This piece from Wired is a mind-blowing read. What is a hyper-object? It is a somewhat disturbing concept of something bigger than an object; something that transcends our understanding as humans. The concept’s inventor, Timothy Morton, defines it as: “phenomena too vast or fundamentally weird for humans to wrap their minds around.”
Okay. What?
Consider examples like “all the plastic in the world” or “climate change” or “a black hole” or “massive oil spills.”
Science fiction author Jeff VanderMeer has said the term “hyper-object” neatly describes the bizarre alien phenomenon he wrote about in Annihilation, his surreal novel turned 2018 movie.
The guy can write. This is as close to a jump-scare that I’ve ever had, reading a book. Even had to put it down for a while to calm down.
Enter the EHR
Now, I’m thinking: the Epic electronic health record’s in-basket is a hyper-object.
Think about it. Something that is weird, difficult for humans to grasp, and alas, vast. To the uninitiated, the Epic EHR in-basket is a message center where much of our internal communication takes place: incoming phone calls from patients can be sent to the in-basket for nurses, docs, assistants to help manage the request; incoming patient portal messages come here; prescription renewals from pharmacies, from patients; consultation reports from specialists, hospital discharge summaries; notifications that “you did not finish writing this note for this patient visit”; test results from blood tests, radiology studies, biopsy reports; nurse-doctor communications; provider-provider communications. Lots of things.
And, for our busy clinicians, some in-baskets have dozens, hundreds — sometimes thousands — of unread messages that can be weeks, months, or even years old. Yikes.
Hyper-object.
Solving the Rubik’s (hyper)cube?
Aside from the idea that we need to improve our internal teamwork and fundamentally redesign how we use our internal tools, there are some simple changes we can start with.
Time to cut our hyper-object down to size. We know that incoming in-basket messages from patients have tripled (see previous post). We know that our healthcare professionals are suffering from burnout (see previous post). We (I) have been guilty of delivering automated messages to our docs that we originally thought were helpful. Maybe it is time for a re-think.
Our plan to resize our Hyper-object:
- Pick a date (in December 2021) for a one-time purge of all messages 6 months or older in our in-baskets. This is 7 million messages. Rationale: If the provider hasn’t handled this by now, either the patient has called or messaged again (a more recent message), already come for a visit, or perhaps even left the practice to go elsewhere. There is no value in keeping these.
- In December, begin a 90-day expiration clock on all new incoming messages. If you haven’t addressed a concern, responded or read a message by 3 months, it will disappear. Yes, there are theoretical risks of deleting reminders to complete a task or respond to a patient. But is it relevant now that a patient called for advice in September when school was starting? Also, it is theoretically possible that a provider will stop someday and spend a weekend reading and replying to thousands of messages, but this is not likely at all.We are aware of some in-baskets with messages that number in the thousands. We are not proud of it. Our current setting where we never delete old messages, I consider a personal failure of bad EHR design and configuration on my part. Behold: the man who ruined healthcare. :( But we’ll fix it now.
- We are discontinuing the delivery of automatic CC messages from consulting specialists back to the referring provider and PCP. In 2011, CT Lin and his merry band thought we were doing everyone a favor by crushing the black hole (a different hyper-object!) of the University docs who never remembered to send a consultation letter back to the referring doc. “Hey, we sent you a patient for this clinical question, and we never heard back from you.” We created a technical solution to automatically send a specialist’s clinic note back to the referring doc and the primary care doc (if different). In the beginning, this was a great idea! However, this rule now sends several hundred thousand messages a year to our 6,000 internal and innumerable community providers. I am personally burying my colleagues. When I asked one of my full-time internal medicine colleagues, he told me, “I receive about 100 to 150 auto-CC notes per week. Every couple of weeks I take a Saturday and read through 200-300 messages, of which about 5 are useful to me. But I can’t not read them — what if I miss something?” What an excellent, OCD physician. But also, a great way to burn out on patient care. You work 40-60 hours a week and then spend evenings and weekends “catching up” on the blizzard of messages and tasks in the EHR.
We need to do today’s work today. By the way, specialists can always manually send an important note back to the referring doc or PCP to say, ‘hey, calling your attention to this’ with a single click. And, our specialists already do this, so I often receive the automated note and a manually sent note for specific concerns.
Thus, I feel pretty good about stopping the automation. How often do you read that sentence from a CMIO?
[This piece was originally published on The Undiscovered Country, a blog written by CT Lin, MD, CMIO at UCHealth and professor at University of Colorado School of Medicine.]
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