial fibrillation patients, AND ALSO that we can calculate the future bleeding risk of anticoagulants (having patients take blood-thinners to prevent stroke in high risk situations). And then we can have a thoughtful data-driven conversation with patients instead of licking our fingers and putting them up to the wind to see which way the wind is blowing that day. You can try it yourself; there are online calculators for CHA2DS2-VASc and HAS-BLED.
CMIO’s take? A big dose of humble pie for the CMIO is part of a good diet. What cool things have YOU discovered in your EHR?
Sometimes our patients push us into our discomfort zone. Thanks to one of my long-time patients, who, as a former smoker, wanted to discuss the risks and benefits of low-dose CT scan Lung Cancer Screening. She had heard of this opportunity at her employer, and wanted to see if I could get her set up for one.
Knowing that we had an entire Lung Cancer Screening clinic set up to discuss this with candidate patients, and to discuss how to think about and address the inevitable “what do I do with THIS tiny nodule in my lung, which is likely benign, but who knows” and “how high IS my risk of cancer exactly, and what is the chance that this will make a difference in my life?”
So, I heavily weighted our discussion: “You could either work with ME and I can figure out some stuff, OR you could go see the EXPERTS who do this all day long and have a thoughtful discussion.”
My patient tells me: “Nah, I want to work with you, and I don’t want another co-pay.”
So there it is. Knowing that we have documentation templates and guides, I dove right in, on the exam-room computer. It does take some humility (see previous post) to discover things in front of your patient (after all, are we NOT supposed to KNOW EVERYTHING?!). But, soon, we discovered there was a nicely structured template, searching “LUNG CANCER SCREEN” in our EHR, that asked the right questions, and then sent me to the above website, which then created a spectacular graph display (for Shared Decision-Making with Patient).
CMIO’s take? Having ‘discoverable’ EHR tools that link to sites of external knowledge, really cool. This is a glimpse into our future, where researchers and knowledge discovery, fully vetted, can be created ANYWHERE and used by ANYONE to improve the care of patients universally. There are more smart people who DON’T work for you, than who DO.
http://chimecentral.org/mediaposts/cmio-leadership-academy-2019-images
Thanks to George Reynolds and those organizing CHIME’s recent Leadership Academy for existing and upcoming CMIO’s. I enjoyed teaching this year with other co-faculty like Brian Patty, Natalie Pageler, Cindy Kuelbs, George, Howard Landa, Keith Fraidenburg and David Butler.
The topics we covered in our Academy over 2 days included such CMIO best hits such as:
Thanks to my awesome and inspiring faculty colleagues; I learned a ton as a N00bie faculty member, and got lots of new books to read, for example Brian Patty’s “What Customers Crave.”
CMIO’s take: See one, do one, teach one is the norm during internship and residency training. Sometimes Teach One ends up being the best learning of all. And, join us next year at CMIO Leadership Academy.
