Thursday, April 24, 2014

A Tribute to Our Mother, Ruby Sanders

Our dear mother, Ruby Aveline Sanders, long time Durango and Dolores resident, died in the early morning of April 23, 2014 in Durango, Colorado.  She died of natural causes, incident to a stroke, in her sleep, in her home, surrounded by two of her daughters and son.

She was the most loving mother imaginable to six children-- Darlene, Eugene, Linda Sue, Patricia, Paula, and Dale.  Tragically, she lost two of her children to accidents at very early age—Linda Sue at 18 months and Eugene at 18 years.  Through her heart and determination, she overcame the sorrow of her losses to serve as a beacon of inspiration to everyone around her, right through the last moments of her life.  The evening before she passed away, she was not feeling well, but she went for a walk around her neighborhood of 60 years anyway, saying, "Well, I'm not going to feel any better if I just sit around." :-)

We are holding a graveside service for Mom, this Saturday, April 26th, at 2 pm, at the Summit Ridge Cemetery (also known as Sunset Memorial Gardens) about 2 miles southeast of Dolores, Colorado, just off the old highway above Lost Canyon, at the intersection of State Highway 184 and County Road 30. Mom's ashes will be buried next to her soul mate, our dear father, Amos Doyle Sanders, and within a mother's reach of our sister and brother, her beloved children, Linda Sue and Eugene. Don't feel obligated to attend, but if you can, we would love to celebrate Mom's life with you.

After services, we will enjoy a party hosted by Mom's brother, our Uncle Vic Hodges, and Aunt Jeanie, at their ranch northeast of Cortez, 24093 Road S, Dolores, Colorado.

On July 19th, 2014, we will host a block party around Mom’s house in Durango to celebrate what would have been her 90th birthday.  Please hold that date on your calendar for this joyous reunion.

If you would like another way to express your love for Mom, you can donate to our sister Trish McCarty’s charter school, StarShine Academy in Phoenix, AZ. Mom was so proud of Trisha's work with so many children, giving them a hand up, from a disadvantaged state of life.  You can also donate to any Labor & Delivery ward at the hospital of your choice, in honor of her daughter Paula’s work as a caring and gentle nurse for the world’s babies.

She was the eldest daughter of Victor and Thelma Hodges, born of strong and true pioneer spirit, on the plains of eastern Colorado in their dugout cabin on a hot and humid July 21st, 1924.  Her dearest friend and sister, LaVella, was born four years later in 1928; her sister Yvonne was born in 1943 and brother Vic in 1946.  In 1931, during the peak of the Great Depression and Dust Bowl, the family turned west, to farm in the greener, cooler mountains of Montezuma County.  In 1942, she married the love of her life, Amos Doyle Sanders, an adventuresome and dashing young man with black hair and hazel eyes, from northern Texas, who came west for the opportunity to work in the booming logging camps of McPhee.  He was a spirited entrepreneur, but like many men of that era, he marched the path of freedom and patriotism and went off to war in March of 1943, forced to leave his beautiful wife, raising their 18-month old daughter, Darlene, and six month old son, Eugene.  In December of 1944 he fought in the forests of the Ardennes and the Battle of the Bulge.  He returned from World War II safely, only to be called back into service again, but this time accompanied by Mom, his partner by his side, and their growing family.  Their military life together would take them to post-WWII Europe and the reconstruction of Germany, back to Durango where Dad was the US Air Force recruiter for western Colorado, then off to Japan and Fuju Air Force Base; March Air Force Base, California; and SAC Headquarters in Omaha; then back to their home in Durango in 1968 when Dad retired. It was a whirlwind life of adventure for the family, and Mom, from tiny Dolores, embraced the adventure with her infectious optimism and determination to always make the best of any situation.  They made an adventure out of everything in their worldwide travels. 

As Mom was fond of saying, “Your Dad and I must have danced a million miles to the sounds of Glen Miller and In the Mood.”  Mom and Dad slept like spoons, entwined together in the arms of one anothers’ love, their entire marriage, unless one of their children had a nightmare and needed their embrace, in which case they would let us sleep between them.

After Dad’s death in 1978—the loss of her third loved one, too early in life-- Mom picked herself up and transformed.  She enrolled in college (Ft Lewis College) for the first time in her life, at age 54.   It was common for her to encounter her son, Dale, also attending the same college, and share a hug as they walked past each other on campus.  They studied together, under many late nights, at her kitchen table.  Prior to Dad’s death, she was a fulltime mother and wife, but after his death, Mom took her first professional job, at Durango Medical, working there for 15 years as a clerk and receptionist. She would often say, “The friends that I made at Durango Medical saved my life after your daddy’s death.  I don’t know what I would have done without them.”  She worked at the local Humane Society Thrift Store for 14 years, again making friends there that would further transform and enrich her life while her remaining four children lived in cities far beyond Durango.  We, her children, cannot express in words the gratitude and thanks we hold for the many friends in Durango who were Mom’s companions and caretakers for so many years, while our lives took us away, for so long.  You were Mom’s sons and daughters, too. Thankfully, God enabled her son, Dale, and his wife, Laure, to return to Durango for the past two and half years, sharing those precious years with her.  To everyone's surprise, Laure and Dale also gave birth to Mom’s last grandchild and Dale’s first child, a completely unexpected event for all of us. That baby, Anna Elizabeth, brought boundless joy into the last two months of Mom’s life.  As the beauty of one life ends, the beauty of another life begins.  We can see the sunshine of Mom’s smile in all of her 29 grandchildren, 17 great grandchildren, and 3 great-great grandchildren.

Mom was known for her enormously deep spirituality. She especially enjoyed her Bible study and Science of Mind groups, while also studying Taoism and Buddhism, always expanding her understanding of God and existence.  She was an insatiable reader, reading at least one novel per week, right up until the time of her death.  For a few years, she loved Sudoku puzzles until “they got too easy.”  She loved to color in coloring books; not children’s coloring books, but very intricate and beautiful pieces of art.  She was always a classy dresser, no matter what the occasion, no matter if she were feeling poorly, she always looked beautifully and tastefully dressed. She loved to walk and hike, and was a fixture in her neighborhood of Crestview, making friends and conversation with everyone as she traveled the streets with her little dogs, for the last 12 years her Yorky, Missy.  Everyone in the neighborhood knew Mom and Missy. The day of her death, Mom took a walk with her daughter, Darlene, saying in her usually determined way, “It won’t do me any good to sit around. I have to keep walking if I want to feel better.”

She epitomized the power of a mother’s love, the strongest power in the Universe.  Her undying faith in her children permeated to her grandchildren, great grandchildren, and great-great grandchildren.  She believed in us, so we believed in us.  She raised her children with kindness and respect, so we sought to give back the same to her.  She also had a wonderful laugh, smile, and sense of humor.  Her son told her just a few weeks before her death, after she paid him one of her usually large compliments, “Mom, I think you would love me even if I were an axe murderer.” She laughed and said, “Well, probably so, but only if you were good at it.”

We will miss everything about you, Mom, as will the thousands of other hearts that were touched by your brightness, or a kind word of praise, a tender hand, or perfectly worded and timely piece of advice.  It will be up to all of us to live the rest of our lives in your honor, and pay forward what you gave to us.  Until we meet again.

Sunday, April 20, 2014

Thoughts on Easter, 2014

I'm not a literalist when it comes to understanding the Bible and New Testament, but that doesn't mean they are not awe inspiring to me.  Quite the opposite... the mystery inspires more awe and curiosity in me, in anticipation to what I hope will be a complete understanding, revealed someday.

There are several events surrounding the sacrificial crucifixion and subsequent resurrection of Christ that particularly inspire me. My dear friend, Lena Monson, a devout Mormon, enlightened me to one of those events.  She said, about the notion of Christ dying in such a tormented and yet selfless manner, in sacrifice for all of humanity, whether that humanity followed and believed in him or not:

“Imagine yourself on the cross, the most innocent person to ever walk the earth, being tortured in such a hideous manner, yet still praying that God forgive your violators.  That alone is horrible enough and the selflessness of that surrender is indescribably beautiful.  Now imagine, at the instantaneous moment of your death and ascendance to heaven, feeling the pain and suffering of every sin ever committed by every human being, past and future, from a minor lie and theft, to the suffering of the Holocaust.  Every sin ever committed, past and future, falling upon you to experience in the flash of a moment.  That was the burden that Christ experienced on the cross and, more importantly, that he knew he was going to experience but never turned from that accountability.”

Imagine and contemplate that level of selfless sacrifice.  If you can’t be moved by that thought, nothing can move you.

Another event about Christ’s death and resurrection that mystifies me is also one of the few things that each of the four Gospels agrees upon pretty clearly—when Christ resurrected, he appeared first to women, not his male apostles.  Of all the defining events of Christianity, the Resurrection is probably the most defining.  The Resurrection is a very, very important event.  Given the rather paternalistic theme of the Bible and New Testament, it is fascinating to me that the most defining moment of Christianity was reserved for first witness by women, notably Mary Magdalene.  Christ’s male apostles sit second chair to the most impressive human event, ever.  Lots of innocent humans were crucified, but only one human has ever come back from the dead (ignoring Lazarus for a moment) and the front row witnesses to that event were women.  I believe there is significance to that witness, which we do not fully understand, especially given the worldwide oppression and violation that consistently befalls women and girls.  In the honor of being the first to witness Christ’s resurrection I believe that there is a message to women—live with confidence and personal accountability because you were honored with one of the most important events, if not the most important event, in human history.  You will be and should be in the front row of all events.  Anna Elizabeth, our beautiful and new baby, I hope you read and remember this throughout your life: Despite what men prefer to think of themselves-- let them go about their charades-- women are the Chosen Ones. 

“Do not be afraid. I am the First and the Last. I am the Living One. I was dead and behold I am alive forever and ever. And I hold the keys to death and Hades.”

Tuesday, April 15, 2014

Simplifying (Eliminating?) Meaningful Use of EMRs

The core premise in this blog is: Federal Meaningful Use (MU) requirements are well-intended, but like a teacher who "teaches to the test", the federal MU program created a very complicated system that might pass the test of MU, but is not producing meaningful results for patients and clinicians.  As reported in MedScape, the first formal study of this kind was published in the April 2014 issue of JAMA Internal Medicine, which shows no correlation between quality of care and MU adherence.  The study validates what common sense told many of us for the last few years.

MU Stage 1 was a jump-start for EMR adoption in the industry.  That's a good thing, I suppose, although MU also created a false market for mediocre products.  It's time to put an end to the federal MU program, eliminate the costly administrative overhead of MU, remove the government subsidies that also create perverse incentives, and let "survival of the fittest" play a bigger part in the process.  Let the fruits of EMR utilization go to the organizations that commit, on their own and without government incentives, to maximizing the value of their EMR investments towards quality improvement, cost reduction, and clinical efficiency.

When I arrived at Northwestern Medicine in 2005, it was clear very early that our EMRs (Epic and Cerner) were not being used in a meaningful way; this was several years before any broad discussion of MU in the industry.  Many Northwestern physicians were still using paper charts alongside the EMR, thus creating a fragmented and dangerous medical record for patients.  

Using the log and audit files in Epic and Cerner, we created an "EMR Utilization Dashboard" for each physician that also rolled up to the organizational level.  The data was revealing.  Outside of General Internal Medicine and a few other spotty areas, the medication list was not being used.  The problem list was not being used. Order entry for medications, prescriptions and tests was not being used.  Templates for documentation efficiency were not being used.  Clinical alerts for best practices were not being used.  Many patient encounters were not being documented in the EMR, indicating the continued use of paper records. In short, these very expensive EMRs were being used only occasionally as expensive word processors and dictation systems.

With input from all physicians, Drs. David Liebovitz, Phil Roemer, Gary Martin and I decided to develop a simple document, describing the core principles of EMR utilization.  Sarah Miller, my director of clinical applications, also played a huge part in this project. We declared that it had to be constrained to a single page, normal spacing and font, and that we had to be data driven.  It was a big success.  Over the next two years, our rudimentary EMR Utilization Dashboard showed steady and significant improvement.  I showed the dashboard and the core principles to John Glaser (then at Partners) while we were both speaking at a conference in Victoria, British Columbia.  A few years later, when John went to ONC to support David Blumenthal, John took the influence of those core principles and dashboard with him.  I'm not exactly sure what role the dashboard and those principles played in seeding the federal MU program, but I suspect they  had some degree of influence.  By the way, we (Northwestern) offered to give the code and dashboard to the EMR vendors so that all clients could benefit, but the vendors declined.  We shared them instead on the Users Groups' web sites.

Below are the simple but effective "Core Principles of EMR Utilization" that we developed and that played a huge part in the progressive value of Cerner and Epic on the Northwestern campus, and laid the foundation for a relatively easy qualification of Northwestern under the federal MU program. 

Core Principles of EMR Utilization


·         All patient appointments/visits are to be documented in the EHR as an encounter.

·         Visit encounters should by closed by the attending physician within 48 hours of the patient visit.


·         All medication prescriptions and refills must be documented in the EHR, including those ordered in a telephone encounter.

·         Medications are to be reviewed at every patient encounter, in accordance with the individual specialty’s standard of care.

·         Every effort should be made to maintain a valid and complete list of patients’ current medications in the EHR, including end dates, discontinuing medications no longer being taken, and removing duplicate medication entries.

Problem Lists

·         All chronic, persistent patient diagnoses or complaints should be documented on the Problem List in the EHR, with the exception of highly sensitive diagnoses such as those associated with mental health care.

·         Problems should be documented using the most specific term applicable to the problem, e.g. mild intermittent asthma vs. asthma.

·         The Problem list should be reviewed and updated at every patient encounter, in accordance with the individual specialty’s standard of care, and problems not currently clinically relevant should be filed to history and marked as resolved.


·         Allergy lists must be actively maintained for validity and completeness for all patients, including marking as reviewed when no new allergies are reported. The allergy list must be reviewed during any encounter in which a medication is ordered.


·         All patient orders must be documented in the EHR.

Progress Notes

·         All patient encounters should have an accompanied progress note that appropriately documents the history, physical, and decision-making in a way that is succinct and minimizes redundant content.

·         If dictating, notes must include the patient’s name and medical record number, the date of the encounter, and the attending physician’s name to ensure timely documentation.

In Basket

·         Patient results and messages should be reviewed within 72 hours of receipt and In Basket coverage should be assigned when clinicians are unable to respond within that time frame.

In the early days of EMRs, the pioneers like Intermountain, Vanderbilt, Duke, and Partners differentiated themselves by developing their own proprietary EMRs and then using them in a meaningful way, without any financial incentive except their own to do so.  Meaningful Use Stage 1 served a valuable purpose-- it jump-started the adoption of commercially supported EMRs in an industry that needed jump-starting.  Maybe we should cancel Stage 2 and Stage 3, spend some of that money on to seed true innovation (think DARPA for healthcare), and let survival of the fittest play a role in deciding which organizations will utilize their EMRs, and subsequent data, most effectively to improve healthcare.

Monday, April 14, 2014

Cool New Vendor and Technology: VerbalCare

Disclosure:  I have absolutely nothing to gain financially or otherwise from the companies that I review, nor do members of my family or friends.

A few weeks ago, I came across VerbalCare, a technology startup company that offers a new form of communication for inpatients and their caregivers. Their goal is to improve the way patients communicate with their healthcare team during inpatient visits and, as byproducts, give nurses some valuable time back into their days, while collecting data about nursing time that feeds a broad variety of valuable analytics use cases, notably nursing labor.

The company began by helping non-verbal patients communicate through an icon-based tablet application, hence the name, VerbalCare.  They found that patients who had couldn’t talk or use a traditional call button, suddenly felt empowered to communicate with their care provider team in the hospital for the first time. After working with nurses at Mass General Hospital, VerbalCare saw a need to help all patients—not just the non-verbal patients-- in hospitals and nursing homes better communicate with their caregivers.  Their solution consists of a patient facing application that runs on a tablet mounted at the bedside. When a patient needs help, they select icons associated with their requests—nursing, housekeeping, dietary, physical therapy, etc.  These requests are then sent to the nurse’s handheld devices - like an iPhone - which in turn enables the nurse to triage and respond to the request seamlessly. Pretty simple, eh? It makes me wonder why I didn’t already think of this and start this company.

The benefits to patients seem obvious, but you have to wonder what nurses think of such a solution.  Through a random study of 120 nurses, the VerbalCare team uncovered some compelling insights around the attitudes of nurses.  The study uncovered that 84% of nurses wished they had a better tool for communication (i.e. not the call-bell). 74% of that group felt that VerbalCare, or a comparable tool, would improve patient-nurse communication and save them time in their day.  My sister, Paula Nabors, is a Labor & Delivery nurse and she thinks the concept is fantastic.  And she’s the smartest person in our family. J

VerbalCare aims to empower the patients to feel better about the care they are receiving, and help nurses improve their days. With this system, nurses know what the requests are before walking into the room, and the requests are sent to the appropriate caregivers. This way people can address needs according to their skill sets. The system can also replace primitive communication technology such as letter boards, white boards and lip-reading. It can be used in any language, which makes everyone's lives easier. Since the system is cloud based, family members can login remotely to see what is occurring with their loved ones. This gives family members better a peace of mind.

As the company grows, they are regularly adding features, for example, a workflow that automates the nursing care plan. Right now, nurses look through these plans and check-in on patients to remind them to do things, such as elevating the bed to 45 degrees. Now these tasks are entered into the software and the patients and their families get reminders for these sorts of activities, too.  These reminders keep appearing until the patient marks that the task was completed. VerbalCare also added in a section where the patient can see his/her care team. This has pictures and bios of the staff, so the patient can feel more connected to their team. Plus, they are launching an on-demand survey tool. With this function, the institution can help improve the patient's comfort. They can ask questions like "Is your room clean enough?" This not only helps the patient, but let's the institution addresses any problem areas before the patient is released.

Right now, the team is working to run a number of pilots for this year and figuring out what analytics and data people want to track. They are looking into the volume of requests, nursing workflows, patient safety initiatives - such as fall prevention - and other ways to improve the patient experience.  As a hospital executive, have you ever wanted a data collection and analysis system that would allow you to see how many patients want their floors to be quieter? If so this solution now exists.  

In terms of the hardware the institution can either use their own hardware or VerbalCare can provide it at a nominal cost.  There will be some challenges to things like power cords, keeping the batteries charged, infection control procedures, and positioning the device on or near the bedside, but none of those are big enough hurdles to threaten the major advantages of VerbalCare.

As we all know the world of healthcare is somewhat archaic so it’s great to see a company focusing on bringing everyday technology to the patient experience. We all use smartphones and tablets in our day to day existence, and it’s great to see a new startup making strides to bring these normal modes of social interaction and communication into the healthcare experience.  

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