- Medical Informatics
- Internal Medicine
Clinical Professor, Medicine - Primary Care and Population Health
Faculty Affiliate, Institute for Human-Centered Artificial Intelligence (HAI)
D&E Ground Medical Ward Director, Stanford University Medical Center (2002 - 2006)
Medical Director for Clinical Informatics, Stanford University Medical Center (2006 - 2007)
Associate Chief Medical Information Officer, Stanford University Medical Center (2007 - 2013)
Chair, Medical Staff HIM Committee, Stanford University Medical Center (2009 - Present)
Chief Medical Information Officer, Stanford University Medical Center (2013 - Present)
Honors & Awards
Award for Professionalism in a Member of the Medicine Housestaff, Stanford University Medical Center (2001)
Charles Dorsey Armstrong Award for Excellence in Patient Care, Stanford University Medical Center (2001)
Regional ACP-ASIM Clinical Vignette Poster Competition, 2nd Prize, American College of Physicians (2001)
Stanford Internal Medicine Divisional Teaching Award, Stanford University Medical Center (2003)
David A. Rytand Clinical Teaching Award, Stanford University Department of Medicine (2005)
Residency: Stanford University School of Medicine (2001) CA
Internship: Stanford University School of Medicine (1999) CA
Medical Education: Dartmouth Geisel School of Medicine Office of the Registrar (1998) NH
Board Certification: American Board of Preventive Medicine, Clinical Informatics (2014)
Board Certification: American Board of Internal Medicine, Internal Medicine (2001)
MD, Dartmouth Medical School, Medicine (1998)
BA, Northwestern University, Bachelor of Arts in Music (1990)
Community and International Work
Arbor Free Clinic, Menlo Park, CA
Education and Care to Underserved Patients
Stanford University Medical School
East Palo Alto
Opportunities for Student Involvement
Current Research and Scholarly Interests
Teaching Physical Examination
Distress Screening Through Patient-Reported Outcomes Measurement Information System (PROMIS) at an Academic Cancer Center and Network Site: Implementation of a Hybrid Model.
JCO oncology practice
Cancer care guidelines recommend regular distress screening of patients, with approximately one in three patients with cancer experiencing significant distress. However, the implementation of such programs is variable and inconsistent. We sought to assess the feasibility of implementing a hybrid electronic and paper screening tool for distress in all patients coming to a large academic cancer center and an associated integrated network site.Patients at an academic cancer center (Stanford Cancer Center) and its associated integrated network site received either an electronic or on-paper modified Patient-Reported Outcomes Measurement Information System-Global Health questionnaire, to assess overall health and distress. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance implementation framework to test and report on the feasibility of using this questionnaire. Iterative workflow changes were made to implement the questionnaire throughout the healthcare system, including processes to integrate with existing electronic health records.From June 2015 to December 2017, 53,954 questionnaires representing 26,242 patients were collected. Approximately 30% of the questionnaires were completed before the visit on an electronic patient portal. The number of patients meeting the positive screen threshold remained around 40% throughout the study period. Following assessment, there were 3,763 referrals to cancer supportive services. Of note, those with a positive screen were more likely to have a referral to supportive care (odds ratio, 6.4; 95% CI, 5.8 to 6.9; P < .0001).The hybrid electronic and on-paper use of a commonly available patient-reported outcome tool, Patient-Reported Outcomes Measurement Information System-Global Health, as a large-scale distress screening method, is feasible at a large integrated cancer center.
View details for DOI 10.1200/OP.20.00473
View details for PubMedID 33830852
Using a Real-Time Locating System to Evaluate the Impact of Telemedicine in an Emergency Department During COVID-19: Observational Study.
Journal of medical Internet research
Telemedicine has been deployed by healthcare systems in response to the COVID-19 pandemic to enable healthcare workers to provide remote care for both outpatients and inpatients. Although it is reasonable to suspect telemedicine visits limit unnecessary personal contact and thus decrease the risk of infection transmission, the impact of the use of such technology on clinician workflows in the emergency department is unknown.To use real-time locating systems (RTLS) to evaluate the impact of a new telemedicine platform, which permitted clinicians located outside patient rooms to interact with patients who were under isolation precautions in the emergency department, on in-person interaction between healthcare workers and patients.A pre-post analysis was conducted using a badge-based RTLS platform to collect movement data including entrances and duration of stay within patient rooms of the emergency department for nursing and physician staff. Movement data was captured between March 2nd, 2020, the date of the first patient screened for COVID-19 in the emergency department, and April 20th, 2020. A new telemedicine platform was deployed on March 29th, 2020. Number of entrances and duration of in-person interactions per patient encounter, adjusted for patient length of stay, were obtained for pre- and post-implementation phases and compared with t-tests to determine statistical significance.There were 15,741 RTLS events linked to 2,662 encounters for patients screened for COVID-19. There was no significant change in number of in-person interactions between the pre- and post-implementation phases for both nurses (5.7 vs 7.0 entrances per patient, p=0.07) and physicians (1.3 vs 1.5 entrances per patient, p=0.12). Total duration of in-person interaction did not change (56.4 vs 55.2 minutes per patient, p=0.74) despite significant increases in telemedicine videoconference frequency (0.6 vs 1.3 videoconferences per patient, p<0.01 for change in daily average) and duration (4.3 vs 12.3 minutes per patient, p<0.01 for change in daily average).Telemedicine was rapidly adopted with the intent of minimizing pathogen exposure to healthcare workers during the COVID-19 pandemic, yet RTLS movement data did not reveal significant changes for in-person interactions between staff and patients under investigation for COVID-19 infection. Additional research is needed to better understand how telemedicine technology may be better incorporated into emergency departments to improve workflows for frontline healthcare clinicians.
View details for DOI 10.2196/29240
View details for PubMedID 34236993
Physicians Leading Physicians: A Physician Engagement Intervention Decreases Inappropriate Use of IICU Level of Care Accommodations.
American journal of medical quality : the official journal of the American College of Medical Quality
Following the adoption of an acuity-adaptable unit model in an academic medical center, a $13M increase in cost of intermediate intensive care unit (IICU) accommodations was observed. The authors followed A3 methodology to determine the root cause of this increase and developed a 3-prong intervention centered on physician engagement, given that physicians have the ability to order a patient's level of care. This intervention consisted of: (1) identifying physician champions to promote appropriate IICU use, (2) visual changes to essential electronic medical record tools, and (3) data-driven feedback to physician champions. In the year following intervention deployment, average IICU length of stay decreased from 1.08 to 0.62 days and average IICU use decreased from 21.4% to 12.3%, corresponding to ~$5.7M cost savings with no significant change in balancing measures observed. Together, these results demonstrate that a multicomponent intervention aimed at engaging physicians reduced inappropriate IICU use with no increase in adverse events.
View details for DOI 10.1097/01.JMQ.0000735480.43566.f9
View details for PubMedID 33883423
Assessment of Electronic Health Record Use Between US and Non-US Health Systems.
JAMA internal medicine
Importance: Understanding how the electronic health record (EHR) system changes clinician work, productivity, and well-being is critical. Little is known regarding global variation in patterns of use.Objective: To provide insights into which EHR activities clinicians spend their time doing, the EHR tools they use, the system messages they receive, and the amount of time they spend using the EHR after hours.Design, Setting, and Participants: This cross-sectional study analyzed the deidentified metadata of ambulatory care health systems in the US, Canada, Northern Europe, Western Europe, the Middle East, and Oceania from January 1, 2019, to August 31, 2019. All of these organizations used the EHR software from Epic Systems and represented most of Epic Systems's ambulatory customer base. The sample included all clinicians with scheduled patient appointments, such as physicians and advanced practice practitioners.Exposures: Clinician EHR use was tracked by deidentified and aggregated metadata across a variety of clinical activities.Main Outcomes and Measures: Descriptive statistics for clinician EHR use included time spent on clinical activities, note documentation (as measured by the percentage of characters in the note generated by automated or manual data entry source), messages received, and time spent after hours.Results: A total of 371 health systems were included in the sample, of which 348 (93.8%) were located in the US and 23 (6.2%) were located in other countries. US clinicians spent more time per day actively using the EHR compared with non-US clinicians (mean time, 90.2 minutes vs 59.1 minutes; P<.001). In addition, US clinicians vs non-US clinicians spent significantly more time performing 4 clinical activities: notes (40.7 minutes vs 30.7 minutes; P<.001), orders (19.5 minutes vs 8.75 minutes; P<.001), in-basket messages (12.5 minutes vs 4.80 minutes; P<.001), and clinical review (17.6 minutes vs 14.8 minutes; P=.01). Clinicians in the US composed more automated note text than their non-US counterparts (77.5% vs 60.8% of note text; P<.001) and received statistically significantly more messages per day (33.8 vs 12.8; P<.001). Furthermore, US clinicians used the EHR for a longer time after hours, logging in 26.5 minutes per day vs 19.5 minutes per day for non-US clinicians (P=.01). The median US clinician spent as much time actively using the EHR per day (90.1 minutes) as a non-US clinician in the 99th percentile of active EHR use time per day (90.7 minutes) in the sample. These results persisted after controlling for organizational characteristics, including structure, type, size, and daily patient volume.Conclusions and Relevance: This study found that US clinicians compared with their non-US counterparts spent substantially more time actively using the EHR for a wide range of clinical activities or tasks. This finding suggests that US clinicians have a greater EHR burden that may be associated with nontechnical factors, which policy makers and health system leaders should consider when addressing clinician wellness.
View details for DOI 10.1001/jamainternmed.2020.7071
View details for PubMedID 33315048
"MAKING A LIST AND CHECKING IT TWICE": A HIGH BLOOD PRESSURE ADVISORY IN PRIMARY CARE
SPRINGER. 2020: S702
View details for Web of Science ID 000567143602227
IT TAKES A VILLAGE: COMPARATIVE ANALYSIS OF STRATEGIES TO IMPROVE PROVIDER ENGAGEMENT FOR WEIGHT MANAGEMENT AT AN ACADEMIC MEDICAL CENTER
SPRINGER. 2020: S667–S668
View details for Web of Science ID 000567143602165
Distress screening through PROMIS at an academic cancer center and network site: Implementation of a hybrid model.
AMER SOC CLINICAL ONCOLOGY. 2020
View details for Web of Science ID 000560368301136
Metrics for assessing physician activity using electronic health record log data.
Journal of the American Medical Informatics Association : JAMIA
Electronic health record (EHR) log data have shown promise in measuring physician time spent on clinical activities, contributing to deeper understanding and further optimization of the clinical environment. In this article, we propose 7 core measures of EHR use that reflect multiple dimensions of practice efficiency: total EHR time, work outside of work, time on documentation, time on prescriptions, inbox time, teamwork for orders, and an aspirational measure for the amount of undivided attention patients receive from their physicians during an encounter, undivided attention. We also illustrate sample use cases for these measures for multiple stakeholders. Finally, standardization of EHR log data measure specifications, as outlined here, will foster cross-study synthesis and comparative research.
View details for DOI 10.1093/jamia/ocz223
View details for PubMedID 32027360
E-HeaRT BPA: electronic health record telemetry BPA.
Postgraduate medical journal
Ccontinuous cardiac monitoring in non-critical care settings is expensive and overutilised. As such, it is an important target of hospital interventions to establish cost-effective, high-quality care. Since inappropriate telemetry use was persistently elevated at our institution, we devised an electronic best practice alert (BPA) and tested it in a randomised controlled fashion.Between 4 March 2018 and 5 July 2018 at our 600-bed academic hospital, all non-critical care patients who had at least one telemetry order were randomised to the control or intervention group. The intervention group received daily BPAs if telemetry was active.275 and 283 patients were randomised to the intervention and control groups, respectively. The intervention group triggered 1042 alerts and trended toward fewer telemetry days (3.8 vs 5.0, p=0.017). The intervention group stopped telemetry 31.7% of the alerted patient-days compared with 23.3% for the control group (OR 1.53, 95% CI 1.24 to 1.88, p<0.001). There were no significant differences in length of stay, rapid responses, code blues, or mortality between the two groups.Using a randomised controlled design, we show that BPAs significantly reduce telemetry without negatively affecting patient outcomes. They should have a role in promoting high-value telemetry use.
View details for DOI 10.1136/postgradmedj-2019-137421
View details for PubMedID 32467108
Rapid Deployment of Inpatient Telemedicine In Response to COVID-19 Across Three Health Systems.
Journal of the American Medical Informatics Association : JAMIA
To reduce pathogen exposure, conserve personal protective equipment, and facilitate health care personnel work participation in the setting of the COVID-19 pandemic, three affiliated institutions rapidly and independently deployed inpatient telemedicine programs during March 2020. We describe key features and early learnings of these programs in the hospital setting.Relevant clinical and operational leadership from an academic medical center, pediatric teaching hospital, and safety net county health system met to share learnings shortly after deploying inpatient telemedicine. A summative analysis of their learnings was re-circulated for approval.All three institutions faced pressure to urgently standup new telemedicine systems while still maintaining secure information exchange. Differences across patient demographics and technological capabilities led to variation in solution design, though key technical considerations were similar. Rapid deployment in each system relied on readily available consumer-grade technology, given the existing familiarity to patients and clinicians and minimal infrastructure investment. Preliminary data from the academic medical center over one month suggested positive adoption with 631 inpatient video calls lasting an average (standard deviation) of 16.5 minutes (19.6) based on inclusion criteria.The threat of an imminent surge of COVID-19 patients drove three institutions to rapidly develop inpatient telemedicine solutions. Concurrently, federal and state regulators temporarily relaxed restrictions that would have previously limited these efforts. Strategic direction from executive leadership, leveraging off-the-shelf hardware, vendor engagement, and clinical workflow integration facilitated rapid deployment.The rapid deployment of inpatient telemedicine is feasible across diverse settings as a response to the COVID-19 pandemic.
View details for DOI 10.1093/jamia/ocaa077
View details for PubMedID 32495830
Technology-Enabled Consumer Engagement: Promising Practices At Four Health Care Delivery Organizations.
Health affairs (Project Hope)
2019; 38 (3): 383–90
Patients' journeys across the care continuum can be improved with patient-centered technology integrated into the care process. Misaligned financial incentives, change management challenges, and privacy concerns are some of the hurdles that have prevented health systems from deploying technology that engages patients along the care continuum. Despite these sociotechnical challenges, some health care organizations have developed innovative approaches to engaging patients. We describe promising technology-enabled consumer engagement practices at two community-based delivery organizations and two academic medical centers to demonstrate the approaches, sociotechnical challenges, and outcomes associated with their implementation. Leadership commitment and payer policies that align with the quadruple aim-enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers-would encourage further deployment and lead to greater consumer engagement along the care continuum.
View details for DOI 10.1377/hlthaff.2018.05027
View details for PubMedID 30830826
Effect of Electronic Clinical Decision Support on 25(OH) Vitamin D Testing.
Journal of general internal medicine
View details for PubMedID 31090033
Effect of Electronic Clinical Decision Support on Imaging for the Evaluation of Acute Low Back Pain in the Ambulatory Care Setting.
To assess the effectiveness of a clinical decision support tool consisting of an electronic medical record Best Practice Alert (BPA) on the frequency of lumbar imaging in patients with acute low back pain (LBP) in the ambulatory care setting. To understand why providers order imaging outside of clinical guidelines.We implemented a BPA pop-up alert on 3/23/16 that informed the ordering physician of the Choosing Wisely recommendation to not order imaging within the first 6 weeks of low back pain in the absence of red flags. We measured imaging rates 1 year before and after implementation of the BPA. To override the BPA, providers could ignore the alert or explain their rationale for ordering imaging using either pre-set options or free-text submission. We tracked pre-set options and manually reviewed 125 free-text submissions.Significant decreases in both total imaging rate (9.6% decrease, p = 0.02) and MRI rate (14.9% decrease, p < 0.01) were observed after implementation of the BPA. No change was found in the rates of x-ray or CT ordering. 64% of providers used pre-set options in overriding the BPA, while 36% of providers entered a free-text submission. Among those providers using a free-text submission, 56% entered a non-guideline supported rationale.The present study demonstrates the effectiveness of a simple, low-cost clinical decision support tool in reducing imaging rates for patients with acute low back pain. We additionally identify reasons providers order imaging outside of clinical guidelines.
View details for DOI 10.1016/j.wneu.2019.11.031
View details for PubMedID 31733384
When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record.
BMJ quality & safety
Order sets are widely used tools in the electronic health record (EHR) for improving healthcare quality. However, there is limited insight into how well they facilitate clinician workflow. We assessed four indicators based on order set usage patterns in the EHR that reflect potential misalignment between order set design and clinician workflow needs.We used data from the EHR on all orders of medication, laboratory, imaging and blood product items at an academic hospital and an itemset mining approach to extract orders that frequently co-occurred with order set use. We identified the following four indicators: infrequent ordering of order set items, rapid retraction of medication orders from order sets, additional a la carte ordering of items not included in order sets and a la carte ordering of items despite being listed in the order set.There was significant variability in workflow alignment across the 11 762 order set items used in the 77 421 inpatient encounters from 2014 to 2017. The median ordering rate was 4.1% (IQR 0.6%-18%) and median medication retraction rate was 4% (IQR 2%-10%). 143 (5%) medications were significantly less likely while 68 (3%) were significantly more likely to be retracted than if the same medication was ordered a la carte. 214 (39%) order sets were associated with least one additional item frequently ordered a la carte and 243 (45%) order sets contained at least one item that was instead more often ordered a la carte.Order sets often do not align with what clinicians need at the point of care. Quantitative insights from EHRs may inform how order sets can be optimised to facilitate clinician workflow.
View details for DOI 10.1136/bmjqs-2018-008968
View details for PubMedID 31164486
Implementation and evaluation of Stanford Health Care store-and-forward teledermatology consultation workflow built within an existing electronic health record system.
Journal of telemedicine and telecare
Introduction Teledermatology services that function separately from patients' primary electronic health record (EHR) can lead to fragmented care, poor provider communication, privacy concerns and billing challenges. This study addresses these challenges by developing PhotoCareMD, a store-and-forward (SAF) teledermatology consultation workflow built entirely within an existing Epic-based EHR. Methods Thirty-six primary care physicians (PCPs) from eight outpatient clinics submitted 215 electronic consults (eConsults) for 211 patients to a Stanford Health Care dermatologist via PhotoCareMD. Comparisons were made with in-person referrals for this same dermatologist prior to initiation of PhotoCareMD. Results Compared to traditional in-person dermatology clinic visits, eConsults decreased the time to diagnosis and treatment from 23 days to 16 hours. The majority (73%) of eConsults were resolved electronically. In-person referrals from PhotoCareMD (27%) had a 50% lower cancellation rate compared with traditional referrals (11% versus 22%). The average in-person visit and documentation was 25 minutes compared with 8 minutes for an eConsult. PhotoCareMD saved 13 additional clinic hours to be made available to the dermatologist over the course of the pilot. At four patients per hour, this opens 52 dermatology clinic slots. Over 96% of patients had a favourable experience and 95% felt this service saved them time. Among PCPs, 100% would recommend PhotoCareMD to their colleagues and 95% said PhotoCareMD was a helpful educational tool. Discussion An internal SAF teledermatology workflow can be effectively implemented to increase access to and quality of dermatologic care. Our workflow can serve as a successful model for other hospitals and specialties.
View details for DOI 10.1177/1357633X18799805
View details for PubMedID 30301409
Health information exchange policies of 11 diverse health systems and the associated impact on volume of exchange.
Journal of the American Medical Informatics Association
2017; 24 (1): 113-122
Provider organizations increasingly have the ability to exchange patient health information electronically. Organizational health information exchange (HIE) policy decisions can impact the extent to which external information is readily available to providers, but this relationship has not been well studied.Our objective was to examine the relationship between electronic exchange of patient health information across organizations and organizational HIE policy decisions. We focused on 2 key decisions: whether to automatically search for information from other organizations and whether to require HIE-specific patient consent.We conducted a retrospective time series analysis of the effect of automatic querying and the patient consent requirement on the monthly volume of clinical summaries exchanged. We could not assess degree of use or usefulness of summaries, organizational decision-making processes, or generalizability to other vendors.Between 2013 and 2015, clinical summary exchange volume increased by 1349% across 11 organizations. Nine of the 11 systems were set up to enable auto-querying, and auto-querying was associated with a significant increase in the monthly rate of exchange (P = .006 for change in trend). Seven of the 11 organizations did not require patient consent specifically for HIE, and these organizations experienced a greater increase in volume of exchange over time compared to organizations that required consent.Automatic querying and limited consent requirements are organizational HIE policy decisions that impact the volume of exchange, and ultimately the information available to providers to support optimal care. Future efforts to ensure effective HIE may need to explicitly address these factors.
View details for DOI 10.1093/jamia/ocw063
View details for PubMedID 27301748
Novel Metrics for Improving Professional Fulfillment.
Annals of internal medicine
2017; 167 (10): 740–41
View details for PubMedID 29052698
Electronic Release of Pathology and Radiology Results to Patients: Opinions and Experiences of Oncologists.
Journal of oncology practice / American Society of Clinical Oncology
2016; 12 (8): e792-9
There is an emerging standard to provide patients rapid electronic access to elements of their medical records. Although surveys of patients generally support it, this practice is controversial among oncologists, because few empiric data are available for scenarios of potentially life-threatening conditions like cancer. We report the views of oncologists about patient electronic access to radiology and pathology results that could potentially indicate disease progression.Four months before oncologists were surveyed, final results of radiology/pathology reports were routinely made available to patients online through a secure portal after a 7-day, hold to provide clinicians time to review and communicate results with the patients. Mixed methods were used to assess physician attitudes and experiences toward this change.One hundred twenty-nine oncologists were surveyed, and 82 (64%) responded. A small majority (54%) responded that the release of reports was somewhat or very beneficial for patients who received normal radiology/pathology results before discussion with a physician, but 87% said it was somewhat or very harmful for patients to receive abnormal results before discussion. Forty-nine percent reported that release of reports had a somewhat or very negative impact on communication with their patients.Almost half of oncologists reported that sharing digital radiology and pathology records had a negative impact on their communication with patients. Patient surveys in similar cancer populations would complement the physician perspective. Efforts are needed to improve consensus among oncologists and patients on how to best communicate such results in a timely fashion.
View details for DOI 10.1200/JOP.2016.011098
View details for PubMedID 27382001
- Oncologists' opinions and experiences with electronic release of radiology and pathology results to patients. AMER SOC CLINICAL ONCOLOGY. 2016
- A User-Centered Design Approach to Information Sharing for Older Patients and Their Families. JAMA internal medicine 2015; 175 (9): 1498-1499
An Exponential Increase in Regional Health Information Exchange With Collaborative Policies and Technologies.
Studies in health technology and informatics
2015; 216: 931-?
In the United States, the ability to securely exchange health information between organization has been limited by technical interoperability, patient identity matching, and variable institutional policies. Here, we examine the regional experience in a national health information exchange network by examining clinical data sharing between eleven Northern California organizations using the same health information exchange (HIE) platform between 2013-2014. We identify key policies and technologies that have led to a dramatic increase in health information exchange.
View details for PubMedID 26262233
- An Exponential Increase in Regional Health Information Exchange With Collaborative Policies and Technologies IOS PRESS. 2015: 931
The electronic health record as a healthcare management strategy and implications for obstetrics and gynecologic practice.
Current opinion in obstetrics & gynecology
2013; 25 (6): 476-481
To review the current trends, utilities, impacts and strategy for electronic health records (EHRs) as related to obstetrics and gynecology.Adoption and utilization of EHRs are increasing rapidly but variably, given pressures of financial incentives, policy and technological advancement. Adoption is outpacing published evidence, but there is a growing body of descriptive literature regarding incentives, benefits, risks and costs of adoption and utilization. Further, there is a rising body of evidence that EHRs can bring benefits to processes and outcomes, and that their implementation can be considered as a healthcare management strategy. Obstetrics and gynecology practices have specific needs, which must be addressed in the adoption of such technology. Specialty specific literature is sparse but should be considered as part of any strategy aimed at achieving quality improvement and practice behavior change.Obstetrics and gynecologic practice presents unique challenges to the effective adoption and use of EHR technologies, but there is promise as the technologies, integration and usability are rapidly improving. This technology will have an increasing impact on the practice of obstetrics and gynecology in the coming years.
View details for DOI 10.1097/GCO.0000000000000029
View details for PubMedID 24185005