How can the Triple Aim help patients? Here’s how.

Three amigos, with very different approaches to Aneurysm repair

My father (hi Dad!) recently was diagnosed with an incidentaloma. In medical speak, that is an “incidental” (or, unintended) finding on an imaging study conducted for an entirely different reason. His physician found an ascending aortic aneurysm of a certain size, on CT scan of the chest.

Dad was interested in finding a vascular surgeon in the Los Angeles area who was experienced in evaluating and if necessary, performing surgery for this condition. “So,” he asks me, “who’s good at vascular surgery in Los Angeles?”

I was completely stumped.

I went online, as all good internet-enabled adult children do, and found several dozen websites that purport to show and rate surgeons in the Los Angeles area. NONE of them were useful. Angie’s list, HealthGrades, lots of commercial and informal sites trying to meet an important need. Either there were no surgeons listed, or maybe there is a fragment of a listing and no data, or maybe there is a marketing blurb associated with that surgeon, or maybe someone ranting about a surgeon with whom they were unhappy. Nothing in terms of quality of care, operation case volumes, patient outcomes, very little of patient satisfaction…

And yet, we now are collecting such data in our massive EHR’s. WHAT IF we took the Triple Aim of improving healthcare:
-Improving health of populations
-Enhancing the experience of care
-Reducing costs

And gave a such tool to our patients? What if we could apply principles to searching for physicians and showed the screen above: how many operations of this type per year, the re-hospitalization rates; the complication rates, the patient satisfaction, the cost of that care, wrapped up with an overall star rating?

Yes, I can hear the outcry now. There are SO MANY REASONS that we can’t do this. As a former hospital CEO (Dennis Brimhall) said to me decades ago:

NO PATIENT SHALL WAIT. This is our vision. I know there are 300 reasons why patients HAVE to wait in our hospital. And yet, we ALL know that waiting is one thing patients hate about our care. So, NO PATIENT SHALL WAIT. And it will be ALL OF US working to solve the 300 things so that this can come true.

So it is, with this vision. It is hard, and nearly impossible with the sociopolitical structures we have now. The technology is just about able to do this, but the much harder work is convincing all the stakeholders in the healthcare industry (and in my own organization!) that this is valuable, this is important, and we must do it.

It is also possible, that by the time we achieve this, the 2 “surgeons” pictured above will have grown up and helped solve this problem. And that clearly irrelevant, untrustworthy guy on the right will have retired.

And, Dad’s fine, by the way. Thanks for asking.

CMIO’s take? If you don’t like change, you’ll like irrelevance even less.

Patient Knowledge and Experience is the largest untapped resource in healthcare


Yes, I firmly believe this. We are starting to mine our EHR data. We can begin to see prescribing patterns, and how they affect patient vital signs (blood pressures, heart rates, pulse ox). We can look at aspirin prescriptions in patients with coronary disease. We can look at steroid inhaler prescriptions in patients with persistent asthma.

But what about patient experience? Those who have conducted Group Visits can begin to see patients educating each other, in ways that physicians, staff, educators don’t understand. “How do you manage your insulin dose when you work swing shifts or night shifts?” “When you catch yet another cold, how does that affect your liquids intake and medications for heart failure?”

Companies like “PatientsLikeMe” are beginning to look at this information as well. It is about time that our EHR vendors (or maybe startup companies) start helping us unlock the knowledge inside our own medical records for the benefit of other patients.

FOR EXAMPLE, in the screenshot above, in a presentation that I give, consider a 55 year old man with worsening knee arthritis. How hard would it be for us to find “patients like me” treated in the past few years with similar symptoms, similar age/sex/activity level/health status, who were faced with a similar decision about choosing an orthopedic operation and physical therapy?

We could say several really interesting things:
-See how many chose each option
-Compare the 3, 6 and 12 month outcomes of each choice, for pain and function
-Evaluate PROMIS (patient reported outcomes) of each option for: overall health, anxiety, depression, functional status.

Who would NOT want such information? Local, recent experience of other people like me, facing a similar challenging decision.

CMIO’s take? Time to disrupt ourselves.

Ukulele parody: Everyone Knows its Becky

Thanks to the medical informatics division at UC San Diego Health for hosting me at their informatics seminar series. I gave a talk about our efforts on improving physician well-being and reducing burnout (see previous blog posts on Sprints and Practice Transformation).

Sometimes, I travel with my ukulele. Sometimes, I sing at the end of my presentations. Sometimes, I climb out of my meditative, introvert bubble and see what happens.

Thanks to the one guy in the seminar who clapped for me. Kidding. UCSD has a great crew of informaticists doing great work. Christopher Longhurst (CIO) and his team are implementing a team with the purpose of getting physicians “Home for dinner” among the many other good things they’re doing.

Anyway, my apologies to The Association, whose song “Everyone Knows It’s Windy” I ripped off and re-purposed.

And yes, since I’m binge-watching “Breaking Bad” right now, I know the song features prominently in one of the episodes (NSFW). Where do you think I got my inspiration?

CMIO’s take? Always keep ’em guessing.

GROK Board: how to instantly understand what’s important about a patient

2018-05 Patient GrokBoard Vision

Thanks to my University of Colorado School of Medicine colleague Steve Ross MD who challenged me to think about how we improve the clinician experience in EHR’s.

Yes, we are all worried about Physician Burnout, and about the EHR Burden, and bemoan how difficult it is to assemble all the important pieces of data about a patient into a coherent whole, so that the physician can GROK the patient (instantly understand; thank you to Robert Heinlein’ Stranger in a Strange Land) and thus treat him/her effectively and humanely.

Let us not forget where we came from. Although paper was more familiar, and tactile, and you could SEE HOW HEAVY a patient’s past medical history was by how many volumes the clerk would deliver from the warehouse and slam down on your desk, it was NEVER a joy to approach the chart and begin to consume it, page by page.

image from

AND YET we are still far away from the ideal state where a physician can walk up to an EHR, bring up the patient, and on ONE SCREEN have a pre-digested, specialty-specific, visit-specific, patient-centered, view of the patient. We have all dreamed of the ideal “chart-biopsy” tool that would allow us to see all the many pieces of a patient’s past history, gathered into one place. I have yet to see such a tool.

In my view, such an ideal GROK-board should pursue the following:

  • Be HUMANE and emphasize the patient’s goals, preferences, and identity
    • Thanks to Gregory Makoul for his fantastic work in patient-physician communication. We need to improve the visibility of patients as humans in the EHR so that physicians can more quickly connect as person to person; this results in improved patient outcomes and less physician burnout.
  • Increase SIGNAL to noise ratio of the information presented
  • Prioritize MOST IMPORTANT next actions
  • Make the RIGHT thing easy
  • Make it QUICK to grok and then act

CMIO’s take? I don’t pretend to have a monopoly on this vision. I challenge all of us to make something better than the GROK-board I threw together the other evening.

AAMC report on UCHealth Sprint (news)

Team Spirit!

More news about our EHR 2.0 Sprint efforts; we’re getting some attention from around the country and it is gratifying on several levels: 1) that organizations are taking Physician Burnout seriously and 2) that our efforts at concretely moving the needle on EHR burden and Physician Burnout are getting some attention nationally.

Certainly our internal clinics are benefitting from these efforts.

CMIO’s take? More is not always better, unless (work and burden) is better.

Coursera: Yale’s “Science of Well-Being”

laurie-santos3  coursera-fb-1

Dr. Laurie Santos, Yale U.

Here we are again, learning from a MOOC (massive, open, online course). This time, I read an article by the NYTimes regarding Laurie Santo’s massively popular Yale course for undergraduates called Psychology and the Good Life. It was apparently, the most popular course at Yale, ever. So, it was with great pleasure I noted that Dr. Santos was adapting it to an online course via Coursera called The Science of Well-Being, and I was immediately in-line to sign up for the free course.

Over 6 weeks, Dr. Santos takes us through the science, and the practical tips needed to identify “mis-wanting” or, wanting things that do NOT make us happy (eg, higher salary, bigger house, engaging in social media, wanting solitude). She also outlines and compares ancient traditions of meditation and compassion with modern science and functional MRI studies where we can see where blood flow goes to which regions of the brain. Having heard of some of this research, I was really happy (!) to have Dr. Santos pull this science all together into a cohesive narrative.

I won’t ruin it for you; you HAVE to take this course. She goes over the big habits that improve happiness, among them: gratitude, compassion, exercise, sleep. I will however, give you the trick that Dr. Santos teaches, originally from Gabrielle Oettingen at NYU, called WOOP: wish, outcome, obstacle, plan. Wish means, to spend time thinking about what what you REALLY want, some habit that if you could change to make your life better, what would that be, and figure out how to say it in 3-5 words. For me, maybe that’s Sleep More. Outcome means, to envision all the great things that you imagine will accrue when you achieve this goal, and to summarize it in a few words. Maybe this is: I will be rested, happier and more creative. Obstacle means, to envision the SPECIFIC road blocks that you can foresee to meeting your goal. Plan means, to create SPECIFIC ways to overcome the obstacles.

Here’s the insight that BLEW my mind. Are you familiar with the book Thinking Fast and Slow? Daniel Kahneman and Amos Tversky discuss System 1 (the automatic, gut-feeling, rapid, doesn’t-take-much-brainpower, lazy system that is always working in your mind) and System 2 (the effortful, rational, give-me-a-minute-and-I’ll-figure-this-out, this-is-who-I-really-am part of your mind). Despite our self-perception that we are always using System 2 to be rational human beings, it is clear that MOST of the time, we are lazy and use System 1. This is why new year’s resolutions so often fail, System 1 takes over and thinks “Oh, I’m tired right now, what’s the harm in starting my resolution TOMORROW. I feel like some ice cream.” System 2 goes and sits in the back seat, waiting for another day.

Turns out, if you think of OBSTACLE and PLAN very very specifically, you can speak directly to System 1!!! Yes, you heard that right. Lazy System 1 actually listens to very specific instructions, even when generalized resolutions are completely ignored.

FOR EXAMPLE: Don’t say “I’m going to get more sleep.” System 1 laughs at this. DO say: OBSTACLE: “I want to go to sleep at 11pm every night, but I always get more energy that time of night.” PLAN: “I’m going to set an alarm at 10:30pm every night, to stop whatever I’m doing, and go read a book for 30 minutes, and go to sleep at 11pm.”

Dr. Oettingen’s research indicates that student grades improve a full grade, and that all sorts of participants improve their lives when setting WOOP goals, with effects persisting for at least 10 weeks after initial goal setting.

CMIO’s take? Sign me up for WOOP! Will you join me?

Book Chapter on OpenNotes for Older Patients

So happy that my book chapter is now in print! Thanks to the John A. Hartford Foundation and Terry Fuller, the book’s indefatigable editor for shepherding this project to completion over the past year. Even more importantly, thanks to my lovely wife Esther Langmack for her many (many) red-inked editorial ‘suggestions’ which turned my tortured writing into something worth reading.

It is a beautiful, thoughtful book, with contributions by important people, like Dr. Karen DeSalvo, the former Assistant Secretary for Health. And then, I also contributed. 🙂

The book discusses all aspects of care of older patients. I delve into the research and practical literature around Electronic health records, specifically online patient portals, and how our older patients have used it effectively. Moreover, healthcare organizations that have adopted online communications, Open Test Results and OpenNotes have increased value to older patients and their families by making more patient information transparent and shareable, and improving medical care overall. Online access and online care is not just for healthy millennial patients anymore.

CMIO’s take? Hooray, recognition that the internet revolution is finally making a dent in healthcare, including for older patients. Thanks to all my research and clinical colleagues for terrific work, insights and friendships.