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 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:
That our surge of hospital patients is manageable
That our hospitalists stay safe and healthy
That any outpatient providers who are called to duty stay safe and healthy
We are grateful for the role we’ve played, and will continue to play
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.
A recapitulation of a series of tweets about my recent experience at the UCHealth’s command center. I rotate the responsibility for the physician support position with about a half-dozen other docs. The command center has been up for almost 3 weeks now.
1/ A day @uchealth Incident Command Center. Constant stream of calls. Room is full of experts (infectious diseases, pulmonary, disaster) with a dozen other directors. Like being the frontal cortex of a massive organism…
2/ If you’ve never served in a Command Center, it is scary as heck, and also exhilarating. Things happen and decisions are made in minutes and hours, not weeks and months, as is more usual in a large organization… is that
3/ Sample incoming call: ‘ICU wants to know whether to send a second COVID test nasal swab on a patient whose test was negative yesterday but the team has high suspicion they have COVID.’ (Yes, not via nasal swab, but by tracheal aspirate for better sampling)
4/ Sample call: ‘Community organization purchased 10 COVID tests somewhere; would we send a medical assistant to perform swabs on their employees.’ (No, test performs poorly for patients with no symptoms.’ and, how do you choose who to swab? And, what would you do differently if you have a result? negative: stay home. Positive: stay home(!)
5/ Sample call: ‘Hey, if ventilators are scarce, we could build Iron Lungs faster: want some?’ (After internal discussion, no: COVID is associated with ARDS (adult respiratory distress syndrome). ARDS causes stiff lungs, unlike polio, and even then they didn’t work well), AND, how to manage IVs and catheters?
6/ Our converted conference room now is 24/7 staffed with executives, directors, nurses, doctors, staff who connect to every part of our 12-hospital, 600 clinic, 4000 provider system. Kinda like a neocortex…
7/ We sit and take calls from all over the system, clarifying the daily-changing policy, delivering nimble responses to moment-to-moment events in our EDs, our clinics, our hospital wards …
8/ We huddle in purposeful groups through the day: medical officers, informaticists, nurse leadership, respiratory therapists, ICU teams, hospitalists, data analysts, facility managers, tent-building teams(!) …
9/ We ‘run the board’ twice a day to ensure our top issues are addressed, re-prioritized, to keep our eye on the ball: racing ahead of the coming tsunami of COVID-infected patients collapsing on our doorstep…
10/ We marshal our supplies, build negative pressure rooms, re-allocate staff, negotiate new partnerships, create and dissolve projects to solve immediate problems…
11/ Dramatically expand our Virtual Health Center for Virtual Urgent Care, expand our nurse call line to handle COVID concern calls, go from 2700 virtual visits last year to 3000 virtual visits per DAY this week…
12/ Discover new trends: hypoxic COVID patients who are surprisingly not short of breath, patients who oxygenate better laying on their stomachs, how poorly bleach wipes interact with electronics(!) …
13/ We tearfully celebrate improvement: today a cluster of patients successfully extubated from the vent, a few patients de-cannulated from ECMO, a hallway of nurses applauding an ECMO survivor…
14/ And yet we have fun… Jurassic organisms battle for supremacy while modern organisms do the same.
15/ Our loyal administrative intern asked our Incident Commander at the end of her day shift: ‘How do you feel? How do you think we’re doing?’ …
16/ Her reply: ‘For the world, terrible. For our country, very worried. Here, we have prepped well, we have a great team, we forecast constantly, and we are going to meet this challenge.’ So proud of her, and us.
I’ve been thinking about giving talks backed by powerpoints. Leaving aside the many talks on “Death by Powerpoint”, the lifeblood of the industry is on slides-man-ship in presenting new ideas to our own organization’s leadership, and at national meetings.
And then you see these lovely presentations by TED speakers who are inspiring, tell great stories, but DO NOT have to provide detailed scientific rigor underneath their high-flying narratives.
We, in informatics, have to contend with both parts of this conundrum: how to tell a compelling story well enough to capture imaginations, and more importantly, purse-strings, and yet back it with enough data and science to be compelling to our very picky bean-counters and scientists.
Further complicating this fact is that often, our powerpoints get distributed by email and have to STAND ALONE to convince others, sometimes. Therefore, the whole TED TALK, with IMAGES ONLY and NO DATA become useless in this context; now we have to figure out EITHER how to write an entire white paper (1-4 page brief that can be read quickly) to supplement any slides we give, or to modify these slides so that they CAN stand alone. Ideally, we can write a powerpoint slide deck that includes enough detail to satisfy data-hounds, and yet engaging enough, with a minimum of words, to create a compelling narrative.
CMIO’s take? Only you can judge if I’ve achieved my goals (see link). This is a summarization of more than a decade of my ‘doing it wrong’ and set of guiding principles that I’ve used to continually improve my own talks. I already presume that you know how to build a Powerpoint deck, and that you’ve read other articles on How-To in powerpoint, maybe Garr Reynolds’ Presentation Zen, or Dan Roam’s Show and Tell. There’s lots out there. But this is my take.
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:
The Role of HIT in Today’s Provider Environment
Setting Vision and Strategy
Making Change Happen
Demonstrating Business Value
Budgets and Business Plans
Creating Effective Teams
Instilling Customer Service as a Value
Building Networks and Community
Achieving Life/Work Balance
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.
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.
Read about informatics (but ONLY after reading about leadership and organizational change)
Lorenzi, Riley, Managing Technological Change
Journal of the American Medical Informatics Association
The Design of Everyday Things (Norman), others
The Glass Cage (Carr)
Books to read (leadership, culture change, a book club if you’re lucky)
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.
OK, nobody has time to read an actual book, so here is William Ury speaking at Creative Mornings about his book. Do you have 30 minutes to be a better person? Ever seen the arm-wrestle exercise? Watch the video.
I’ve read his book several times now. At least put it on your bookshelf. My take-aways for me and my colleagues and my work. We discussed this in our Large PIG book club recently.
Separate people from the problem. Personality is NOT at issue. Avoid blame on either side
Focus on interests, not positions. Be curious. See (and demonstrate your understanding of) the other party’s position clearly
Learn to manage emotions. Allow expression of strong emotions. Else, may block clear thinking
Escape the cycle of action and reaction. Instead, explore interests, invent options for mutual gain, leverage differences, brainstorm jointly as “wizards” (lower level persons who are permitted to work on ideas without leadership pressure)
Prepare your BATNA (Best Alternative To Negotiated Agreement) What will you do if you don’t agree?
Seek a third party who is trusted by both sides
Be SOFT on the people (care about the person), HARD on the problem (principled thinking)
I’ve read authors with similar points: -Steven Covey: Listen first to understand, THEN speak to be understood -Crucial Conversations: Make it safe to converse, Control your own stories, Contribute to shared pool of meaning, Ask other’s interpretations, Be tentative in your theories, Seek win-win opportunities.
CMIO’s take? This is a foundational book for Informatics and leadership in general. Find time to learn these lessons. Find the win-win.
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.
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.
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!
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!
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.