Showing Rx Co-Pay Cost at time of Prescribing, in the EHR (info transparency!)

Sometimes you work hard, and cool things happen. UCHealth is partnering with RxRevu, makers of SwiftRx, an EHR-embedded tool that shows prescribing doctors the co-pay cost of patient medications AT THE TIME OF PRESCRIBING! We believe we’re one of the first in the country to do this successfully.

Yes, at the time of prescribing. NOT the usual “guess-again” game that we’re all tired of. “Hey, I’m gonna prescribe doxycycline from this chronic condition. It’s an older drug so, I’m GUESSING it will be inexpensive at the pharmacy, but WHO KNOWS?!” And then the inevitable phone call “Doc? That prescription has a $241 copay! Isn’t there something else?”

We are all tired of this game.

After quite a bit of hard work and innovative partnering with RxRevu, we are pleased to have launched, about a month ago, the ability for our docs to prescribe medicines within our EHR, and (like magic!) right within their workflow (don’t have to make a phone call, don’t have to launch a web browser and figure out the patient’s insurance specifics, or look up in some massive formulary book), right in our EHR, we see the co-pay! The Real-time benefits check shows up in about 1-2 seconds, just like above.

With that particular patient, we saved him about $200 by switching from tablets to capsules. Silly, but true.

Here’s the news article on SwiftRx at UCHealth.

Here’s the recent webinar I participated in describing this innovation.

CMIO’s take? There are so many ways information transparency will help us and our patients, in healthcare. Have you found success with information transparency? Let me know!

EHR Sprint Optimization Executive Summary – using Stories, Images AND Data to change minds

Many of you know that in my role as CMIO at UCHealth, I’ve stepped in my share of potholes. My Failure Resume is replete with examples (eg: my 16 year journey to implementing Open Notes). Having studied the Open Notes phenomenon back in 2000 and published in 2003, it was a big disappointment when, after presenting to the medical leaders at University of Colorado, I was soundly voted down for implementing this transparency initiative (sharing doctors progress notes with patients online) repeatedly in 2002, 2003, 2004, until I stopped asking. Then, about a decade later, AFTER the Open Notes organization (thanks, Tom Delbanco and others) formed and pushed the agenda in 2011, we gathered steam and I finally succeeded in May 2016 to implement Open Notes system-wide for several million patients). You can call it a failure or an eventual success.

Nevertheless, when we implemented our Sprint Team for EHR optimization, we were at risk of being disbanded and told to return to our usual jobs (I had “stolen” these resources from IT and informatics to “Sprint” one endocrinology clinic of 29 doctors). In defense of our program I wrote this 1 page Executive Summary. We know that readership of white papers drops by half with every additional page. I included images/graphs (internal marketing, make your document attractive and interesting), STORIES (because, what p-value has ever REALLY changed someone’s mind?) and DATA (because, what self-respecting doctor or leader DOESN’T ask for evidence?).

And no, it wasn’t an overnight success, but it was one of the core documents that drove our executive team to finally approve the budget to continue our Sprint efforts. Download the 2-year-summary version below.

https://www.dropbox.com/s/o3qh33l7wdna3xe/2018-08%202y%20Sprint%20Aggregate%20Exec%20Sum.pdf?dl=0

We have now sprinted over 750 clinicians, hundreds of ancillary staff (MA’s, RN’s, front desk clerks), over 70 clinics, with uniformly RAVE reviews. And, even better news, we were recently funded to DOUBLE our Sprint team to 22 people. We are grateful to our leaders for such foresight.

CMIO’s take? Sometimes internal marketing can be as or more important that external marketing. Do you have success stories of how you wrote/composed documents for success? Let me know.

New PIGlet? Or, interested in medical informatics? How to start…

Piglet: ie a New PIG (physician informatics group member)

Are you a PIGlet? Someone interested in the field of medical informatics? One of our newest informaticists coined the term PIGlet (Physician Informatics Group member). Cute. Increasingly I’m meeting with medical students, medical residents and now physicians as well as allied health persons (nurses, physical therapists) interested in the field, and unsure how to get started. Well…

Fallacy: informatics is about designing computer screens and talking with vendors about features and screen design.

Fallacy: informatics is about going into a dark room, creating a fantastic tool and launching it into the public and collecting all the acclaim from co-workers who instantly understand why you are requiring more clicks and typing to complete your amazing new software package.

Fallacy: informatics is about being smarter than everyone else and just KNOWING that your solution you cooked up in your head is going to work for everyone IF ONLY THEY DID THINGS THE RIGHT WAY, like you.

Instead: informatics is about creating a vision of what healthcare COULD BE, empowered with knowledge. This is a team sport. It is about collaboration: collecting everyone’s best ideas, developing consensus, trying a bunch of things in small batches, seeing what works, and then making a big bet, measuring outcomes, and diving back in for the next cycle of improvement. Done well, Informatics is Design Thinking and Teamwork, and the “information technology” is just how it is implemented. This is completely the opposite of what many think informatics is.

They’re … wrong.

Here are some ideas for getting started. A fair number of these are associated with a TED talk or other online video summaries.

  1. Read about informatics (but ONLY after reading about leadership and organizational change)
    1. Lorenzi, Riley, Managing Technological Change
    2. Journal of the American Medical Informatics Association
    3. The Design of Everyday Things (Norman), others
    4. Nudge (Thaler)
    5. The Glass Cage (Carr)
  2. Books to read (leadership, culture change, a book club if you’re lucky)
    1. Leading Change (Kotter)
    2. Good to Great (Collins), and others
    3. Death by Meeting (Lencioni)
    4. Delivering Happiness (Hsieh)
    5. Tribal Leadership (Logan)
  3. Books on self improvement
    1. Getting Things Done (Allen)
    2. Deep Work (Newport)
    3. The ONE Thing (Keller)
    4. Atomic Habits (Clear)
    5. The Practicing Mind (Sterner)

There are blogs:

Above all, be curious, be useful, pace yourself, take care of yourself so that when opportunities arise, you can occasionally sprint into action. Create learning habits to stay abreast of changes that affect your clinical practice and that of your colleagues. Read broadly about other industries unrelated to your own, and how problems are solved elsewhere.

CMIO’s take? Informatics has become a crucial part of medical training. The most commonly used (and often hated) tool for physicians today is the EHR; more common than the Yankauer, the retractor, the scalpel, the stethoscope, even. Why not develop exceptional skills with this tool? Until it matures into a self-aware entity (! a later post), it is on US to shape it into a useful tool.

I Can See Clearly That My Sprain is Gone – Ukulele parody (and an XGM talk)

Author along with co-conspirator Peter Sachs MD. Neither can sing.

We (Dr. Peter Sachs, Vice Chair of Radiology at UCHealth, and I) recently had the pleasure of presenting our recent quality improvement work at Epic’s XGM (eXpert’s Group Meeting) in Verona, WI this week. In brief, we created and turned on the ability for patients to view their own radiology IMAGES online in their patient portal. We had already been sharing radiology REPORTS with our patients for over a decade, and this is an additional step towards information transparency. We think we are among the first to do this.

Despite some minor misgivings on the part of our clinical leaders, we were given the green light to turn this on. Short answer, over 22,000 patients viewed their images in the first month, September 2018 and … no complaints from either doctors or patients! So, we get to keep our jobs!

If you have 2 minutes, here’s the song:

And, if you have another 25 minutes, here’s the talk, and some Q/A after:

Patients Viewing Their Radiology Images Online. Peter Sachs, CT Lin, XGM 2019

CMIO’s take? It is terrific to have a close community of like-minded physician informaticists and technologists pulling to improve healthcare and patient experience, and celebrating each other’s successes. I’m ever grateful to innovative and inspiring colleagues.

What is a Yottabyte, and How Do You Treat It? (a talk)

I gave a keynote speech late last year at Technology Awareness Day, hosted by the University of Colorado, Anschutz Medical Campus about Big Data, Tech acceleration, and Artificial Intelligence, as applied to healthcare.

I enjoy making my colleagues uncomfortable. How long will doctors have jobs? Will the AI eliminate internal medicine doctors? If Watson can beat humans at Jeopardy, can it beat me at reading medical literature? Can it be dermatologists at diagnosing skin cancer? Can it beat radiologists at interpreting CT scan images?

It is true that the most complex object known to us is the human brain, with its trillions of neurons and extensive interconnections. From this physical matter, something called “general adaptive intelligence” and “consciousness” arises, neither of which we understand or know how to construct or deconstruct. On the other hand, fundamentally though, isn’t a neuron a collection of physical and chemical processes that we DO understand? And then extrapolating upward then, is it not conceivable that we could eventually figure out how to construct a human brain in all its complexity? Hmm.

Reading books like “Life 3.0” and “Superintelligence” gets me thinking about stuff like this. It is both humbling and exciting at the same time.

CMIO’s take? Decide for yourself. I know, it is almost an hour long, and who has an hour anymore, especially if TED speakers can get their point across in 10 minutes? Well, consider my talk a series of 4-5 TED talks. Yeah, that’s it.

Denver Regional Clinical Informatics Summit (and ukulele) – second annual, hosted at UCHealth

Okay, so you’re probably here for the Informatics knowledge, but too bad, we’ll lead with ukulele. Thanks to Dave Beuther for writing us a world-premiere song parody of Grace Vanderwaal’s “I don’t know my name” ultimately winning America’s Got Talent a couple years ago (meaning Grace, not Dave).

I’m really grateful to our Denver Region sister-health-systems. We have quite a few health systems in our region with Clinical Informatics expertise, and we spent the better part of a day getting to know each other, conduct round tables, and discuss our common challenges in designing next-generation, innovative Electronic Health Records to improve the care of patients in Colorado. Thanks to attendees and leaders from: Boulder Community, Steamboat (Yampa Valley), Centura Health, Children’s Hospital Colorado, Denver Health, Kaiser, National Jewish Health, SCL Health, UCHealth and the Denver VA Medical Center.

Amy Hassell explains how components of the Virtual Health Center work to Summit attendees from across Metro Denver

We had about 30 attendees from various health systems touring our Virtual Health Center (VHC), seeing our capabilities for Virtual ICU, Virtual Remote Monitoring, Virtual Urgent Care, Safety View, Telemetry and more.

About 50 attendees participated in our afternoon Clinical Informatics Seminars, a series of Round Table discussions ranging across such topics as Clinical Documentation, Order Sets, EHR burden and optimization, Physician Builders, Virtual Health, Innovation, Clinical Decision Support, Analytics and Data Science. Whew!

What’s a good conference without a Selfie?!

We wrapped up the day with an evening CHIMSS (Colorado chapter Health Information Systems Society) event with a keynote by Dr. Rich Zane on Innovation in Healthcare.

This was followed by a panel discussion on innovation with Brandi Koepp, Pharmacy Coordinator, UCHealth, Paul Schadler, SCL Health, David Beuther, National Jewish Health.

Here are the reviews of the event! https://www.surveymonkey.com/stories/SM-P7KFLZDL/

The evening CHIMSS event in the Bruce Schroeffel Conference Center main auditorium @UCHealth

CMIO’s take? Although we could probably benefit from more frequent information sharing and collaboration, for my taste (as coordinator), once a year is pretty good! It is cool what our sister health systems are doing to improve the care of patients; we are better together!

Video: Dr. Sieja discusses EHR Optimization Sprints

Congratulations to Dr. Sieja and team for publication of UCHealths’ experience regarding EHR Optimization Sprints. You can do it too! Read about our published experience at Mayo Clinic Proceedings.

https://www.mayoclinicproceedings.org/article/S0025-6196(18)30788-2/fulltext#appsec1

There are several online supplements: additional specifics about how we conducted the program (30-60-90 day planning meetings, agendas for the 2 weeks of activity, etc), and the actual pre and post-intervention surveys.

Optimization Sprints: Improving Clinician Satisfaction and Teamwork by Rapidly Reducing Electronic Health Record Burden (published in Mayo Clinic Proceedings Feb 2019)

Sprint team action shot!

Congratulations to Amber Sieja, Katie Markley, Jon Pell, Christine Gonzalez, Brian Redig, Patrick Kneeland, co-authors on our published article in Mayo Clinic Proceedings this week. I’ve spoken of some of the details on this blog, so I’ll let the paper speak for itself. Nice to be recognized! Coming soon: a video by Dr. Sieja explaining some of the highlights of the paper.

https://ac.els-cdn.com/S0025619618307882/1-s2.0-S0025619618307882-main.pdf?_tid=c94d2fe7-8f2b-4e66-9852-277fb952f3eb&acdnat=1551313804_a8d687bb190fdb632cd1ed9f45c8ef41

CMIO’s take? When team members do great work, we all get better.

How Do You Balance Patient Care and Research with Online Patients? Our Proposed Protocol

Flask from nounproject.com

What would you do with the following research requests?

  • The CEO of the health system would like for all patients using the EHR patient portal to be asked to sign a consent form to participate in our system-wide strategic BioBank. In this strategic project, we aim to capture an “extra tube of blood” when a patient is already getting blood drawn for a lab test for clinical care. Then we would apply genetic analysis to large populations of patients to see if we can discover gene-disease linkages that may be useful to patients. May we set up this consent form and present it to patients?
  • A researcher would like to survey ALL patients in the health system to ask them their opinions about marijuana use, both recreational and medical. It would be about 20 questions. The researcher does NOT have an existing relationship with most patients he/she wishes to survey.
  • A physician specialist would like to ask all the patients in his/her own clinic about their symptoms of arthritis, to understand how he/she can improve their own clinic’s care process and maybe publish the improvements when completed.

Such are the challenges of our MHC (My Health Connection) patient portal Clinical Leadership Advisory Group. Our goal is to protect our patients, who have signed up for MHC primarily as a communication tool between patient and clinic/physician, and not allow unsolicited research requests (potentially from hundreds of researchers) or “quality improvement” surveys or projects from “email spamming” their patient portal message inbox. AND YET, we believe that a large fraction of our patients might welcome the chance to participate in a research trial and increase our medical knowledge. How to do this? We struggled and discussed for hours, and came up with the following principles, that we are gradually implementing:

White Paper: Research queries using My Health Connection (MHC)

Executive Summary: How shall we decide on permitting researchers to use MHC for recruiting and contacting patients? Until now, research recruitment has been off-limits. We propose a framework for permissible MHC use for research recruitment and a path forward.

Background:

My Health Connection is the UCHealth rebranded MyChart patient online portal to the EHR. Patients sign up for MHC with the express intent of using it to communicate with their healthcare team directly. We have had repeated complaints from patients when they hear from unexpected sources (Administrators sending messages regarding “flu shots” or other health maintenance, as required by Meaningful Use federal regulations). We have thus been very careful about protecting patient’s presumed interest in using MHC as a purely clinical communication tool.

On the other hand, Researchers at UCHealth have great interest in using MHC for research recruitment. We have not yet (Dec 2018) implemented the Research Module within Epic for recruitment and management of potential and patients currently engaged in research trials.

Our IRB (institutional review board to protect patient rights) has been an excellent partner in restricting use of EHR for research recruitment, balancing patient needs, clinic needs, researcher needs.

To date, the only exception to research use within MHC has been: the UCHealth BioBank for recruitment, processing and notification of patient’s genomic data such as pharmacogenomics and other screenings, approved by Strategic Executive Group (SEG) at UCHealth.

Additionally, the MHC clinical leadership group have previously declined a research request to broadcast a marijuana survey to all 400,000 MHC patients.

MHC clinical leadership HAS allowed broadcasts through MHC for drug or device recalls when there are patient safety concerns.  It has also allowed general health broadcasts as required to meet federal Meaningful Use regulations for patient portal implementation and use (see above).

Assessment/Recommendations for MHC research framework

  1. Large UCHealth strategic initiatives (including research) using MHC are approved by System Executives. IRB approval is also necessary. MHC clinical group also informed.
  2. Research requests by a Principal Investigator (PI) recruiting patients within his/her own clinical practice (where there already exists a treatment relationship between that investigator and/or his/her colleagues and their cohort of patients), should meet ALL the following criteria:
    1. IRB authorizes this project to use MHC for recruitment and communication
    1. Recruited patients have all been seen in the clinic(s) where the principal investigator and co-investigators work, so that there is an EXISTING physician-patient relationship
    1. The Principal Investigator (PI) or authorized study team members, send and receive MHC messages individually. This is not the responsibility of the MHC IT team.
    1. Online MHC recruitment should mirror any paper- or phone-based IRB-approved process
    1. COUNTER-EXAMPLE: System-wide targeted patients across many clinics WILL NOT BE APPROVED AT THIS TIME. An existing physician-patient relationship must already exist between recruited patient and the investigator(s)
    1. There will be ongoing assessment of any complaint received
    1. The MHC team will investigate a method for PI’s to update a patient’s chart in case of DECLINING FURTHER RESEARCH RECRUITMENT.
      1. If patient declines for an individual study it will be up to the PI to track that
      1. If patient declines for ANY research outreach via MHC, we anticipate creating an FYI flag called “NO MHC RESEARCH RECRUITMENT” that we can query later to prevent outreach errors
    1. MHC team will and will not:
      1. WILL: require investigators to ask permission of Clinical Advisory Committee prior to start
      1. WILL: permit 1:1 MHC recruitment messaging from PI to patient when project approved
      1. WILL NOT construct research questionnaires for online transmittal
      1. WILL NOT have patients sign online consents via MHC
      1. WILL NOT help track patients in study via reports or alerts
    1. Approvals thus needed:
      1. IRB
      1. MHC Clinical Advisory Committee
      1. UCHealth Marketing for allowable messages in MHC
      1. UCHealth Patient Literacy Team for 8th grade wording or clearer
    1. Monitoring
      1. PI would present MHC component of research plan to MHC Clinical Advisory
      1. PI would present 6-monthly updates during study to MHC Clinical Advisory
        1. Patient recruitment numerator/denominator
        1. Assurances about only recruiting from permitted clinics/units
        1. Refusal rates and other concerns from patients, clinicians, staff
        1. Anticipated close of research or translation into standard practice
  • NOT PERMITTED: Patient recruitment outside of an investigator’s clinic (eg: show me all diabetes patients; maybe 40,000 patients or please facilitate the outreach to all DM patients). Not allowed at present
  • FUTURE opportunities:  Epic does have a Research Module that we have not yet implemented. It may be possible to integrate research recruitment that follows all IRB necessary protocols to protect patient privacy. UCHealth will partner with UCD School of Medicine leadership to consider implementing this module in the future. As our tools evolve and with patient feedback, we will discuss the tools at MHC clinical group to review and update this guideline.

CMIO’s take: Have YOU implemented a research module within your EHR? Does it solve this problem? Please let me know in the comments!

Large PIG Annual Summary FY-2017-18: our successes, challenges, and plans for the coming year

Our Large PIG (actually JIG: Joint Informatics Group)

How do you give thanks and acknowledge your teams each year? I know WE don’t do it nearly enough. Here’s a partial list of our PIG achievements from 2017-18, now that we’re into 2019 (I know, I know, I can’t blog fast enough to keep up with smart amazing colleagues, a great problem to have).

Physician Informatics Group Annual Executive Summary
Submitted by CT Lin MD, August 20, 2018

Vision statement: We improve physician/APP and team wellness and effectiveness by building extraordinary relationships and innovative tools.

FY2017-18 Achievements

  • Go Lives: MANY Clinics, 2 Hospitals
  • Sprint: 17 Sprints in 2 years, 496 providers, 315 staff
  • PI’s conduct specialty-specific and general projects to improve provider and staff efficiency and effectiveness in patient care
  • PI’s create and educate via newsletters, tip sheets, videos, meetings
  • PI’s help review, test, educate and implement Epic upgrades
  • PI’s develop and lead service line governance for UCHealth
  • PI’s chair or co-chair or participate in at least 2 dozen UCHealth governance committees to guide both Epic EHR development as well as UCHealth provider leadership overall.

Examples of successful projects:

  • Conversion of OIC (infusion) orders from “referrals” to “Therapy Plans” for safety, efficiency
  • Creation of 5 new UCHealth-wide service lines to facilitate Epic EHR build, reduce unnecessary variation
  • Creation of an APP Epic Concierge meeting to improve effectiveness and training
  • Dragon Speech expansion and elimination of Partial Dictation
  • Creation of a PI onboarding document, training, getting-up-to-speed
  • Creation of an Opioid management steer and Epic customizations to support initiative
  • Implementation and expansion of innovation partner tools within Epic: AgileMD, RxREVU, APPRISS
  • Implementation of Radiology Indications software, phase I
  • Implementation of patient access to images via My Health Connection
  • Use of EHR, scheduling and billing data to improve clinic operation efficiency, effectiveness
  • Creation of an Universal APSO note to improve both standardization AND customization
  • Creation of an MA-smartform to dramatically improve consistency of data capture in Practice Transform
  • Connection of Epic data to ORIEN (oncology research network) with dramatic efficiencies
  • Implementation of iECG, physician informatics/organizational change support to change EKG capture platforms across all hospitals/clinics
  • EPCS: E-prescribe Controlled Substances deployment of 2-factor authentication
  • Support of Palliative Care and Spine Surgery smartforms, note templates, registry reporting tools
  • Standardization of UCHealth Order Sets, physician leadership, phase I
  • Support of AMC Neurology Practice Transformation, note templates, flowsheets
  • Book Club: Read books this year on Organizational Change, Communication, Connection: Design of Everyday Things, Good to Great, Great by Choice, Crucial Conversations, Leading Change, Nudge
  • Creation of Small PIG program to mentor newer PI’s

Opportunities for Improvement

  • Counseling and coaching of PI(s) to further improve internal and external communication and leadership skills in a rapidly growing organization
  • More emphasis on analytics, use of information in our PI role, beyond “go live” and “optimization”

Plans for Coming Year

  • Implementation of approved Sprint Team 2, improvements on process for Team 1
  • Implementation of expanded rollout of Practice Transformation (changing the MA:MD ratio to 2:1), and supporting EHR tools
  • Support of ongoing hospital go lives
  • Ongoing redesign of PI support of clinic go-lives and onboarding individual providers
  • Incorporate analytics into Sprint
  • Dragon speech QI/research project: Dragon in the exam room
  • Radiology imaging shown to patients QI/research project
  • Expansion of Innovation projects
  • Expansion of MHC questionnaires, possibly PROMIS questionnaires
  • Acceleration of the Order Set Synchronization project
  • Further reducing the EHR burden, improving patient care and human connection, in everything we do

CMIO’s take? What’s YOUR take? What do you plan for the coming year?

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