C. T. Lin, MD, FACP is CMIO at University of Colorado Health.
Tell me about yourself and the health system.
My title is chief medical information officer of UC Health. We were just University of Colorado Hospital and now we are now a five-hospital partnership.
That role allows me to continue to practice medicine, both inpatient and outpatient. It’s about 20 percent of my job to see patients in general and internal medicine. Then 80 percent of my job is overseeing the deployment of our electronic health record, the physician-computer interface, and the information flow through the organization.
Is it important that you continue to see patients to be successful in the other 80 percent of your job?
Yes, both for my own sanity and a reality check. Because I feel like if I stop seeing patients, I become more of a suit and less of a healthcare provider. Also because, as one of my colleagues said, you have to eat your own dog food sometimes. I find that to be a helpful grounding. I also enjoy seeing patients. So for several reasons, I think it’s important for me to continue.
You’ve used the terms “secretive” and “paternalistic” about hospitals sharing patient information with the patients themselves. Is that a challenge in most places and is it changing?
Yes and yes. It’s a challenge in many places. I’ve been talking about opening up the patient’s chart for both online communication as well as release of test results — and soon, opening up their progress notes — for over a decade. We started working on this in 2002.
Even now — perhaps a little bit less so than back then — there’s a lot of resistance from physicians, from administrators, to thinking that, “Why would we? This is doctor’s work. This is not patient information. It’s too hard to explain. it’s going to increase our workload.” There’s lot of potential fears, and unfortunately, there’s very little research data.
It’s a little better. We’re helping to contribute to the data. But a lot of it’s theoretical fear with no grounding in the research data or real-life experience.
There’s not a lot of pressure being brought on hospitals and doctors to force the issue. Are there any signs of a growing movement that will increase expectations?
I agree that there’s not a lot of pressure. There’s not a lot of organized patient pressure, aside from the Society for Participatory Medicine. You probably have interviewed Danny Sands or he’s been a contributor before. I really like what that group is doing. In fact, we’ve published in their journal as well, in terms of our views on trying to be more transparent.
But aside from groups like that, which are applying some pressure, hospitals do not feel a lot of direct pressure from their individual patients. Meaningful Use has helped with that in terms of saying that certain fraction of your patients need to receive and be able to download and transmit their own patient information. But that’s viewed as a government regulation, not as the right thing to do just yet. So unfortunately, that’s the case.
Describe how the My Health Connection portal supports how patients want the healthcare system to work.
Patients want to be treated with respect. They want doctors to be responsive to them. They want to have convenience of accessing advice.
We make it so hard for them. We say that our office hours are from here to here. You can then talk to an on-call person, who may or may not know you. We put high school graduates on the phones so that when patients have symptoms, you have to struggle through the first line of defense with the front desk staff. If you’re lucky, maybe you get the triage nurse. And boy, it’s all nearly unheard of that you actually get to talk to the doctor on the telephone.
Part of that is intentional, because we think that doctors are overworked, and part of it is old structure. Allowing us to have online transactions allows patients to bypass all of that. They can get directly to medical knowledge. They can get directly to opinions from others. They can get directly to other patients’ experience, as well as get directly to their doctor.
This improves patient satisfaction, but threatens the hierarchy of the doctor being in the center of the spider web. Sometimes they’re not any more. Sometimes they’re not up on the latest research on Familial Mediterranean Fever, whereas the patient spent 12 hours reading on the latest thing. The hierarchy is being overturned. Physicians who are not ready for this change are being very much threatened by it.
Is today’s practice of medicine configured correctly for the expectations of population health management, where instead of seeing patients sitting in front of you, you are managing patients who may not have reached out to you at all?
Boy, that’s an hour’s conversation. Yes, I think that medicine is not configured appropriately for the coming pressure of population health management.
We have several big things standing in our way. One is the payment structure, which we still are in for the most part fee-for-service. That’s beginning to change and it is changing in the right direction. In some ways, it’s back to the future where we had capitated care and you were paid per-member, per-month. You could be motivated to say, for my 2,500 patients in my panel, it’s more efficient for me to make phone calls. In some cases, my staff to make phone calls, in some cases, me to do online conversations. Then restrict in-person visits to my sickest, most complex patients.
If we were paid for that sort of model, which I think is coming, then online transactions will become a much more attractive option for physicians, who currently look at online transactions as stealing from my mouth because I don’t get to bill for that work at this point.
Will motivation change in the right direction under a risk-based or value-based model?
I hope so. Certain organizations have tried this a couple of times before with variable success. I don’t have a crystal ball, but I’m hopeful that payment reform will push us much more towards online or creative ways of not forcing patients to come see us in clinic.
All of us in healthcare are patients ourselves at one time or another and we’re usually just as unhappy as everyone else with the result. Do you hear a lot of those stories?
Yes, but unfortunately less so from the decision makers in the organization. Does that make sense? I mean, you hear it in meetings occasionally, “Hey, I was really frustrated when my mother, XYZ.” But the folks who really need to internalize that need to be the C-suite folks who need to say, you know, this is so important to us that we need to move forward.
We had a CEO, this was a couple of CEOs ago, who really championed and passed for us. He had a saying: “We should not make any changes in our systems unless a patient feels a beneficial impact.” I thought that was a brilliant way of taking a filter towards all of the activities at the hospital and the clinics.
Is the health system using patient input for more substantial decision-making in areas that would have been strictly in the medical domain before?
Yes, we’re starting to. We formed a patient and family-centered care group. It’s a 30-member panel of former and current patients who meet monthly. We frequently take topics to them.
For example, when we have concerns or complaints from patients about, “You released this test result too soon,” or, “How come you wait a whole week to give me this test result? I think you need to change that,” it’s no longer a C.T. plus a couple of physician champions making a decision. We take that to the PFCC group and we say, “One of your patient colleagues says this. What do you guys think?” Then they give us feedback on that sort of thing. Increasingly, we’re trying to insert one of the PFCC representatives into many of our committees for hospital decision making in general, but that’s a slow process.
I borrowed John Halamka and CareGroup’s rules on release of test results to patients. To this day, when I go to the Epic meetings and formerly Allscripts meetings and talk about our policy on test results release, people are aghast that we are this aggressive. I think the rules are to release all blood tests with no delay, with the exception of HIV and genetics testing. Then we release all plain film results with no delay. In fact, patients see it the same time as the doctor does, with only a seven-day delay on CAT scans, MRIs, and PET scans, and then a 14-day delay in pathology. That served us well since 2009, so it’s been five years now.
Then we’re moving towards OpenNotes. We were invited to be part of the Open Notes project back in 2011, but it turns out that was the year that we were deploying Epic and ripping everything out from underneath all the doctors’ feet. We did not have an appetite to do that. But we’re looking to get primary care into OpenNotes by summer of this year.
Is the primary patient benefit of giving patients access to their results that they can be relieved at getting a normal result, or do they have other reactions?
What we’re seeing from patients is, “Why is there any delay? This is about me. This is not for you to sit on and think about for a week or two. I want to know for myself. And if I have a question, I have Google and millions of hits and pages I can read about, so that by the time I have an interaction with my doctor, I can have an intelligent question.” That was perhaps the biggest push from our patients who value the immediate release.
Secondarily, we insist that our physicians also send an interpretation message along, but we ask patients their forgiveness that it could take up to two business days for our doctors to comment on the test result. Commonly, they’ll get their lipid panel, and then two days later, their doctor will say, “This looks pretty good and here’s what I would recommend next.”
In fact, one of my patients said, “What I really like about your system is that not only is it on my portal, but my portal’s mobile on my phone. It’s like having my doctor in my pocket. It’s really a very positive loop.”
The other thing that patients tell us is, “When you show this to us this transparently, it means you have nothing to hide. I don’t often look at my test results in real time, but the fact that I get a ding and know that it’s on its way and you’re not hiding anything from me really increases my trust in the organization.”
It has always puzzled me that for inpatients, there’s no patient equivalent of the medication administration record or a daily itinerary. We make the patients sit there in a box and either come to them or wheel them out when we want something. Do you see any pressure to make them feel more in charge during their admission?
Absolutely. In fact, I think it was Tom Delbanco who wrote a nice opinion piece challenging physicians on the inpatient side that just because the paradigm is that we never share anything with a patient, is that truly the best care? He challenges us, and I agree, that having the patient look over their med list allows them to get more educated; allowing a family member to look it over as well. It’s another set of eyes for safety.
We are striving to move in that direction. The challenge is, even we don’t know sometimes what’s happening with the patient that day. The primary care team comes by and says, we consulted GI, we think you might need an endoscopy. A few hours later, the GI team comes by. They have to decide whether endoscopy is the right thing to do for this patient and whether or not to bump someone else off the schedule so that this patient gets the endoscopy. The plans may change three or four times during the day.
Being able to show that to the patient in a way that’s comprehensible. The patient wakes up in the morning and says, where’s my schedule that says my endoscopy is at two? Well, five times during the day that schedule plan will have changed. Is that worse or better for the patient to see that you’re on the schedule, you’re not on the schedule, you’re at the end of the day, you’re at 2:00. No, you’re off the schedule again. “What are you guys doing? Are you not talking to each other? This is crazy.”
We have some practical things we have to solve in order to be able to present something to the patient that makes sense and that doesn’t increase anxiety.
Is the system so illogical that to expose any of it to a patient can do nothing but harm?
I don’t necessarily agree with it, but it’s not a straightforward, obvious answer of, “Let’s just open the kimono, it’ll be great.” That’s not true.
At the same time — I know I’m talking out of both sides of my mouth — I want to push hard for transparency. But you have to leaven that with some realistic expectation that it appears to be chaotic unless you are very familiar with how a hospital works. The first time you see it, you’re like, “What the heck is going on here?”
Releasing test results on the inpatients is something else that we have written about. But if you go to JOPM, the Journal of Participatory Medicine, we wrote a two-page editorial or case study about a patient who we had signed up through My Doctor’s Office and clinic when they were a transplant candidate. This patient underwent a transplant and went into the ICU. When he was unconscious, his wife was using his portal to access inpatient test results because we did not filter them out.
As a consequence, the patient was telling the nurse, “Hey, that potassium result is back, how come you’re not doing anything about it?” We had an emergency call from that nurse to our office saying, “I didn’t realize that patients could get their own test results. This is a terrible idea. You need to turn this off. You are ruining my ability to care for this patient.”
That alarmed us. We did not make a change, but we went to investigate. The next nurse on shift, said, “This is the best thing ever. I finally have a way to engage the patient and the family in a way that I could never do before. I could ask them, you know, if you would just let me know when you see that test result — I’m looking as well, but when you see that blood gas come back and I haven’t seen it yet, feel free to give me a buzz. I can come over and we can have a talk about what we’re doing and why.”
We have completely divergent ICU opinions about whether this is a good idea for test results release on the inpatient. We think fundamentally it’s the right thing, but we have to retrain our nurses and our physicians and our staff, to be able to accommodate that sort of conversation, because in many cases we’re not ready for it.
What technology possibilities have the most promise to improve patient engagement in the next three to five years?
Three to five years is a long horizon. Three to five years ago, there was no such thing as an iPhone.
We’re completely upside down, and I think mobile has really moved along a great way. It would be neat to have patients be able to gather virtual teams to care for them. Moving into the future, personalized medicine is a big catch phrase, but means different things to different people. In some cases, it means being able to use my genetics and customize a treatment for me. That’s been well written about.
What’s been a little bit less written about is personalized medicine, where for a patient can aggregate a group of experts that he wishes to put together, not necessarily what the physician wants to put together, and be able to have a multi-disciplinary conversation. I’m not exactly sure what form that takes, but you could have a primary care-internal medicine input, you could have a cardiology input, you could have a pulmonary input and some way — whether it’s asynchronous or synchronous conversation — get your experts to communicate together about your care.
That would be an astounding way of moving forward using transparent records and transparent communication as a foundation. I’m not quite sure exactly what that looks like yet.
Do you have any final thoughts?
I wear a couple of hats in addition to my CMIO hat. One of them is on physician-patient communication. I teach a workshop at University of Colorado to our medical students and our residents called “Difficult Physician-Patient Relationships.” There are communication tools that we teach that, unfortunately, many of my colleagues don’t regularly use. What’s worse is that when we move to electronic tools like personal health records and electronic health records, we know that emotional connections between patients and physicians are 60 percent body language and 30 percent tone of voice and pace of speaking. It’s only about 10 percent the actual words that you use.
When you strip away 90 percent of a connection between a physician and patient and leave the words behind, it’s proportionally more difficult to establish a good relationship. I’m not sure many people are looking at that unintended consequence as we’re moving to virtual communication and virtual relationships. There’s probably a need for explicit retraining of physicians to handle an altered relationship in order to continue to derive the most value from it going forward.