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.

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?

“E in EHR does not stand for Fax” — Steve Hess, CIO

I constantly enjoy the creativity of my colleagues. In this case, Steve Hess, our CIO at UCHealth, made this statement during a discussion about our fax-server software linked to our EHR. As our organization has grown, we have added hundreds of clinics, and now we’re approaching a dozen hospitals in our network, all on a single instance of an EHR.

Consequently, our communication and IT architecture is primarily based on within-EHR communications, the so-called Inbasket. However, we often communicate with healthcare entities (insurance companies, out-of-network clinics and hospitals, skilled nursing and rehab facilities, etc). To force others to use our EHR’s inbasket is unrealistic.

So, even in this 21st century, the lowest common denominator for communication between healthcare entities is … FAX. Our organization faxes millions (yes, MILLIONS) of virtual sheets of paper each month, a veritable blizzard of paper. Furthermore, our faxing volume now is bumping against our licensing limit, and Steve, very rightly, is pushing back against any increase in our faxing capability, and this is where he notes:

“The E in EHR does NOT stand for Fax.”

Which is hilarious. And sad at the same time. Where is our national interoperability? Haven’t we been working toward electronic seamless communication for over a decade as we furiously install EHR’s in every clinic, every ER, every hospital? Yes, and nothing is ever that easy.

So, thinking through our fax problem, several things became clear:

  1. Faxing STILL is the lowest common denominator. If our clinic notes and other messages to other clinicians MUST go through, fax is still the best most reliable method. Who wants to go back to stamps and envelopes? (let’s not talk about mailing test results to patients, as we still do that for some patients: don’t get me started)
  2. For all clinics and hospitals willing to use our web-based secure portal, what we call “Provider Connection”, we can set our communication strategy to send e-messages through that portal. Independent clinics and hospitals who are closely affiliated with use, do use this, and this works well.
  3. For all clinics and hospitals (independent of us) who use their own licensed version of the Epic EHR, we are gradually learning to turn on between-organization messaging, and these e-messages will gradually replace fax. This is getting going.
  4. For all clinics and hospitals on our instance of our EHR, we should be sending ALL notes and messages electronically through EHR e-messaging to our respective inbaskets.
  5. For all clinics that have connected to CORHIO (the Colorado Regional Health Information Organization and other Health Information Exchanges cannot get up to speed fast enough for us) we should be able to turn off our point-to-point communications like Fax because we deliver all notes and results from our EHR to CORHIO’s exchange, which then can deliver results to ANY EHR in the state.
  6. There are still hundreds of organizations out there who use a non-Epic EHR with no capacity for electronic interconnection to CORHIO, or who still use NO EHR. Then, these clinics only have ONE method to send or receive all these incoming messages: FAX. Sad.

Here is where we run into some surprises. Turns out, not ALL of our clinicians in our OWN ORGANIZATION have agreed to use e-messaging and still rely on Fax. What? Old habits die hard. It turns out, while our attention was elsewhere, some of our clinicians and clinic managers were able to convince someone in the IT organization to alter the setting for delivery of test results and referral letters from e-messages BACK TO FAX. On the one hand, I can see a reason why. Some clinicians are used to having the sound of the fax and the presence of paper in the fax-received tray as their TO DO task list, and never “got into email” (really?!). Some clinicians work at multiple healthcare organizations and do not want to check the inbasket of their general email, and the inbasket of the EHR for hospital 1, and the inbasket of the EHR for hospital 2, etc. I could see this being a huge hassle, where ONE fax machine could be the single TO DO list. SO, THIS PROMPTS SOME ACTIONS on our part:

  • All employed clinicians at UCHealth MUST use e-messaging. We will embark on a clean-up of our internal process. Why install an EHR and then let people continue to fax within our organization? It is like buying a Porsche and then cutting out the floorboards and pushing with our feet like Fred Flintstone.
  • Re-examine every affiliate clinic and hospital and figure out how to switch as many communications from fax to e-messaging with Provider Connection. In some cases, like the clinician with multiple hospitals, such a switch might dramatically worsen their clinical work, and we would make exceptions there.
  • Push on CORHIO and other HIE’s to improve between-organization messaging and link our EHR to their systems to make such messaging seamless.
  • Accelerate our investigation of Epic EHR interconnect messaging so that we can send/receive messages from other organizations that also use Epic.
  • Consider a drop-dead date (like “killer app”, this is a terrible term in healthcare) when we might say: “Fax is dead. In order to receive clinical messages from us, you must use Epic EHR or Provider Connection.” I think we’re not quite there yet.

CMIO’s take? Quotable quips are easy to say, and make us feel ridiculous sometimes. But then you have to take a hard look at yourself, and your organization, and the state of healthcare technology, and decide what to do. Do you have a similar story? Let me know.

Letting patients file their Advance Care Planning (Advance Directives) online via Patient Portal (Hillary Lum et al)

Dr. Hillary Lum

https://www.sciencedirect.com/science/article/pii/S0885392418310479

Thanks to Dr. Lum for her persistence and clarity of purpose. She led a team of physician leaders and IT staffers through a complex process, resulting in a first-of-its-kind online tool:

The ability for patients to complete their Advance Care Planning and upload the results using an EHR (electronic health record) patient portal. 

Why is this so important 

  • Very few patients, much less US adults, have an Advance Care Planning document (including Advance Directive, Living Will, 5 Wishes, No CPR, or any other document that records the wishes of the patient in regards end-of-life care)
  • It is difficult for patients to find the form, to understand the form, complete the form, return the form, AND THEN to have clinical staff file or record the form and its wishes in a way that is easily accessible by both healthcare providers as well as patients themselves.
  • Patients without any advance care planning documents risk the possibility of receiving unwanted care at the end of their lives; since patients are so often non-communicative as their health deteriorates, unless the doctors and nurses have a clear statement from the patient, we must assume that the patient wants CPR and other aggressive measures, even if it borders on inappropriate. This tragedy can easily be avoided with easily available documents expressing the patient’s wishes.

And now, at UCHealth, patients can avoid this risk! From the privacy of home, patients can now log in, launch the Advance Care Planning module, complete the questions, and even upload any signed documents in regards to their wishes, into their online Patient Portal, in a permanent storage location easily accessible by the patient (or their permitted proxy) or any of their healthcare providers at UCHealth.

This is pretty cool, and a big leap forward. In fact, even without any publicity to patients (the module just appeared in the portal), over 1000 patients recorded a NEW advance care plan in the first month after this module went live. And, patients continue to sign up at a constant rate.

We hope this continues at UCHealth, and more importantly, that other organizations start doing this as well. Only 36% of US adults (studied in 2017) have an advance directive; meaning that about 2/3 do NOT!

CMIO’s take? We have a lot of work to do, people. Let’s get the rate of advance care planning much closer to 100% of US adults; we never know when we’re going to need one, and by then it is often too late.

Open notes in a Resident clinic: research study results

19498357-10-4-cover

Research study paper is here:    http://ow.ly/6eY530jYZJy

We’re published! Thanks to co-authors Bradley Crotty MD, Corey Lyons MD, and Matthew Moles MD, we helped a multi-health system collaborative to study the idea of Open Notes in primary care residencies (family medicine and internal medicine at University of Colorado Health system), with research findings above.

Ultimately there is some anxiety from both faculty and residents about patients reading their written progress notes online, after the physicians have signed off on those visit notes. We are happy to claim that our program, of all the training programs was least optimistic that this would turn out well for our physicians and patients.

Overall, though, since we gathered this survey data, we have gone on to turn on Open Notes throughout our health system (UCHealth) and now uniformly offer Open Notes to all patients in our 700 clinics, 11 hospitals, and 21 emergency departments. The fear that the “world would come to an end” has not yet come to pass, and we are hearing positive things from our patients about their ability to read notes and benefit from them, including:

  • I often forget much of what we discussed in the visit, now I can go back and refresh my memory
  • Sometimes my wife asks me “what did the doctor say?” and now we can go review it together
  • Sometimes my other doctors don’t receive the consultation letter from my specialist, and now I can show him/her that letter/note from my patient portal. I can be in charge of my own information
  • I can use my doctors note to look up words I don’t understand and get more background information so that I can ask more intelligent questions at my next visit; I feel like a part of my own healthcare team

CMIO’s take: it is good to study what we do. As Robert Anderson MD, one of my mentors told me: “We should use the laboratory of our direct patient care to study and learn. Everything we do with patients should be evaluated and can be improved.” Thanks, Bob!

Happy holidays from the Large PIGs, JIG, and CMIO

Dave Corry arriving late to our group photo, to the CMIO’s amusement and dismay

I hope that you are making plans to celebrate the season, to connect with friends, colleagues, family, and take time for yourself.

I consider myself so fortunate to work with such a great group of informaticists or informaticians (inforMAGICIANs?!), or informatics people, whatever we call ourselves. The work we do, sometimes seems like a grind, but keep in mind, fellow informagicians, that we strive to improve the lives of patients, colleagues and staff by improving the information systems we use for the greater good. 

We try to keep it light in our naming of projects and committees. For example, our Joint Informatics Group (including clinical informatics nurses as well as physician informatics) is JIG. Our physician informatics group are the PIGs. This leads to the New PIG book club, the Small PIG leadership group, and the meeting, which encompasses all physician informaticists: Large PIG. 

And, be sure to throw up your hands and have a good laugh once in awhile. By the way, here’s an updated picture with Dave raising a glass. 

CMIO’s take? Here’s to you and the good work we all do. Cheers!

The Glass Cage by Nicholas Carr (book review)

The Glass Cage pbk mech.indd

One of our book club books, for the ‘clinical decision support’ team for the electronic health record at our institution. We have now read it in our Large PIG book club meeting (the Physician Informatics Group: we try hard not to take ourselves too seriously). Some of us were depressed after reading. The initial optimism of the ‘glass cockpit’, the fancy new computerized design of the complex Airbus aircraft, are instead proving to be a ‘glass cage’, which isolates us and anesthetizes us from the real world. The author provides riveting examples of glass cages: the Inuit who lose their cultural skills of navigating brutally inhospitable landscapes because of GPS and snowmobiles, also, the pilots who make error because of automation, leading to automation bias and automation complacency: thinking the computer must be right, and the computer will know, so I don’t have to. Further, our attention wanders as we cede responsibility for moment to moment control of the task. How do we fight such a trend and temptation, as designers?

Yet the author speaks about ‘adaptive automation’ where a computer could detect the cognitive load or stress in a human partner, and share the cognitive work appropriately. He speaks of Charles Lindbergh, describing his plane as an extension of himself, as a ‘we.’ Can we aspire to improving the design of our current electronic systems to such a partnership that avoids the anesthetic effect and instead becomes more than the sum of the partners? Chess is now played best by human-computer partners; could health care and other industries be the same? And what could that look like? The Glass Cage gives us an evidence-based view into that future (and hopeful) world.

UPDATE: We had a great discussion during our recent book club. As an indicator, several of my colleagues told me: “I don’t like this book.” Perfect! It made for a juicy, spirited conversation about the benefits and risks of automation and how the stories in the book did or did not apply to healthcare and what we were building. Maybe we can consider “adaptive automation” so that the computer scales up and down its assistance as the clinician comes under crisis so that the human can focus on problem solving and the computer can increasingly assist with routine tasks. And then, we need to take care that “automation complacency” does not increase. We already have heard of clinicians saying “Well, EHR did not pop up an alert for a drug interaction, so that means it must be safe to prescribe this new med for this patient.” Whoa, are we giving away the primacy of our own training and experience to an algorithm already?

CMIO’s take: keep reading, keep learning. It is only through extensive experience from reading and books that we can learn from others in healthcare, and from others in other industries divergent from our own. There are more smart people who DON’T work for you, than who do.