Thorough communication is crucial to the patient experience, particularly in healthcare. The 21st Century Cures Act requires that patients have quick access to information in their electronic health records, giving them the ability to be more engaged with their care than ever before. However, the availability of information is just one part of the equation. It’s important to consider patients’ actionable insights to improve the entire healthcare experience.
In this episode of the In Network podcast feature Designing for Health, UCHealth CMIO Dr. CT Lin speaks with Nordic Chief Medical Officer Dr. Craig Joseph and Head of Thought Leadership Dr. Jerome Pagani. Dr. Lin shares how he applies aspects of mindfulness in both his personal and professional lives, how being intentional about the patient experience can improve the overall healthcare journey, and why he’s passionate about transparency. Make sure to listen to the entire episode for a special treat only Dr. Lin himself could strum up.
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[03:12] How Dr. Lin has incorporated aspects of mindfulness into both his personal and professional life
[06:05] Thoughts on the EHR suppressing patient’s messages of gratitude
[08:02] A failure resume and the concept of not shooting the second arrow
[11:03] Ways in which to involve patients to make their experience better
[14:29] Open notes and operationalizing transparency
[19:56] Communicating a vision or idea through a one-pager
[23:37] Things that are so well-designed they bring him joy
[27:00] A special treat
Dr. Craig Joseph: Well, thank you so much for joining us, CT. Are you ready to get into some excellent conversations regarding healthcare?
Dr. CT Lin: Let's do it.
Dr. Craig Joseph: CT, can you tell us a little bit about your background?
Dr. CT Lin: Right. Yes. I'm an internal medicine physician, have been practicing for almost 30 years now, and I'm also the chief medical information officer at UCHealth in Colorado. I started my journey as chief complainer in 1997. I wrote a seven-page screed about how terrible the computer systems we had at the time and how very little automation we had in our electronic health records. And at that point, I was, they hired me on as a 0.1 FTE because, really 4 hours is kind of generous for the couple of committee meetings we’ll ask you to attend. And I was the lone voice in the wilderness for electronic records going forward. And until more recently, we've installed the electronic health record with our Epic vendor. And I have a team of 20 fun physician informaticists who work with me to try to reduce the burden and improve quality of care.
Dr. Craig Joseph: And are they all fun?
Dr. CT Lin: Are they fun? Well, they're effective, and they represent their departments. And in fact, I love the fact that I have a couple of surgeons, because we have surgeons who will say, you know, this effing computer system is terrible, and don't send that primary care doctor, CT Lin, he doesn't know anything about, you know, what surgeons do. You know, he doesn't know that we help people. We help people. And so, I'm able to send my surgeon down there who says, you know, I canceled my first robot surgery case because you apparently have a problem with the computer, and they can have a surgeon-to-surgeon conversation. I just love that. And so, having a team actually makes us way way more effective than just me in the pilot's seat.
Dr. Craig Joseph: So, I just wanted to ask about some of the mindfulness that you've been both talking about and writing about in both your work life and your personal life. Two areas that I thought were very interesting were your gratitude letter and failure resume, and wondering if you could kind of talk about where you came up with these ideas. I acknowledge that you didn't come up with the ideas, but how you’re incorporating them into your kind of personal life and then maybe at some point in your professional life as well.
Dr. CT Lin: Sure. So, the fun part is that I'm widely known in my health system as the guy who ruined healthcare. Right? So, you know, if you have a keyboard is going to
f’ing make us type on the keyboard. And so, I actually do teach a communications workshop in favor of trying to improve physicians' lives and well-being. And I actually did have a colleague say, “Isn't it ironic that it's you here teaching this course because you're the guy who ruined it in the first place?” “So, you're welcome,” I said. And one of the tools that we teach in that workshop is the idea of gratitude. A: It's completely free, no cost, and B: It takes seconds to execute as a task or as a tool for both the giver’s well-being as well as the recipient's well-being. So that's the surprising part, is that there's as much benefit that accrues to the person giving the gratitude as the person receiving gratitude. And so that's just, you know, five seconds or 10 seconds of talking to your nurse, your medical assistant, and saying you're, you know, really that was a challenging interaction in there. And thanks for coming in and really helping with this particular task that made things better. And it takes nothing to do that. And yet people remember that for days afterwards. And it builds the relationship. You can take that to the next level by writing a gratitude letter. And in my readings, I read about this idea of a gratitude letter. Is there someone in your life who served as a mentor or a guide, or even just had a brief conversation that sort of changed the direction of where you were going? And have you ever said, thank you? That person is probably many people who you could say that's the case. And so, I recently did. I had a mentor who is not doing well and is in palliative care and wrote me a note saying, you know, I just want to thank you for your partnership, and I'm going to be you know, I'm going into hospice, and so forth. And I drove up there, wrote him this gratitude letter that I've taught many others to do. And so, it kind of summarized our career together and how he changed the path of my life. And I wrote that, and I read it to him, and there's not a dry eye in the house when you do that. And I felt very good about being able to tell him how he changed my life. And I think about it now that, this is months ago, and so there are downstream benefits to, again, not only the recipient but to the giver. And this, in research studies seems to be sustained for months afterward. So that's a huge thing that, you know, it's free. And do we do this? No, we should develop these habits.
Dr. Craig Joseph: Yeah, I think that's something that we don't do that we should do. And that makes a lot of sense. Let's pivot just for a second, continuing on gratitude, though, when patients express gratitude back to their physicians via the patient portal, some EHRs are leveraging technology to suppress those. And it's a double-edged sword. I'd be interested in hearing your thoughts on whether that makes a lot of sense.
Dr. CT Lin: I've been on both sides of this conversation. In the very beginning, I thought, “Why are you taking away the one thing, that you look at your InBasket and you get a thank you? Why would you suppress that?” And at the same time, I do know that when you look at the statistics for my organization that our message volume has more than tripled since the beginning of the pandemic. In 2019, we were receiving about 53,000 messages a month into our portal for our physicians, and it has ballooned to 182,000. That's more than, 350% increase. And so, how do we significantly address reducing this burden? One way would be to take non-necessary messages out, and you would think, well, no, we want those thank you messages. And at the same time, though, the way that these messages are routed are to the medical assistant pools, and so now you are doubling, tripling, how many ping pongs does this message go through? Thank you goes to the MA who has to say, oh, forward, forward to the right doctor. And the doctor goes, delete, right? And so that's two actions for a ‘thx’ from a patient. So that's two messages someone had to click, and can we suppress those automatically? And so that's what our EHR vendors trying to do to reduce at least the count. So, I think now I swung all the way over to saying, “Yeah, we probably should do that.” At the same time, though, we really should accrue these in such a way that's not interruptive that we can deliver it. And this is something we're asking our EHR vendor to do. Maybe can you summarize it weekly or daily, once a day to say at least seven people said, thank you, yes, I can receive that once, but please don't send it to me onesie, twosie, all the time, for example.
Dr. Craig Joseph: Yeah, that makes sense. So, let's talk about your resume or, more specifically, your failure resume. I guess that's a little different. I remember when you posted it on your blog, and it got a lot of feedback. So, tell me about your failure resume.
Dr. CT Lin: So the first thing to say about my failure resume is that I've been writing a blog now for almost four years, and by far, my most popular blog post was my failures. Thank you very much. This came out of a conversation I had with one of my junior faculty who I work with who made the offhand comment. Well, of course, when you do a project, it's successful. I mean, everything you touch is great. You know, you've never really experienced failure, have you? And I'm like, oh, you know, I've been in this business 30 years, and it's not until the last few that I figured out how to actually be successful. I have 10 years of failures that I can show you. And I thought, why not? Why not show that? And so, I went back and culled through my archives in my voluminous emails and all the things I failed at and summarized them in a way that's kind of funny. And then also in a way that allows you to learn from your silly mistakes and publishing that actually got people thinking, maybe all senior faculty, all senior physicians should think about writing their own version of a failure resume so that we all acknowledge that we're human and we grew into who we are. And we didn't start off being, you know, CMIO, we didn't start off being, you know, at the pinnacle of our career.
Dr. Jerome Pagani: It's important to reflect on places where efforts haven't been as successful as possible. But that sort of rumination can also be harmful. You talked about learning from our mistakes, but the flip side of gratitude can be judging ourselves a little harshly
Dr. CT Lin: So part of writing a failure resume is to create humor out of your past. And we all learn from lessons from our past. And as one day, one evening, I'm ruminating about something that had not gone well in our informatics work. And my daughter, who's in the midst of her college career in contemplative neuroscience, if you believe there's an independent major like that, had been reading “The Book of Joy.” And, you know, it's remarkable how many things you can learn from your kids, because she sat me down and said, “Dad, well, you shouldn't be shooting the second arrow.” And I'm thinking, “What are you talking about?” And she's like, dad, “Didn't you read the Book of Joy?” This is the conversation between Bishop Tutu and the Dalai Lama, and they're comparing, you know, mindful traditions. And one of the concepts is not to shoot the second arrow because the first arrow is the injury or the perceived insult, physical or mental from external, right. So, someone shot the first arrow at you, and then you shoot the second arrow at yourself by ruminating and thinking about it and just making it worse and digging the hole deeper and accusing yourself of not being good enough. And she says, “It's unnecessary, Dad, to shoot the second arrow.” I sat there, and I'm like, what? Who is this person? And where did she come from? Because I clearly did not raise this person. So, it's a fun thing to think about that there are these traditions that are thousands of years old, and people have been dealing with these sorts of ruminations forever, and we can forgive ourselves.
Dr. Jerome Pagani: I love that. And the idea that there's balance between being able to learn from your mistakes but not using them for self-flagellation. Craig and I talk a lot about the importance of having the right stakeholders at the table when you're thinking about designing a new process and getting that feedback. And you are a big proponent of making sure that we listen to patients. I think you said one of your colleagues talks about the greatest untapped resource in healthcare really are the experiences of our patients. So, can you expand on that a little bit?
Dr. CT Lin: Yeah, this conversation came out of our push a few years ago for group visits. And I'm going to acknowledge that I don't have enough large enough practice volume to actually take advantage of group visits, but I know that some of my colleagues, for example, will do a diabetes-specific group visit or, even more cleverly, an urgent care set of group visits. And this was, of course, before the pandemic, when you could bring people into a larger room, sit them around, and actually learn from each other. You'd have a physician, you know, talk to one person or describe something in general about diabetes care and make sure everyone acknowledges how that works for them. And then, in addition to that, they would have a social worker sort of take over and lead part of the conversation while the clinician’s sort of documenting in the group visit about the things that they spoke in common about. And it turns out that when you bring people together like that, they will turn to each other and teach each other things, because there will be times when the diabetes patients will say, “You know, so what happens when the blood sugar goes up, and I'm sick with a viral infection, and my blood sugar has a problem, and I'm not hungry, though, what do I do?” And the physician goes, “Well, I don't have a textbook chapter on that.” And the patient in the seat next to them will turn to them and say, “Well, when that happens for me, I do this with my insulin adjustment, and I do this with the metformin, and then I catch up much, much more quickly because I've tried this four or five different ways, and this works best for me,” and that's the best thing ever to have patient's actual experience inform other patients. And I took from that conversation the idea that, you know, we have patient portals, we have 2.1 million patients with an account with us. And why aren't we asking them to teach us about their experience? Why don't we tap into what I consider to be the largest untapped resource in healthcare, which is patients' experience about their illness. I know that some online forums like PatientsLikeMe and so forth, have tried to do this in various formats. And in fact, I'm aware that a epilepsy researcher did actually reach out to several thousand epilepsy patients and actually come up and publish a paper with that collaboration of epilepsy patients. So, there's a lot of knowledge out there, a lot of sophistication, and we're kind of ignoring it. And why aren't we getting into that space? And I think that's an interesting idea.
Dr. Jerome Pagani: I think what’s so fascinating about that example, it's a demonstration of how you can make the patient experience better at the same time, improving the practice of medicine, which is phenomenal. Is there also evidence that it moves the needle on health outcomes?
Dr. CT Lin: I know that some of my physician colleagues despise the idea of the patient who has Googled their disease. Right? Oh, please don't send me the patient with an inch of printouts. You know, I went to Joe Bob's Alzheimer's website, and they want me to take these 50 supplements. They said they're proven. Okay, so. Right. But at the same time, what I don't want is a patient who comes in and says, “You know, I took those blood pressure pills. I didn't like them. Give me another set.” And you're like, well, no. Did you exercise? Did you do the other things that make your blood pressure better? No, no, I'm here for the pills. Like, okay, so I would much rather an engaged patient who's curious and interested and invested in their own health rather than the person who comes in and says, “It's your problem, your stuff is not working. Try something else.” Right. So, I love the idea of the engaged patient.
Dr. Jerome Pagani: So, you've been a proponent of transparency long before OpenNotes was even a thing. Can you tell us a little bit about how you've operationalized that at the University of Colorado and why it's really making healthcare better for everybody?
Dr. CT Lin: I began my interest with information transparency back in 2001. We had a different EHR back then. We had a patient portal that was a copy-paste portal. Right. I'll go ahead and say it, Allscripts was our EHR vendor, and they partnered with Channel Health, which had a non-integrated patient portal. And the statement was, “Don't worry, it's only two logins. You can log in over there for the patient messages, you login over here for your electronic health record. You know, it’s just two, it's not hard. In fact, you have a computer with windows. You can actually have both windows up at the same time. It's amazing. And so, we ended up having our medical assistants at 7 a.m., at 11 a.m., and at 4 p.m. copy and paste messages back and forth so that physicians only had to log into one. That was my big innovation. Like, you only have to log in to one, and other people will copy and paste for you. Well, we're not done with copy and paste, apparently, in this day and age. However, that's a different conversation. And we were able to show with our randomized trial back in 2001 that showing patients their test results, showing patients their progress notes, and allowing them to message back and forth, A: Did not bring the house down. The volume of messages, it took on average, five additional minutes per day for the experimental group over the control group in terms of effort for nurses and physicians. So, A: not a huge burden at that time and, B: patients' satisfaction with not only communication but also with their perceived quality of care statistically significantly better, 11% improvement in perceived quality of care just because you turned on a tool with all this access, and patients go, I can't get this level of care anywhere else. No one else shows me the notes or the results or allows me to send messages online. And so, I have loyalty. I can stick with it. I thought that was amazing. And we published this randomized controlled trial. I'll just say, if you even today, because we, our acronym, was so poorly spelled, SPPARO, S-P-P-A-R-O, if you Google that and you'll still get our research results. And very naively, thinking that physicians and physician groups are scientists and change minds because of P values, I thought I'll just waltz into the 40-member physician leadership group, show my P values on these beautiful slides, and it will be a slam dunk. Everyone will transform the way they do care, and we'll all be a transparent organization. It's going to be magical. I walked in there, I did my slides, you know, people looked at each other, and just like Machiavelli says, the reason that difficult things or change in an organization is so difficult, is because, at best, your advocates are lukewarm. And just like that, my advocates were like, you know, that's really interesting, and I would like to hear more, and maybe you can come to our faculty meeting in my division and talk about it some more. And then Machiavelli also says, and your detractors have all the passion in the world because the next guy stands up and says, “You know, CT, where I trained the medical record is a dangerous place, and patients have no reason to be in there. We talk about cancer, we talk about, you know, the risk of deterioration. And these are notes for myself so that I can take excellent care of the patient. And it's not for the patient. Do you realize I have decades of experience that I would have to explain that I write in shorthand and now I have to write it in layman's terms. No, we're not doing this. We're not.” And so, he sits down and the next day goes, “Yeah, what Bob said.” And the next guy goes, “Yeah, I'm with Frank and Bob.” And pretty soon, half the room is like, “No, no, over my dead body.” And I walked out of there thinking, wait, the P values were significant, and I have good stories from, and what happened? And it wasn't till decades later, someone showed me a copy of the book by John Carter, “Leading Change,” and I realized, you know, of the, what, eight tasks, I hadn't done six of them. I tried to set a vision, but did I have a guiding coalition? Did I have people backing me, do I have medical leadership saying, as a vision, we are a transparent organization, you have to answer to the boss? I'm not the boss. Do I have a burning platform? Hey, no one else is doing this. Why do we have to be the first ones? I don't want to be the first one. And so, I had done none of that homework. And it's just embarrassing to me that, you know, seven, eight years later, OpenNotes comes along, replicates my study, and shows the same thing, and then they get traction moving forward. And I didn't realize that, you know, it's more than just science. It's leadership. It's managing change. It's a whole different thing. Now, having said that, I did have the last laugh, because even by 2016, not much had changed in the state of Colorado. And when I came around and applied those principles of leading change, creating the burning platform, and the guiding coalition and so forth, I was able to actually take the entire organization, which at that point was about 1.5 million patients, and by default make it a organizational standard that we are transparent with test results, with progress notes, a number of years prior to the information blocking regulation that just passed. So, and you know what? I still have a job. The world did not come to an end. The sky did not fall down. And the vast, vast majority of patients appreciate, that, you know, this transparency means that I'm more engaged in my healthcare. So, we're pushing forward.
Dr. Jerome Pagani: Individual efforts are temporary, but P values are forever.
Dr. CT Lin: [laughs] Nice.
Dr. Craig Joseph: I have just printed two dozen t-shirts that say in big letters, “But the P value.” That's a done deal. And if anyone's interested, I'll be selling them for $29.95.
CT Lin: I love it.
Dr. Craig Joseph: CT, am I pronouncing that right? Yeah. CT, you were just talking about how important it is to communicate that vision if you're trying to change an organization and a big part of human-centered design focuses on communication, trying to transmit important information from one person to another. And you've found a number of ways to do this, both professionally and personally. Can you talk about your one-pager? It's another thing that I think has been fairly popular on your blog. Tell me about how that one-pager works and some of your success stories there.
Dr. CT Lin: I will tell this as a counterexample, because for my open notes project, I, as an internist, by gosh, I was going to anticipate everyone's possible argument against open notes. And so, I wrote an FAQ that was 16 pages long, single-spaced, and brilliantly argued. Right? Here's all the reasons and the research behind why every one of your questions is nonsense. And yes, it is a theoretical risk, but it doesn't play out in real life. And I'm going to lay out all the arguments for it. And I didn't realize, as someone in my future career told me, you know, every page of an executive summary beyond the first page cuts your readership in half. So, at 16 pages, how many people do you think are reading that thing? And I'm like, “Huh. Exactly zero.” In fact, when I go and talk to my colleagues, did you read the thing I wrote? And they're like, “Yeah, I received it, and it's somewhere in the stacks. I was going to get to it. I don't know where I put it.” So, yes, we all know it goes in the circular file. And so, I ended up, and I say this to my junior faculty colleagues now is, if you have an important change project that you're trying to get in front of people, you have one side of one piece of paper to do so. This is very similar to my resident when I was an intern, would say you have one side of a three-by-five card to write down everything salient about your patient on rounds, because if it takes more one side of three by five, you're being too verbose. Right? And so similarly, just like with a newspaper, the phrase in newspaper lingo is above the fold. Right? So, is your news article going to be above the fold on the front page? And how can you communicate the most important things on one side of one piece of paper? And so, I've held myself to that standard. I have dozens of examples now where you can actually communicate important, complex items on one side of one piece of paper. And furthermore, it's not just single-spaced, you know, quickly typed words. You really have to think about your words because you want to speak to both the left brain and the right brain. We do have physicians, all of us are left-brain driven, well we claim to be left-brain driven. What's the P value? If you don't have a P value? I'm like, well, see, you're your study’s no good, you don't have a P value. Well, I had an excess of those previously, but you also have to come with stories. You have to come with the narrative that captures the imagination. Right? Daniel Kahneman in the book, “Thinking Fast and Slow” says no one ever changed their mind because of a number. They need a story. The only thing that competes with a story is a better story. And the only thing that competes with a better story is, you know, data that supports a better story. But you have to tell a story. And so, where on your one-pager do you have your story, which might be quotes from end users, and where is your P value? Because you studied it, and you gathered data to support it, and you need to make it attractive. You need to have maybe your, you know, your social media hook that says, you know, did you know you're doing it wrong? You're like, oh, you know, what is the clickbait title that makes you pick up the piece of paper? What kind of image do you have there that makes it a sort of a pretty thing that you are interested in looking at? And then how do you lay out your arguments both for a right-brainer and a left-brainer? And those are the components, I think, of a good one-pager.
Dr. Craig Joseph: So, ultimately, it does all come down to P values. That's what I've heard. I’m not sure if I’m taking the right approach.
Dr. CT Lin: Exactly.
Dr. Jerome Pagani: We usually ask everyone to tell us about experiences they've had with, you know, two or three things that are so well designed that they just bring you joy to interact with.
Dr. CT Lin: So, I have two things to think about. One is that I will admit that I have been a gamer in my past life, or my current life, whatever. One of my favorite games is on Apple Arcade on my phone called Outlander's. And my kids look at that and like, “Yeah, you're just playing your informatics governance role on this little tiny game.” It's an exploration game where as an explorer, you're supposed to, you know, build a farm and grow some crops and try to expand your territory. And can you achieve your goal in, you know, 29 days before you run out of food or whatever it is, and you can reallocate your resources. And the thing that I think brings me joy there is, like, Simon Sinek talks about the infinite game, right? So, in finite games like football, like Outlander's, there's a goal. You either finish your farm in 69 days, or you don't, and then you win, or you don't win. And having that sort of satisfaction of, yes, I did it right, I won the game, is something that we don't necessarily get in real life. Our real life is infinite, and the goal of an infinite game is to stay in the game, and there's no winning. And so sometimes it is helpful to just sit down and go right in the next hour and a half, am I going to win this game, and can I get better at that? And so, I do enjoy sort of having a finite game and going, yes, there's some sort of dopamine rewards I can get from that. The other thing I love is this book by Donald Norman called “Emotional Design,” and he claims that not only in his earlier work, as he talks about good design as efficient design, sometimes good design might not be the most efficient design, but it's beautiful, and it just engages you. And I'll just make an example, on the cover of his book is an orange juicer. And it's spectacular. It looks like an alien spaceship. It's an upside-down teardrop shape with ridges on the top. And then it's got legs that come up and out, three legs in a tripod that come up and out. And it's just shaped like a spaceship that just landed. And what you do is you cut your orange in half, and you put the orange on top of the juicer, and it just beautifully runs down the outside shape and drips into the cup that's positioned just below the juicer. Now, he says, admittedly, the thing works terribly. It squeaks a lot, and it moves around, and it's not very stable, but it's so beautiful. It's front and center on my counter in the kitchen. And we all stare at it every day. And it's just gorgeous. And I love owning it, and sometimes I use it, but, boy, it's just beautiful sitting there. So, you know, there's these things of beauty that you have to think about. Well, how can we bring more moments of beauty into our lives like that?
Dr. Jerome Pagani: I love that.
Dr. CT Lin: And that's another thing that I love. You know, having picked up my ukulele in Hawaii on a trip once. As I always do, I go through all the closets and see what's there. And I thought, what's this tiny guitar thing? There's a tiny guitar in here. Well, what is that all about? And come to find out, it comes with a three-inch square manual. And “Michael, Row Your Boat” is exactly one finger on one string. I can play a song. This is amazing. And after four nights of strumming with it, I had to have one. And for 70 bucks, I brought one home. And I haven't looked back since.
Dr. Jerome Pagani: Would you play a little something for us now?
Dr. CT Lin: I maybe could. One of the things I like doing is if physicians don't like the message that I bring them about electronic health records, at least I can maybe sing about it. And this is my song called “Dear Burned-out Colleague” to “Dear Theodosia” from the Alexander Hamilton musical.
[To the tune of “Dear Theodosia” from “Hamilton”]
Dear burned-out colleague, what to say to you?
You've tried so hard, your wrists already ache.
When you use the EHR you cried, and it broke my heart.
I am dedicating every day to you.
Online charts were never quite your style.
When you dictate, you knock me out, I fall apart.
And I thought I was so smart.
We will eliminate your frustration.
We’ll make a sprint for you.
We'll make it right for you.
If we lay a strong enough foundation, we'll pass it on to you.
We'll teach you Dragon too, and you'll blow us all away.
Yeah, you'll blow us all away.
Dr. Jerome Pagani: That certainly brought me joy. Thanks so much. CT Lin, thank you for joining us on our podcast.
Dr. CT Lin: My pleasure. Thanks for having me.