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At the HIT Summit in Minneapolis, an MD Informaticist’s Perspective on Clinical Transformation

June 18, 2018
by Mark Hagland
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Karl Poterack, M.D. shared his perspectives on the role of clinical informatics in the standardization of medical practice at the Mayo Clinic organization

On Thursday, June 14, at the Health IT Summit in Minneapolis, sponsored by Healthcare Informatics, Karl Poterack, M.D., delivered a presentation on “The Role of Clinical Informatics in Practice and EHR Convergence.” Dr. Poterack, who is based at Mayo headquarters in Rochester, Minnesota, is a practicing anesthesiologist and the medical director of applied clinical informatics at the Mayo Clinic organization, based in the headquarters office of that patient care organization, in Rochester, Minnesota.

Following up on the presentation by Cris Ross, Mayo’s CIO, the day before, Dr. Poterack noted, speaking of the unified electronic health record currently being implemented at Mayo, that, “One of the things we were really doing with implementing a new EHR is using it as tool to drive workflow and practice innovation, and to get everybody on the same page to drive best practice. I’m an anesthesiologist and board-certified informatician. I still practice anesthesia,” he added.

“I’m going to identify some of the issues involved clinical practice and workflow convergence,” Poterack told his audience. “And I’ll connect those issues to core informatics content, and issues around EHR practice convergence.”

Going on, Poterack said, “We are an academic, physician-led, multispecialty group practice, non-profit. Once upon a time, we were almost unique in being an entity where the bottom line of the physician group practice was the same as the bottom line for the hospital. Once upon a time, that was almost a unique situation; now that’s not so unusual. And there is an extent to which it makes it a little bit easier to undertake some changes. It’s not easy to make change, but easier than it was,” he said. He noted the size of the Mayo organization, which encompasses 20 hospitals in five states, including three “destination medical centers,” in Rochester, Phoenix, and Jacksonville, as well as what is called the “Mayo Health System,” which encompasses six community hospitals, and 11 critical access hospitals. Altogether, the Mayo Clinic organization encompasses about 2,900 staffed beds, 76,000 employees, and  1.3 million clinic visits, 130,000 hospital admissions, and over $11 billion gross revenue every year.

With regard to how information technology can be used to help drive the standardization of clinical practice, Poterack provided his audience with a few examples. “For example,” he said, “there have been major differences in anesthesia practice between Minnesota and Arizona. In Arizona, if you were a pre-menopausal woman undergoing anesthesia, you routinely underwent a pregnancy test first, since the risk to a fetus is high. But that rarely happened in Rochester. The reality,” he said, “is that there were hundreds, maybe thousands, of examples like that, where the workflows and clinical practices were different. And we wanted to leverage our EHR to drive uniformity in practice.”

Further, he said, “We didn’t want geography to determine the care practices you experienced. And even though there is one Mayo culture, there are subcultures in Jacksonville and Phoenix; and that includes differences in resources. For example, Rochester has big residency programs. It would be unheard of for a physician in a Rochester to round on a big inpatient service all by him or herself. In Jacksonville and Phoenix, it’s very common. But in the health system, a physician doesn’t have that kind of help. So there are some real resource differences. And every time you consider a change, there’s, the ‘We couldn’t possibly do it that way’ response. And sometimes, that means, we don’t want to do it that way.”

Poterack cited two process “laws”: Hofstadter’s Law, which says that “It always takes longer than you expect, even when you take into account Hofstadter’s Law”; and Sayre’s Law, which says that, “In any dispute, the intensity of feeling is inversely proportional to the value of the issues at stake.” With regard to Sayre’s law, Poterack qualified his comment somewhat, saying that, “While we’ve had some very contentious debates over things that don’t matter, we’ve also had some contentious debates over things that did matter.”

The six core lessons learned, he said, are the following: “Identify the stakeholders and those with expertise; get them all in a room; be careful of the loudest voice in the room; look to science and best practices; have a set of principles to help you say ‘no’; keep your eyes on the prize—keep goals and limits in sight, and focus on timeline, scope, goals, and resources” in moving forward with any initiative. “You’ll have to say no to a lot of people,” he said. “So to the greatest extent possible, you’ve got to have a set of principles to guide you” in moving forward towards any broad goals.

Karl Poterack, M.D.

Following his presentation, Dr. Poterack sat down with Healthcare Informatics Editor-in-Chief Mark Hagland. Below are excerpts from that interview.

You’ve just shared great examples of some of the challenges around creating a unified clinical practice culture in the Mayo organization. Having covered healthcare for nearly three decades, I’ve seen a massive change in the physician culture in the U.S. overall. And one element in that change has been the shift away from ‘lone-wolf’ medical practice, and towards multidisciplinary team-based, transparent, accountable practice. How are your efforts fitting into that context?

You’ve absolutely identified what the issue is. And that’s changed over the years; the younger physicians, people who have come out of medical school recently, are more used to collaborating with other physicians and with other clinicians on the team, not so much anymore as lone wolves making all the decisions alone. Physicians are very competitive; you can use that in this context. And one of the things that’s been found to be very useful is to show people how they’ve been performing compared to their peers. And if you show somebody that they’re an outlier and not doing as well as their colleagues along some measure, in the end, those things have generally found to be very effective. So you can use that competitive nature to help move people forward in these areas.

Is it harder to create cultural change among specialists than among primary care physicians?

I think the specialists tend to view themselves as being in an almost unique environment. My patients are different form anyone else, my practice is different from anyone else’s. Many specialists have that attitude, but in many cases, they are also the most data-driven and evidence-driven, and if you can show them good data and evidence, they’ll come around. And there are some fundamental human factors—if you can get someone to think that it’s their idea, they’ll be far more enthusiastic about it.

How difficult is it to move everyone towards standardized practices? Many years ago, physicians in practice really did practice as though they were lone wolves for the most part.

In a lot of areas, it hasn’t been that difficult; but there have been certain areas where it has been. The physicians have to feel they’re creating the process, and they’re buying into it. When I said, identify stakeholders and experts-this goes to your Geisinger story—you have to identify the physicians whom other physicians will listen to—and that’s not always people in official roles like department chair; it’s natural leaders. And ultimately, this is a retail exercise. For every one of these clinical scenarios, whether pregnancy testing, managing diabetes, whatever it might be, you’ve just got to get down in the dirt, and get into discussions with all the key stakeholders in that area, and work out what you’re going to do. You can’t do it wholesale. But if you have enough of those retail discussions, it changes the culture. I’m not just going to close the door to the exam room.

How optimistic or pessimistic are you in terms of the shift taking place in U.S. healthcare system overall, in terms of moving towards mapping out processes and moving into continuous clinical performance improvement?

I’m actually fairly optimistic. I’ve seen things change a lot. I graduated from medical school in 1985, and I remember the first time in the early 1990s when someone came into a committee meeting and talked about W. Edwards Deming, and I was one of those who thought he was nuts. He was right; he was just ahead of his time. So I’ve seen things change where that sort of thinking was completely rejected; now, the thinking is accepted; how we apply it on a daily basis still has a ways to go. But people are more accepting in terms of thinking about how to apply this to best practices.

Do you have any advice or thoughts to share with CIOs and CMIOs in patient care organizations?

I think that the environment has gotten a lot more favorable in terms physicians being more receptive to working on a team, working as part of a system, and in essence, getting used to the idea that you’re not just alone in a room doing whatever you want. I think that physicians are more receptive to seeing that you can use evidence and data to follow it to best practices.

I think there is a perception on the part of a lot of physicians—and whether this is reality or not depends on the institution—but there’s a perception that a lot of the information technology isn’t really there to serve them and to serve patients, but that they’re there to serve the technology. And there is some truth to that in some places. It would be good for CIOs and CMIOs to be aware of that and to recognize that to the extent that that perception is based in reality, to try to do something about that. I think a lot of physicians do have some pretty good points about technology not serving them at the moment.

Do you think that EHRs are going to get better overall, in the coming months and years?

That’s a loaded question. I think they will. I think the real question is going to be, will progress be just little incremental steps, or will there be a transformational leap that makes things a lot easier? I think a couple of ways we’re hampered—the interface; keyboard-mouse-point-and-click is probably not the most efficient interface. Also, EHRs tend to be one-size-fits-all across different specialties. What I need as an anesthesiologist is very different from what a PCP needs in a clinic, from what an emergency physician needs in the ED, etc.—we almost need different front ends, and maybe even different back ends. So there’s room for improvement.

Is there anything you’d like to add?

This might be preaching to the choir, but I’d make the pitch that there’s a crucial role for people with informatics skill sets, who are clinicians first, and understand the clinical world, but have enough of an understanding of the IT that they can translate and interpret between clinicians and IT.

I’ve often said that clinical informaticists are almost like UN interpreters, when they sit in meetings with pure clinician leaders and with pure IT leaders. Would you agree?

Yes, I absolutely would; that’s a very good analogy.




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AMA Creates Digital Health Playbook to Guide Providers on Implementations

October 18, 2018
by Rajiv Leventhal, Managing Editor
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The American Medical Association (AMA) has created a new resource that aims to help physicians extend care beyond the exam room with technologies that are changing the way patients interact with healthcare.

The resource, called the Digital Health Implementation Playbook, offers a guide for providers on the path to applying digital health solutions, including key steps, best practices, and resources to accelerate and achieve digital health adoption. The AMA made this announcement in conjunction with the Digital Health Collaborative and Connected Health Conference taking place in Boston this week.

According to AMA officials, physicians are optimistic about the potential of digital health innovation to benefit medicine and expect to use more digital health tools in the near future. However, complex factors inhibit adoption.

The Playbook is designed for care teams and administrators in medical practices of all sizes and areas of specialty. Officials note that it’s a living document that will be updated to include new content over time. As the Playbook evolves, it will provide a 12-steps process to guide the implementation of a variety of digital health solutions. The first six steps are core to the implementation of any digital health solution, while the subsequent six steps focus on specific digital health solutions and the unique considerations relevant to that specific technology.

As it stands now, the Playbook provides resources for the implementation of remote patient monitoring (RPM) using devices, trackers and sensors to capture and record patient generated health data outside of the traditional clinical environment.

And as more connected devices and wearables are validated as accurate and reliable healthcare tools, the medical community will increasingly look to integrate digital health and mobile health technology into medical practices to better understand and manage chronic diseases outside of the practice environment as healthcare shifts toward value-based reimbursements, note AMA officials.

"Implementing digital health technology has been a challenge for those without a clear course to success," said AMA Chair-elect Jesse M. Ehrenfeld, M.D. "The AMA is committed to making technology an asset, not a burden, and the Playbook provides the medical community with widespread access to a proven path for implementing digitally enabled health and care.

More than 80 physicians, care team members, healthcare administrators, patients and digital health thought leaders contributed their expertise and input to the Playbook, according to the AMA.

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New Report Examines Healthcare in the “Amazon Era”

October 5, 2018
by Rajiv Leventhal, Managing Editor
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Hospital business leaders are open, and even optimistic, about the benefits of innovation from non-traditional healthcare players, such as Amazon and Apple, according to a new report from Captains of Industry, a marketing consultancy.

The research, which included interviews with hospital leaders across 11 hospitals in the Boston area, identified a gap between where hospital executives expect Amazon to debut in the marketplace and the areas where the market truly desires innovation. Principally, while hospital executives anticipate Amazon entering healthcare through supply chain and retail initiatives, the majority of respondents pointed to consumer-facing healthcare IT as the area most in need of transformation.

Indeed, hospital executives are keenly watching Amazon given its strategic edge. While Apple and Microsoft have the most traceable digital footprint inside hospitals today, healthcare leaders ranked Amazon as the #1 company most capable of bringing transformative change to healthcare in the next three years, the study found

As Healthcare Informatics reported in January, Amazon, Berkshire Hathaway, and JPMorgan Chase & Co announced they were teaming up on an initiative to improve satisfaction and reduce costs for their companies’ employees. Although not many details are known about this collaboration, the organizations named Atul Gawande, M.D., as CEO of the initiative, back in June.

Meanwhile, in August, Amazon said it would be part of another endeavor related to healthcare—to remove interoperability barriers and to make progress on adoption of health data standards. For this, Amazon will be teaming up with Microsoft, Google, IBM, and others to jointly commit to support healthcare interoperability by advancing healthcare standards such as HL7 (Health Level Seven International), FHIR (Fast Healthcare Interoperability Resources), and the Argonaut Project.

Indeed, over the past year, industry observers have had their eye on non-traditional healthcare players such as Amazon and what they can bring to the table from an innovation and cost-cutting perspective. One recent survey of 100 healthcare organization leaders found that most C-suite executives do have their eyes on Amazon to shake up healthcare.

This latest report, “Healthcare in the Amazon Era,” researchers explore the transition to Amazon era healthcare. It seeks to define the strategic questions that organizations, hospitals and leaders on the edge of medicine and technology must address to deliver care and conduct business in the Amazon era of healthcare.

“The ability to distribute healthcare broadly, reliably and timely—when the patient wants it—is exciting, but business leaders and clinicians who participated in this study call for a future where healthcare in the Amazon era is also safe, equitable and sustainable for all involved,” Lauren Prentiss, strategy director for Captains of Industry and head of Captains Research, said in a statement accompanying the report. “Delivering against those parameters is incredibly difficult. But the more we do it, the more rewarding it will be. Not only for those shaping the Amazon era of healthcare, but for our society as a whole.”

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CDC IT Leader Details Progress on Developing an EHR Blockchain

October 1, 2018
by Heather Landi, Associate Editor
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Blockchain is an innovative technology that has garnered a significant amount of interest across many industries, and, within the U.S. healthcare industry, thought leaders and innovators continue to weigh in on the potential opportunities, and the countless complexities, around the adoption of blockchain technologies.

Many healthcare organizations are pushing forward with pilot projects and proof of concept initiatives to explore the development of blockchain and distributed ledger technologies, yet this is a technology that is still very much in its nascent stages. Potential use cases for blockchain in healthcare will be topic of discussion by a panel of experts during the Healthcare Informatics Beverly Hills Health IT Summit, scheduled for November 8-9 at the Sofitel Los Angeles at Beverly Hills.

As noted in a Fast Company article, companies like IBM and Microsoft are exploring how the technology can be used in traditional industries to sync up data like logs and transaction records between business associates, like health providers and the Centers for Disease Control and Prevention (CDC). IBM and the CDC’s National Center for Health Statistics are collaborating to build a proof of concept for an electronic health record (EHR) blockchain, and there is the potential for the technology to be used as a data system that could track public health issues.

The CDC’s National Center for Health Statistics collects a large amount of health data from surveys. The blockchain project is focused on the National Ambulatory Medical Care Survey (NAMCS), which is a national survey designed to provide information about the provision of medical care services in office-based physician practices in the U.S. NAMCS is designed to meet the need for objective, reliable information about the provision and use of ambulatory medical care services in the United States. Findings are based on a sample of visits to non-federally employed office-based physicians who are primarily engaged in direct patient care and, starting in 2006, a separate sample of visits to community health centers, according to the CDC’s website.

Askari Rizvi, chief of the technical services branch of the CDC’s Division of Health Care Statistics, says the CDC looks for innovative solutions to resolve business problems and is developing a blockchain use case to potentially see what types of current and future EHR data collection challenges can be addressed. Rizvi recently spoke with Healthcare Informatics Associate Editor Heather Landi about this proof of concept project, what project leaders have learned so far about blockchain’s potential and what they hope to accomplish with the project. Below are excerpts of that interview.

What is the CDC-IBM blockchain collaboration focused on and what is the aim of the project?

The collaboration started about a year and a half ago. The CDC has an official collaborative agreement with IBM. The CDC is a large organization, and we have a lot of different centers and I’m part of the National Center for Health Statistics. The CDC’s Innovations Committee reached out to several centers to see if anyone had a project to utilize blockchain for, and I made a case for the EHR proof of concept on a blockchain project, and it was well received within the CDC community along with IBM as well. I picked one of our services, called the National Ambulatory Medical Care Survey, or NAMCS, and we based the proof of concept on the NAMCS to get us started. Currently, it’s quite a process to capture that data [for the NAMCS], so the idea is to capture EHR data, so that we can bypass a lot of that and so we can get the data in real-time.

Askari Rizvi

We have created a proof of concept, but we do have a small application where we can demo the project. I’ve spoken at a number of conferences and events where we have demoed the project. The entire project is hosted at IBM and it is a research and development project. It does not have any real data. I want to be very clear because we take privacy and security extremely seriously here at NAMCS; all the data that in this proof of concept is completely synthetic data. And, because it is an R&D project, and there’s no real data involved, we could put it offshore. There’s a lot of legislation and regulations we would normally follow in a traditional federal application, which you don’t have to do when you’re doing a research and development project. But as we move toward a production solution, which would be a long-term strategy, then we would need to get the appropriate approvals and the authority to operate.

Based on what you have seen so far, what are the benefits of using blockchain?

Essentially, we’ve created a promising EHR blockchain proof of concept based off our NAMCS. Thus far, the primary benefits that seem quite promising are consent management, sharing of data, enhanced privacy and security controls and embedded audit trails. The long-term vision is to be able to collect large sets of data, which should provide researchers and organizations the ability to develop deeper insights and trends. We are at a stage with our proof of concept where we are recruiting for partners, specifically EHR vendors. The vision is to partner up with EHR vendors to build capability in our solution where the sharing of the data becomes simple for the providers, and, at that point, all we would need is consent from the providers.

What drew your interest to exploring blockchain technology? Are there particular challenges that blockchain might help to solve?

I have a hefty background in IT; I’ve been doing it for a few decades. Anytime I see a new technology, I’m interested in finding out what it has to offer, so essentially, that is what piqued my interest. By no means am I a blockchain expert. It was more so as an R&D project, to see what it is and how can it possibly help us manage our national healthcare surveys. As we’ve been through a series of meetings and working sessions, we began to realize that it will enhance the privacy and security of our service, which is always a key aspect, along with better sharing of the data, consent management, and the audit trails.

But, besides that, there was another primary goal. The survey response rates have been declining throughout the industry, so we wanted to think out of the box in order to compensate for that. The idea was if we can build a solution with EHR vendors or these larger systems that host a lot of the data that we need for research, then it would become a lot easier. We would have larger data sets, and we would have them in real-time; there wouldn’t be any issues with the frequency of the data that we are receiving. Some people describe blockchain as a decentralized database, and it really depends on the model that we create going forward. We’re flexible; we have capped the proof of concept at a very high level in terms of flexibility, because depending on the partners that we select, we want to make things as easy as possible for them. I think for the next steps, once we have a number of partners, then we would ask for them to send data from their EHR system and then we would move forward.

What are the next steps with this project, and what is the long-term goal?

What we’ve built so far, it is promising. I see that it does offer several benefits, in terms of privacy and security and audit trails. For the next steps, when we’re able to get a number of providers and if we’re able to build a bridge, or let’s say [the providers] are a node on our blockchain, then it becomes easier to share data from that EHR system for any of the providers, because we would build that bridge between our application and the different EHR vendors. All the providers would need to do is to give us consent, and then we would have that data, from that EHR system. It’s a very long-term strategy. It’s not going to be done any time in the next few months. It is a holy grail of where we are headed, and then we can tap into the data, and depending on the different data sets, we can even enhance the data collection that we currently do. There are many data elements that we collect, and EHR systems have a lot more data elements, so we’re increasing our ability to capture additional data sets, and then providing the flexibility for researchers to be able to run their analysis, look at deeper insights, and come up with trends.

I just want to, again, that all the data for this blockchain prototype is completely synthetic; there is no real data that we’re using here. And, I want to be clear on our current state versus our “to-be” state. So, current state is, we have developed this proof of concept, it’s off-site, no data, and, on top of that, we’re simulating providers. The “to-be” state would be to get providers, partner up with them, start collecting synthetic data from them and then moving toward production state.

What does the status of this proof of concept signify to you about the potential for blockchain adoption in healthcare? Do you see other potential use cases?

There are a number of different centers in CDC that are focused on solving different business problems for CDC, and their mission and goals are very different. I think blockchain could be used for a number of those business units. The idea over here is to get this R&D project off the ground, get it working, have providers on board and move forward towards a production stage. I think that will open things up where others can see that this product looks promising and that it could resolve certain issues. People use blockchain for supply chain management, so another use case could be where the CDC could see the different areas when you are tracking down let’s say, some sort of bacteria in a product. If you have a system that’s developed on a blockchain, you can see where that product originated from. Essentially, you could work your way backwards, go all the way to the origins of where that product came from, and you could identify the source. That would be another use case.

Moving forward, what are some of the potential challenges with this project?

We’re at a juncture where we need to partner up with the EHR vendors or different providers or systems. I think that would be the current challenge, or the biggest challenge for us to face. We want to make sure we’re able to pick the right partners, so we can get something going and continue to make progress.


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