EHR v Covid-19. Prepping for the Surge: Inpatient Guide for Outpatient Doctors – Guest Blog

Inpatient Guide for Outpatient Docs: Table of Contents

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 were gratified to find that a large number of internists practicing outpatient (clinic) medicine were willing to serve as part of the Surge teams and were interested in this just-in-time training.

There was so much interest in our training tools (document plus embedded videos) that the University of Colorado General Medicine division re-arranged the Grand Rounds schedule, and we presented this material to 150 interested outpatient internists at this week’s Grand Rounds, held by Zoom meeting.

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
Rich Altman, MD, University of Colorado

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.

Richard Altman, MD

COVID Incident Command: a day-in-the-life

The author, defended by his creature creations.

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.

Innovation partnerships at UCHealth (Healthfinch)

Tracy Sawyer, RN

Our UCHealth Care Innovation Center is dedicated to implementing partnerships with companies that improve and simplify our work. Our most recent example is our partnership with Healthfinch to improve prescription renewals, by assessing the data in the electronic health record, presenting it to nurses and pharmacists on a centralized prescription renewal team and demonstrating efficiencies, like cutting per-prescription refill time in half.

As we move into value-based contracts in healthcare, and continually need to remove inefficiencies and lower costs, to stay competitive, partnerships like this will move us in the right direction. See the video of UCHealth’s Tracy Sawyer RN, speaking at the AMDIS conference in Ojai, California, as she describes our journey and our results: http://info.healthfinch.com/implementing-charlie-at-a-centralized-renewal-center-experiences-at-uc-health

CMIO’s take? There are more smart people who DON’T work for you, than who do. Find a way to work with them when you can.

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.

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.

Steven Strogatz (NYTimes) on a future for AI via AlphaZero

AlphaZero is now the undisputed champion of Go and now of chess. It recently battled Stockfish, the former chess computer heavyweight, and in that series of 100 matches, it won 28, drew 72, AND LOST NONE.

Lets hear that again. AlphaZero, the deep learning computer originally designed to play and beat human players at Go, the ancient board game, has recently been redesigned in a couple ways: 1) to take the original game rules AND NO HUMAN EXPERIENCE as its starting point, and 2) now can receive the rules for almost ANY game (in this example, chess) as its starting point. Then the programmers set AlphaZero to play itself AND LEARN THE STRATEGIES of the game by brute force and whether each strategy led to a victory or defeat. 

AlphaZero, having spent time playing itself millions of times and having discerned and taught itself the principles of chess, it only considered 60,000 moves per second instead of 60 million by Stockfish. It played smarter and faster.

“AlphaZero had the finesse of a virtuoso and the power of a machine.”

But, can it teach us its insights? No. Perhaps the most troubling paragraphs in this article is:

“What is frustrating about machine learning, however, is that the algorithms can’t articulate what they’re thinking. We don’t know why they work, so we don’t know if they can be trusted. AlphaZero gives every appearance of having discovered some important principles about chess, but it can’t share that understanding with us. Not yet, at least. As human beings, we want more than answers. We want insight. This is going to be a source of tension in our interactions with computers from now on.”

I am both heartened and disturbed by this. Heartened in that AI is on the launch pad to apply itself to all kinds of human challenges that have been difficult to solve until now. Disturbed also; how long will AlphaZero and its contemporaries need human insight and input before it’s always-accelerating capability outstrips our brains’ hardware and our ability to keep up and be relevant?

CMIO’s take? I have no take. I’m gonna wait for my auto-correct from Siri to get smart enough to finish writing this post.

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.

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!