YVMC’s head nurse Maria took me aside yesterday: “I have BIG favor to ask of you.” With trepidation, I stepped aside for a brief chat. “I need you to write a song about Mark and Heather; they’ve been amazing and led the teams to our EHR go-live success. And, can you put it together by tomorrow’s 9am Safety Huddle?”
What!?! Seriously? Does she know how hard it is for me to write these, learn to play the song (badly), practice enough to be willing to play in public?
Oh, well.
Turns out, looking through my song parody library on my Notes app on my phone, I had a parody song, I called “Anschutz Roads” written in 2011 for our initial Epic go live at University of Colorado Hospital. With growing relief, I found that I could adapt it for our purposes here. I also recruited Juliette Callander, Manager of the UCHealth Rev Cycle team, and equally important, a wonderful singer, whose harmonies added a lot to the song.
She took me up on the challenge of learning the melody and the words, as I struggled to get my chord progressions and my strum pattern down. A few minutes of rehearsal in the nearby board room the next morning, and we were on stage at the end of Safety Huddle.
CMIO’s take? You can’t always get what you want, but if you try sometimes, you get what you need. I enjoyed how embarrassed Mark and Heather were during the song. Thanks, you guys are great. Also, I’m winding down my daily coverage of YVMC EHR go live, and returning to our regularly scheduled weekly posts starting tomorrow. See you then!
Finally, the Command Center begins to fill out with analysts supporting the full spectrum of IT areas: ambulatory, scheduling, inpatient, informatics, nursing, staff, health info management, security, networking, desktop support, interfaces, speech recognition, implementation specialists (jack-of-all-trades support).
Overall we are doing well. No big fires, just a steady stream of the usual. Printers not mapped to the right spot, meaning that printouts (after visit summary, printed orders for external labs, etc). Security challenges. Some clinics switched from ‘community connect’ to employed clinics, so all the clinicians have new security for logins an their previous personalized settings were ‘lost.’ Some test results are not flowing exactly as expected. So each of these requires investigation and fixing. It is rewarding to see issues come in and watch them be fixed within minutes to hours, since we are focused.
Fun fact: we’re using Microsoft Teams to communicate internally. All of my physicians in the Large PIG (physician informatics group) are on Teams. We have set up a communication channel called YVMC go live (Yampa Valley Medical Center), and conversation threads regarding clinic support as well as hospital support. As issues come and go, we post our conversation there, Facebook-like (except stored securely and not polluted by silly cat videos or rogue-bots), so that my entire team is not spammed by me, and anyone interested can dip into the conversation as needed, as each of them will rotate through Steamboat for 1-2 days, and can see all the issues posed and resolved previously. Teams is not perfect, but it is good-enough. We can link to shared calendars, to common file storage, to best practice tip sheets, for addresses of all the clinics. We can set it to “ping” us on our phones and our desktops, and can treat it as both email-like, file storage-like, as well as instant-message like. And our email congestion is slightly less.
Finally, another uke song:
CMIO’s take? Whew. Going back to the hotel to put my feet up. Back at it tomorrow.
Red shirts swarming the nurse/physician work areas. Cool hospital art. Cool hospital art marred by presence of the author.
I love hospital art. Why not improve the lives of employees by showing something beautiful?
Day 2 is going well. It is fascinating to see each department with very different concerns come together to solve problems.
Love these clever posters.
We have a doc who can order tests and prescriptions but can’t place billing charges without ‘changing context.’ Call the command center. We can fix it.
We have a doc whose USB Dragon mic doesn’t work. Solution: call in a ticket to command center with details, move to a different computer until it is fixed.
Some breast milk scanning process is not well known. Send a red shirt with expertise. Teach the new workflow, get staff up to speed. Done, this morning.
Someone in respiratory therapy is trying to place a lactate order, as they always used to. Can’t do it in the new system. Ok, something we didn’t find out during our ‘discovery’ interviews. It is always something. We’re on it.
Of course when you can sneak in a song…
If You’re Going to Yampa Valley. Based on the Scott Mackenzie song ‘If you’re going to San Francisco.’
CMIO’s take? Good news: everything we solve today is one less crisis tomorrow when we are back to full speed patient care.
These suspicious looking characters are Jon Pell MD, Hospitalist and informaticist, Mark Clark, CIO YVMC, Dave Corry MD, informaticist and vascular surgeon, and yours truly. We’re here wearing red shirts and supporting the physicians and staff for day ONE.
Remarkably few calls to the command center, scant login issues, only 20 open issues on the tracker. Very quiet and quite calm for day one.
Unlike other industries where one may have to remind oneself of the larger mission of IT (eg not just supporting users and making sure the network and software is working) it is abundantly clear who we serve as we walk around. Beautiful photos of moms and babies on the Women and Infants unit.
Magically, these computers went from inoperable to fully functional overnight.
We are SET! Dozens of fresh red shirts, ready to be donned. We have invaded the local hotels and will be set for go live in the morning.
Furthermore, lots of pens and papers to sketch out issues, problem solve. And of course lots of tissues for the tears … of empathy. Yes, we anticipate being sad for everyone for whom we will have ‘moved their cheese‘ in the process of replacing their previous medical record system with UCHealth’s system EHR. For this, we anticipate saying ‘sorry’ all week long.
Meantime, behind the scenes, feverish activity in the Cutover room. In front of these dozen computers, hospital and IT teammates are gathering data on the handful of patients who we anticipate will stay overnight in the hospital and thus will need to have their data moved by hand (some copy and paste) from one EHR to another so that the docs will ‘hit the ground running’ in the morning. This means all the demographic information, their med list, their IVs, their diagnoses, any treatment plans for nurses, their active treatment orders and any pending labs or tests.
The cutover moment will be 2am when the old system is retired and the new one is live. We have databases to convert, interfaces to move, we have to unhook the transcription system and move it, we have to unhook the speech recognition system and move it. We have to add hundreds of new physicians to the database and grant them the correct security access. There are tons of mini settings to get right: hospital admit privileges? Ability to dictate? License to use Dragon speech? Ability to badge into the OB suite? Privileges to do EPCS? (E-prescribe controlled substances?) did we capture their digital signature? Did they come to training and get certified to use the EHR? Are they a surgeon and need access to the OR schedule? Do we have them set up in the right clinic? Do they have the right ER tools if they work in the ER? Months of planning come down to tonight and tomorrow.
And this is just the stuff that a CMIO cares about.
The CIO’s team also handles: Cloud storage, network traffic, downtime plans, Outlook integration, single sign on, employee badge management, coordinating meals for about 100 workers, hotel accommodations, network interfaces, wireless access points, brand new WOWs (workstations on wheels) retiring the old EHR and old habits and workflows, etc. Whew.
CMIO’s take? It is an exciting time. Stay tuned! We’ll be live blogging all weekend and into next week. We’ll try hard to bring you the pitter-patter excitement of a Go Live. One of my colleagues compares it to ‘replacing an aircraft engine in mid flight.’ He’s not wrong.
I’m here at YVMC: Yampa Valley Medical Center in Steamboat CO for Friday’s Epic EHR go live. Setting up the command center, at least half the room is festive. Prepping for the inevitable phone calls. We are finishing up our Preflight sessions, an innovation we created to get docs ready for the big day. Beyond the classroom and online training, we put docs in front of our Physician Informaticists to discuss actual workflow and also to double check that they can login successfully, and finally to teach them some personalization within the EHR:
Create some auto-correct phrases to expand common abbreviations into readable words
Learn how to build macros for physical exam and review of systems
Learn how to build smartphrases for commonly typed statements that docs say: risks and benefits, usual treatment for common conditions, the ABCDE of melanoma screening, any of a dozen common items.
‘Wrench in’ frequently used quick-reports that docs of that specialty use, to get at problem lists, diabetes reports, flowsheet trends
It is fascinating to meet a new crew of physicians. Fun to see what local culture has m built. We are proud to be joining such a reputable hospital in our front range and have them join the UCHealth family.
Maybe this time there will be time to record ‘Epic Central.’ We’ll see.
CMIO’s take? It is good to be growing. Better than the alternative. Reminds us of the importance of our work, our vision for the Physician Informatics group: ‘We improve physician and team wellness and effectiveness by building extraordinary relationships and innovative tools.’
Proud of our COO and CIO and their efforts to revolutionize our Operating Room Efficiency through machine learning as well as some social engineering.
SBAR statement
Situation: Operating Rooms are some of the most expensive real estate in a hospital. How can we improve utilization rates in the face of surgeons protecting their OR time (motivations are not aligned), AND there is poor, non-realtime data on OR utilization?
Background: OR block times are allocated to surgeons (CT Lin gets Tuesdays all day and Thursday mornings in OR #3; just kidding, I’m not a surgeon). CT Lin thus protects his time slot. Sometimes he’s busy and uses the entire time, but often he doesn’t need all that time; and an OR team (anesthesia, nurses, techs) sit around idle. How can we use modern tools, social engineering, data analytics to improve utilization WITHOUT building lots more Operating Rooms?
Assessment/Recommendations:
Apply machine learning to several years of OR scheduling data. Figure out that there is a way to ‘shape’ the OR schedule from previous experience so that each operation lasts as long as it needs to.
Figure out how to move blocks around to use the same allocated time more fully.
Create a social media “OR block exchange” tool to allow surgeons to release block time without penalty and bid for unused blocks when needing extra OR time.
Create incentive that those who ‘release’ blocks consistently and keep their actual OR usage percentage high, get first dibs on any unused blocks. Win-win!
Result; $10M increase in revenue from better utilization, no need to build new OR’s. Read the linked article for details.
CMIO’s take? Wow, love it when innovation is more than just talk. Proud of the results of our Innovation work.
Thanks to videographer @DrDannySands for taping my latest spontaneous ukulele performance of “Doc Prudence” a uke parody song and cautionary tale (not really) about Open Notes at #sgim18 (Society of General Internal Medicine, national meeting in Denver last week).
CMIO’s take? Self-aggrandizement never pays off. OR, taking oneself too seriously never pays off. One of these two. Or maybe both.
There is a risk, in a large and growing IT organization in a large and growing health system (we’re up to 9 hospitals, 400 clinics) is getting disconnected among the hundreds of employees and colleagues within this unit. We certainly don’t have all of it figured out, but there are proud moments when we do something good…
(like untalented folks playing ukulele – see https://youtu.be/EC6yXXYl1vY) (as an aside, did you know that YouTube now AUTOMATICALLY generates closed caption content?) (although bad singing apparently still stumps it!) (and, there is a tool for humans to correct the computer-generated text) (hey, everybody, just like transcriptionists everywhere, who are employed by companies applying Speech Recognition to incoming physician dictations BEFORE having a human correct the computer generated text, I’m now also officially a Correctionist! the new title, apparently, for transcriptionists doing this new work).
Whew! I’ve always wanted to create a parenthetical aside that took on a life of its own (see my previous review of the book Mezzanine for the most artful and entertaining example of massively meandering asides).
Nevertheless, after some initial hesitance, gradual persuasion, and some non-standard funding, we’ve had a ping-pong table ensconced in the midst of our IT building for several years.
Okay, so we haven’t always been as quiet as we should be, to avoid disturbing those unfortunate enough to have a cubicle near the Ping Pong room. And, yes there is always the persistent business pressure of converting that conference room back into more offices, but we have held on (so far).
Use of the table is sporadic, and I feel, insufficient to deliver the quantity and quality of potential joy and human connection that comes with such an unexpected resource. In other words: HEY PEOPLE WHERE IS EVERYBODY.
I know, West Coast start-up companies all have ping pong tables and foosball, and the perks to attract millennials and them younger folks who, I’m told, are constantly joining the workforce. Sure. I’m just an aging boomer trying to keep up.
WHICH brings me finally to my point. After years of inertia, I put the finishing touches on my Ping Pong Ladder last night, and mounted it with some help (and, an IT colleague’s pen that has a built-in Level!)
This is a flashback to my heady days, in college, of being the Athletic Director in my dorm, and trying to convince my classmates that playing an intramural sport actually helps reduce stress and improve academic performance. In those days, I built and posted a ping-pong ladder in the basement of our dorm and had an active cadre of about a dozen classmates with more enthusiasm than skill, and had a grand time.
Heady days of collegeOK, actually, heady days of college. The “athletic director.” Uh-huh.
However, the contrast here, is (okay, you can stop laughing now).
The contrast here is, nobody knows what a ping pong ladder is! Really?! “Hey, when is the tournament?” “How does this thing work?” There’s a bigger social commentary here, too much FaceTime and not enough face time. Too much texting and not enough bowling. If you haven’t heard about or read Putnam’s amazing critique of the modern age, Bowling Alone, (TL;DR) at least read the synopsis, like I did.
I had to explain the underpinnings of the Ladder to several colleagues; that you challenge up to 3 spots up the ladder, and if you win, you take their spot and everyone else moves down, and that fundamentally, it is about social connections, finding someone to play ping-pong with, and having a social construct, an excuse to blow off some steam, have a chat, get some blood flowing, and then get back to work. No need to even break a sweat if you don’t want to. The good news is, everyone has either played ping pong or is willing to try. At least that is my hope.
Did you know, by the way, that official ping pong rules changed decades ago? Seriously? I learned that a game was first to 21, that you served 5 times in a row then switched, etc. Now, games are to 11, and you switch EVERY 2 SERVES. Apparently, nobody has time anymore. But, games do move more quickly, and more folks do get to play. So there’s that.
And of course, thanks to the first followers; it would be a sad day if my tile was the only one on the ladder. We had 19 colleagues put up a tile on our first day. Hooray!
CMIO’s take? Do you have a ping-pong ladder? or have you had to explain some ancient social norm recently to a younger colleague? Do we even think Ping Pong Ladders can survive in this modern age? Or is it time for the Boomer and his sad Ladder to walk into the sunset? Let me know.
Okay, so this “forward looking” image is somewhat self-serving.
Recently I was asked by a colleague, how would I size up current EHR’s: what are the major wins and major needed improvements? In about an hour, and off the top of my head, I wrote this list. It is neither comprehensive nor deeply reasoned. However, it IS a compilation of frustrations and grateful moments that come from having help design, implement and USE an EHR over the past 2 decades.
See Youtube, from a Boston EHR interest group, CRICO: https://www.youtube.com/watch?v=VHMJaV7zJxE Provocative; I don’t agree with all of it, but it provokes a lot of discussion, see below.
MAJOR win: engaging the patient using the portal: online communication, access to records, Open Notes, Open Results, is just the beginning of a needed improvement in information transparency. Anything that eliminates the telephone tag circus is good.
MAJOR win: having the chart accessible ANYWHERE ANYTIME avoids missing data (medical errors from handoffs of care) and paper filing and paper shuffling costs. As one colleague wrote: PAPER KILLS. In the late 1990’s between 1/3 and 2/3 of patient appointments did NOT have the relevant paper chart pulled in time for me to see the patient. How embarrassing. This no longer happens. Also, our paper filing, despite a team of 50 in medical records, was always 2-3 weeks BEHIND. Even if you DID receive the paper chart, chances were good you did not see the recent report you needed.
MAJOR win: improvements in legibility (sometimes at the cost of unreadability due to note bloat). How many times per day did used to I take a paper chart to a colleague or nurse and ask “what you think this says?”
MAJOR win: easy narrative documentation using Speech Recognition, and increasingly, Natural Language Processing (detecting codified concepts using machine learning). We only just starting to see the fruits of these technologies. A typical physician’s cost for human transcription, per year is about $15,000. And the turnaround time can be days, resulting in missing data during that time. Speech rec is instant. AND NLP has the potential to create instant alerting and reminders.
MAJOR win: reminders and alerts improve the frequency of doing the right thing at the right time more often (when well designed). This is the FLIP SIDE of of Alert Fatigue (see below). I love when my system reminds me to vaccinate, or screen for colon cancer, or screen for depression, particularly when I catch and prevent an illness that I would otherwise have missed.
NEEDED IMPROVEMENT: alert fatigue: poorly designed, terrible signal-to-noise ratio of alerts. Enough has been written about this. Our Physician Informatics Group (PIG: yes, we don’t take ourselves seriously), constantly struggles to improve the SIGNAL to NOISE ratio of these alerts, and to reduce alerting. I consider it a personal failure if we have implement at “Best Practice Alert” that stops a doctor’s work, instead of designing a smarter EHR that “guides” and “nudges” a doctor’s behavior, so that we make the RIGHT THING EASY.
NEEDED IMPROVEMENT: Better ways of capturing physician-patient interaction (see #1), maybe full video recording instead of typing out a history, and having the machine collate into a timeline, concise narrative.
NEEDED IMPROVEMENT: user interface design: (see #1), why can’t the electronics disappear into the wall until it is needed and then pop in with reminders and context-sensitive help just-in-time?
NEEDED IMPROVEMENT: how to eliminate communication barriers and snafu’s based on nurse-physician-patient ping-pong messages.
CMIO’s take? Send me a message! What’s missing? What would you take issue with? Let’s craft a message to our EHR vendors and demand innovation and something better. I’m convinced we’re in version 20 of something that will need 50 versions to get right.
Okay, so we haven’t always been as quiet as we should be, to avoid disturbing those unfortunate enough to have a cubicle near the Ping Pong room. And, yes there is always the persistent business pressure of converting that conference room back into more offices, but we have held on (so far).
