November 10: Today on the Community channel, it’s an Interview in Action live from CHIME’s Fall Forum with CT Lin, MD, CMIO at UCHealth. What are CMIOs primarily focused on right now? What are the biggest problems facing physicians today? There was a 350% increase in patient messages from the beginning of the pandemic until now. What technologies can be applied in the areas of messaging and documentation to decrease this ongoing burden?
This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.interview in action from the:
All right. Here we are from the Chime Fall Forum, and we are here with Dr. CT Lynn, and I am excited to talk about you. I see your posts on social media. You guys are doing a lot of really interesting things. Tell us a little bit about uc Health.
Uc Health. So uc Health is wow, we're, I think 16 hospitals now in total for community. Independents that use our EHR and 12 on site on our instance of Epic and about 900 clinics we're about 4,000 providers, physicians, and a, something like 20,000 nurses. And in our database, we have somewhere between two and a half, 3 million patients.
Are you beyond one state or just
Yes. We're mainly in Colorado. But we extend into Wyoming and Nebraska,
Wyoming and Nebraska. Yeah. Okay. Well, this is the first time we've met. Yeah. And I'm looking forward to diving into a bunch of topics. So as a CMIO what are you primarily focused on right now?
The number one topic for us is physician burnout. Physician provider burnout. Right. nurses as well, although I'm not the primary driver for the initiatives we have in that area, we know that turnover is a great problem and. Pajama time is an enormous trouble where after hours clinicians are done with their clinic, clinicians are done with their shift and they're charting late into the night because they're not done with interacting with the electronic health record.
Whether it's documentation, whether it's placing orders, whether it's responding to messages, there's a ton more work after work.
Now, we have a lot of transparency into that problem now, right? From the technology standpoint. We can look in and, and see what's going on. Can we tell what they're struggling with?
Yeah. So the big, but the big topics are documentation, number one. And then secondly, it's responding to messages. I can tell you that we have had a 350% increase in patient messages from the beginning of the pandemic till now. And because our patients have discovered this wonderful new way of communicating with us, that volume has not decreased. So, for example, we were at 53,000 messages a month. We're running about 183,000 messages a month.
So that's a good thing from a population health standpoint. Yeah. But it's a incredible new burden on the clinicians. So how are we addressing that?
Well so that's one of our initiatives is reducing the inbasket burden or redesigning the inbasket in a major way. Step at doing this was recognizing that not all of our clinicians have ideal workflows. In fact, some of our clinicians have over 15,000 messages in their inba that they've not dealt with 15,000. And so if you can imagine coming to work and you, I'll show you my email box, It's 15,000. Yeah. Might as well just close it and go on, do the rest of my day.
Right. And it's just gonna get bigger at this point. What we've really. And we, this took talking to our compliance team and our legal team and our clinical leadership to say what would happen if we were delete everything older than six months. Because either A, they've found a new doctor, they've called two or three other times, gotten their think taken care of.
We're seen in the clinic already. Who's gonna go back? Which what doctor is gonna go, I'm gonna take the next two weeks off and just deal with all this stuff from last year and from 10. 0% of our doctors are gonna do it. So all it's doing, it's burdening our technology and it's creating psychological overhead.
And so we decided to make that decision. And we ended up about a year ago, deleting 12 million messages that were older than six months.
Did you analyze the messages to see, do the clinic, does the doctor actually need these messages, or should they be going somewhere else?
All those messages refer to data that's elsewhere in the, eh. Hey, a test result came back. Well, the test result's always in the ehr. This is just your notification. So should we keep that? What's the legal liability of keeping it versus not keeping it? Is it better for us to say, Well, we never acted on it, but it's sitting there versus saying, We wiped it out because we've moved on and they've taken care of this in the course of the rest of their care.
It's a very difficult thing to answer. So yes, you could nash your teeth and wr your hands and go, Oh, we can't delete anything. Well, then we're gonna be still in the same spot. That's, it's so not only did we do the 12 month deletion, we also said going forward, and this was December of 21, going forward, every in basket messages and message has a 90 day expiration. It's never gonna stay more than 90 days. You're gonna act on it in three months or it's gone.
It's interesting. We just had a lengthy conversation about data retention with a bunch of security officers, and as you'd imagine, the hardest thing is to get the organization to set a policy. and there's downstream consequences of not sending the policy all along the way.
Talk to me about documentation, though. I, I see and hear a lot of physicians who are frustrated. It feels like they're documenting things that aren't relevant, that doesn't need to be, or it's just related to the business of healthcare and whatnot. They're, they're just looking at it going, Do we really need to document all these things? Is there some sort of documentation? Redesign or re rethought.
So I actually give a talk on the design of Apso notes. So we came up with Apso notes about 10 years ago, Apso notes, if you might. So soap notes are pretty standard subjective, objective, assessment and plan. And I pulled the trigger about 10 years ago and said in a white lie to my colleagues, Oh, our new EHR only comes with abs.
Like, what? What? And so we have to invert the note so that the assessment and plans the first thing. So it doesn't matter. Version one of note getting rid workload is taking the thing that clinicians most wanna see, which is, what was my thinking? What was my conclusion? How did you put it together and how, you know, how did my colleagues put it together?
Why put it at the bottom of a 17 page scroll when you could put it at the very top? My plan was, this guy has chest pain, that's probably angel. And we're gonna do a treadmill test and then cath, and then we're gonna do this. And then the rest is, here's the history of the patient. Here's the exam, here's all the supporting document.
That got me to my conclusion. But if you're trying to race through the chart and figure out what happened when, what happened when, what happened when, why do we make it click and scroll, click and scroll. So that's one thing is that you can pack your way to a more usable EHR interface just with simple things like an
But beyond that, right? If I hearken back, I'll tell the story of my pediatrician when I went to college, asked me, So what are you gonna. And I said well, I think I go, I'm gonna go to med school. And he said two things to me that were astounding. Number one, he says, Professional courtesy, no charge for a colleague.
So we don't do that anymore, but I was my jaws on the floor like, Wow, people do that. That's what's what it's like to be on the inside. And number one, number two, he says, And I'm also gonna give you your entire medical record to take with you. And he reaches over to his three ring binder and takes out a single sheet of paper that has 18 years of my life's medical record.
It's date, Initial wcc, well, child check initials. The next date is, No, this is another date. Annual physical, well, you know, initials next date you I for upper respiratory infection, Amoxicillin, initials, like that's my entire life. On one side of one piece of paper, what have we lost? When clinicians could really, in shorthand say, What you really mean, I could just glance at this and go, I, I get what happened to this guy.
This person. Yeah. Whereas that. 12 visits on one half of a sheet of paper would now be a half inch thick, you know, regulatory nightmare.
Can we take those discrete data elements from the EHR and create that summary very quickly that you could view
I think there's an opportunity for doing something like that, to have something, digest it down to something. There's, there's a guy out the UK who actually came up with the idea of tweeting the chart. He says, Once you finish your note, I'm gonna give you 160 characters. And summarize on one line what's going on in your progress note from today. And so now if you just read a series of tweets, you know exactly what happened to this patient at the hospital.
What a brilliant idea. That's 160 more characters than doctors wanna write though, . But what a great, I mean, so people are thinking about this sort of innovation is, Can you tweet your progress note? Yes. Your progress note's seven pages long. What's the one thing I need to know about your progress note?
Well, he is getting better. Well, thank you. That's all I really needed to know.
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📍 📍 The notes are now going straight to patients. Yes. What kind of challenge is that creating?an open notes organization in:
Right where I trained, they. The medical record is dangerous. We put important stuff in there that's important for my colleagues and myself to know. And we use medical terminology because this is precise. We don't use layman's terms because that sort of messes things up and then we can't share those with patients because really this is dangerous stuff.
I might talk about the theory of cancer when I don't, I'm not ready to tell patients about it. In fact, one of our palliative care clinics, actually after we made the transition, We're getting lots of angry calls from families of palliative care oncology patients who are dying because there's a mandatory question in our note from the federal government that says, You have to answer this question.
Would you be surprised if this patient died in the next six months? And I'd say, Yes, but we didn't talk about it. I'm getting angry for how dare you sneak this in? How come you didn't tell me all this sort of thing? And they say, You need to withhold all of our notes. We're different than everybody else.
You can't share. But you can't do that. You can't do that. You can't, well, the penalty's only a million dollars per instance if you are found guilty of withholding notes from patients. And at the same time, other clinicians in that same practice said, This has actually prompted some of the most engaging conversations with my patient and my family members than ever before, because I'm gonna tell them what I'm gonna write in my note is this, and I'm gonna answer yes and here's why.
And I didn't think that that was important. Didn't rise to the level of importance to sharing with the family until now that I know they're gonna read it, we might as well have that conversation. It actually forces a better conversation.
It's interesting I I've heard the physicians argue this. I've even heard some executives at EHR organizations argue this but one of the things we want to do is we want patients to be engaged Absolutely. In their health. And that level of transparency causes dialogue, conversation, and engagement. Right? It's like it's finally saying, It's like you're looking at your kids and going, I finally trust you with this information.
So I'll tell you that's the basement level conversation of information sharing and blocking is, can we get clinicians over the cultural divide of saying, Actually it's okay to share this with. And yes, I can learn to not call them pejorative names. Like this smelly, non-compliant patient comes back again.
Maybe I don't use words like that. That should be pretty easy. Right. So that's the basement conversation. Yeah. Change your language so that you know if you got this published in the newspaper, Would you be concerned that this was published? You're just stating facts. And then sometimes you can say the patient and I about my disagree diagnosis of depression. They don't feel like they have depression, but that's what I'm concerned about. You can do that in a neutral way rather than saying, This patient refuses to acknowledge that they have, you know, So there are some learnings at that basement level. The more interesting stuff happens at the first and second floor level where it, where you have proxy access to a minor's chart, and now we're talking about pregnancy and who writes what in the. And so there are some nuances you have to work through. Say
there are nuances by state as well, right?
At what age is that interesting and so forth. And so that's second floor, third floor conversation. And then, And that also bleeds into test results. Should we withhold the pregnancy test result? Well, you want to tell the patient, but you don't want the proxy necessarily to find out about it.
Or the patient went for mental health counseling in our state's rights about not having to review this with a parent that they saw at mental. So there's some really nuanced stuff that we have to work through. Now, I'll tell you though, the one thing that I really love that one of my neurosurgeons came up with, which is in releasing test results to patients specifically complex radiology, CT scans, MRIs, where there might be a first diagnosed.
Of cancer or a pathology. Hey, we're doing a biopsy and turns out that has cancer. And the nightmare scenario is the result releases Friday afternoon. There's no one available. The patient stews on it a weekend. And CT Lin is ruining healthcare. Well, why are you doing this? And it turns out when you actually ask patients, they're 90% to 10%, I'd like to see it.
Now, why are you withholding it? Our previous policy is we withhold it for two weeks to give doctors. To read it, digest it, come up with a plan of action, call a patient, and in the meantime what's happened? Our patients have gone straight to medical records and got the result anyway. I can't wait for you.
What are you doing? Withholding it from me, right? And so why not release it? Some of our patients would say, I'd rather get the cancer diagnosis at home, have my own freak out, Google it like crazy, think about it. And then the next day or two, come to the doctor and say, I have a lot of questions for you.
Whereas the contrary, contrary. . If I come to the doc, if you require that, I come see you and then you say the word cancer, I haven't heard, I won't hear a single other thing you say to me, The rest of it, that's a wasted visit for me. Yeah. Why are you doing it that way? Whereas on the other hand, it is true, 10% of our patients will say, Yeah, that's, I don't wanna know.
I don't wanna know until my doctor tells me. And what we don't have yet from our EHR vendors, and this is a request we put in, allow patients to pre designate. I'm a person who doesn't want to see that result. Give them that.
I just go into my, Into my portal. Yeah. And check that off.
I'm the kind of person I want to see right away. I'm the kind of person that you need to wait until the doctor contacts me. That's, And we don't know that. We can't know that without a lot more conversation with a patient. But it would be great to give them that setting.
Wow. We're at 15 minutes. We could talk for another 30 minutes. Cuz this is fascinating and there's plenty. We could talk ai, we could talk a bunch of different topics. Yeah, we will have to catch up again. Great. Thank you. Thank you. Nice meeting you. 📍 Appreciate it.
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