Guest blogger – The Undiscovered Country

EHR analyst v Covid. Making a difference with Ear Guards made with 3D printing (Guest post: Guy Ristoff)

Guy Ristoff, his sister-in-law Mollie, and brother Bill

My name is Guy Ristoff. I work for the EPIC IT Team at UCHealth (Colorado) as an Analyst. I also have a 3D printer. A few weeks ago, I started seeing a bunch of people posting in 3D printer Facebook groups about ear guards to use with surgical masks. I thought it was a great idea for me to explore here at UCHealth.

I contacted a unit I have done some EPIC build for and asked if they would want some. I created my first 10, delivered them to the hospital, and hoped they liked them. I then contacted Gwen Martinez from the Clinical Informatics team and she sent an email blast to a group of people about the ear guards. Within 20 minutes, we started to get responses. It was amazing! The first few “orders” were coming from the Northern Region. My brother lives in Wellington and has 3D printer as well. I called and asked him if he would be interested in donating ear guards to the Poudre Valley and MCR. He was excited to help! His kiddos even got in on the fun by making thank you cards for the staff.

As for production, I can make 17 of them per batch, which takes about 4 hours. It is not a super-fast process, but it is a lot of fun making something that helps people be more comfortable. My brother has made and dropped off 80 of them. I have created 122 of them for the AMC and MHC campus so far. I am dropping those in the mail and at the hospital today! I will keep up production, so keep the orders coming. I am just happy to be able to help!

Here is my machine making a batch of them

Example of a clinician wearing a mask protected by the ear guard

CMIO’s take? Thanks to all our creative Epic/IT team members like Guy, to step up and help in every way that they can. –CT Lin MD

“What Matters to You?” instead of “What’s the Matter with You?” -guest post, Heather Coats, PhD, APRN-BC

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.

https://www.npr.org/sections/health-shots/2019/06/08/729351842/storytelling-helps-hospital-staff-discover-the-person-within-the-patient

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

“What is a Large PIG”? or, How to set up a Physician Champion for success during a hospital EHR go-live. Guest Post by Jonathan Pell MD

JonPell

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):

ChampionAndPhysicianReadinessLeads

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: attend early EHR training, and attend extra 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!)

Reducing Physician Burnout using an Agile team (EHR 2.0 Sprints), Guest Post by Brian Redig

A little over a year ago, CT Lin, CMIO at UCHealth asked “How might we reduce physician burnout associated with the use of the electronic health record?” as part of an initiative he coined EHR2.0. Through collaboration with Physician Informatics, Epic Certified Analysts, and Trainers, the optimization sprint pilot was quickly out of the starting blocks. Would the experience be the 100 meter sprint or the 110 meter hurdles?

The team accelerated quickly generating ideas. They sent out surveys, evaluated provider efficiency profiles, created checklists, investigated prior optimization requests, and observed providers interacting with the system. The team included Ambulatory Analysts, Trainers, a Scrum Master, a Nurse Informaticist, and a Physician Informaticist. They had two weeks to accomplish as much as possible through interaction in the provider’s clinic establishing a medium for collaboration in real time.

The hurdles could be anticipated; “everything is critical!”, governance, change control, communication, capacity constraints, time, trust, and differing opinions. Next, too much work in progress could create a residue effect as the analysts bounce between ideas instead of focusing on immediate next steps towards completion. Finally, how do we identify and address assumptions, inferences, and facts?

The team leveraged agile methodologies in running the sprint to help address some of these obstacles. They used a Kanban board (Backlog, To Do, Doing, Done) as a way to visualize their work and agree to the work in progress, a Burn Up chart to show their accomplishments, and a Daily Scrum (Huddle) to discuss challenges, priorities, next steps, and context for the upcoming work.

The key to the sprint became the stakeholder participation in prioritizing what was important to them and assisting with trade-offs. Instead of ideas having a static prioritization of critical, they float relative to other ideas. There was also simultaneous exploration of the problem and solution domains as the immersion provided immediate feedback loops. The focus quickly shifted from linear/more is better to high value deliverables.

The team was thinking through doing expressed best by the Chinese proverb,

“What I hear, I forget;
What I see, I remember;
What I do, I understand.”
–Confucius

Early results across the finish line demonstrate high impact to Epic flow sheets, SmartLinks, note templates, In Basket efficiency, Synopsis, and Med Rec along with positive net promotor scores.

The experience was neither a 100 meter sprint nor a 110 meter hurdle, it was a Tough Mudder!

The fastest way to the finish line was to lower hurdles through collaboration and provide performance enhancing features that minimized mundane clerical activities, streamlined charting time, and stimulated the cognitive clinical art of practicing medicine.