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The Promise and Pitfalls of HIT in Pediatrics: What Boston Children’s Hospital Has Learned

August 7, 2018
by Rajiv Leventhal
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At the Boston Health IT Summit, a regional CIO discusses the many issues pediatricians have with health IT, and how lessons can be applied to the adult world

Nearly one-quarter (24 percent) of the total U.S. population is under the age of 18, though many providers who only care for adults might not realize that this number is so high, according to Daniel Nigrin, M.D., senior vice president and CIO, Boston Children's Hospital.

Nigrin, who presented at the Boston Health IT Summit on August 7, noted that given this large  percentage, even if a specific provider doesn’t work with kids directly, the chances are strong that someone he or she works with does. Indeed, health IT issues in pediatrics affect a much broader group than just those pediatricians, Nigrin said, as those children eventually become adults, leading to lots of back-and-forth between providers.

“Children also tend to be more susceptible to harm,” he noted, speaking to the need for advanced health IT in the pediatric community. “Things such as medication dosing can cause harm, and even death, much more so than in the adult world due to children’s size,” Nigrin said at the Health IT Summit.

And while plenty of challenges remain, Nigrin believes that a “dramatic transformation” has taken place in recent years regarding health IT functionality and the sophistication of tools that the vendor community has provided pediatricians, offering weight-based dosing as one example.

Nonetheless, Nigrin spoke about the major patient privacy conundrum in this space, particularly as it relates to adolescents and patient portals. He noted that when one thinks about the data that is shared in portals, in the context of a teenager, there is routine information such as medications, lab results, listings of physician visits, and in some cases, the sharing of clinic notes, via the OpenNotes initiative, which Boston Children’s participates in.

But for “non-routine” information, processes can get tricky, he admitted. For instance, for a teen patient who has visited his or her doctor privately—say to obtain contraceptives or for a mental health issue— how do those private conversations make it into the portal, if at all? “There is a reason pediatricians kick parents out of the room when kids become teens,” Nigrin said.

“And many of us now also have systems in which we remind patients about appointments through text messages or the portal. But is it the patient or the teenager who is [getting the message]? You have to be careful.” He added that there are lots of technical and process challenges related to privacy that still must be ironed out, and this “drives vendors crazy, because in many instances it requires a complete re-architecture of their systems.”

There are additionally plenty of health IT issues that affect newborn care as well, Nigrin said. In the olden days of healthcare technology, he explained, EHRs (electronic health records) were not developed to consider modern age-specific time units. “In pediatrics, we don’t think about the 0.019-year-old patient or the 4,440-day old-patient. We think about patients as seven- or 12-years-old.  Time-toggling in EHRs has become important, but that wasn’t thought about in the early days,” he said.

Other newborn health IT issues include linking a mother’s EHR record to baby’s EHR record, as one can be critically important for the other. A mother’s infections or pre-existing conditions, for instance, are vital to know when treating her baby, Nigrin attested. Recording the birth date and time in the EHR is also quite important, he noted, as some conditions, such as hyperbilirubinemia—which occurs when there is too much bilirubin in the blood—requires knowing the amount of time that has elapsed since the baby was born.

After Nigrin’s presentation, Healthcare Informatics Editor-in-Chief Mark Hagland sat down to ask the CIO about some of the pediatric health IT issues he outlined and how they can be compared to the adult population.

For instance, Nigrin again referenced the teenage patient portal privacy topic, noting that the analogy in the adult world would be the geriatric population. “When you have an aging parent and you as a child are assisting that parent with his or her care, even though the parent is handing over aspects of care to you, there are probably things in the record that are not appropriate for you to see.” As such, he continued, “The ability to pivot on the data that is shown or not shown is a general problem that needs to be solved by health IT community. It’s not limited to pediatrics.”

When asked about his biggest lesson learned as it relates to patient safety and pediatric health IT, Nigrin said that preventing alert fatigue would be the biggest one. He noted how there are incredible IT systems that alert clinicians if they are about to engage in inappropriate medication dosing. “But the issue is that we alert so often that providers see them as ‘nuisance alerts,’ and then inappropriately override them.”

As such, Nigrin’s team has been looking at ways to better present the alerts to providers, such as leveraging SMART on FHIR specifications. A key issue with the alerts as they exist now, he added, is that they contain a lot of text, and some color, making it tough for clinicians to quickly discern whether the alert is another nuisance or a real problem. “Doctors are overwhelmed; it’s mind-boggling when you look at the number of alerts that an inpatient doctor will receive in a day. So we’re looking at new graphical ways to present it to them,” Nigrin acknowledged. 

For a particular medication, for example, Boston Children’s clinical IT leaders will now look at historical norms for a dose range given over a period of one or two years, Nigrin explained. Using that historical data as the reference range—as opposed to general by-the-book standards—providers can be graphically presented (with the organization’s internal data) the medication doses they are administering versus what’s appropriate.

In the end, Nigrin believes that healthcare, in this current moment, is amid one the sector’s most exciting times. Reflecting on his presentation, he contended that now that the industry has mostly completed its transition from paper to digital, with far better tools currently available, it’s time to “start harnessing the power of data.”

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Healthcare Leaders on Unlocking the Value of Disruption: “Digital Innovation Needs to be a Strategic Priority”

October 23, 2018
by Heather Landi, Associate Editor
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Health systems are feeling the pressure from digital disruptors coming into the market along with the increasing demand to be more consumer-focused, noted one healthcare CIO during a recent healthcare innovation conference.

“We are going to be disrupted by Apple and Amazon, if we don’t change,” Adam Landman, vice president and CIO of Boston-based Brigham Health, said during a panel discussion at the FT Digital Health Summit in New York City last week.

At the same time, however, many forward-thinking healthcare executives see digital technology as a tool that can be leveraged to support value-based care with the aim of better patient outcomes at lower cost.

During the FT Digital Health Summit, sponsored by Financial Times Live, a panel of healthcare industry leaders, including Landman, along with Chet Robson, medical director, clinical programs and quality for Deerfield, Ill.-based Walgreens and Nelia Padilla, global lead, digital health at IQVIA, a company that provides technology solutions and contract research services, discussed the role of digital technology in achieving value-based care as well as the significant barriers to adopting digital solutions and the headway their organizations are making with digital innovation.

Speaking to the challenges, Landman noted the oft-cited analogy that the leaders of healthcare provider organizations have one foot in two canoes—fee-for-service and value-based care. “A small percentage in most healthcare systems right now are in value-based care, and, in most health systems, in general, a much larger component is in fee-for-service. Many of us truly want to go to value-based care and embrace those practices, but I think it’s just very challenging. We’re only seeing some of the potential to the movement to value-based care.”

When asked by an audience member about why the adoption of digital technologies in healthcare was not occurring at a more rapid pace, the panelists cited a number of barriers, including the current lack of an evidence base around digital tools and health outcomes.

Operationally, digital innovation needs to be a priority, Landman said. “It takes a leadership mandate and it takes funding along with it, and it needs to become a strategic priority,” Landman said. “One of the challenges we face, on the provider side, there are a lot of competing priorities right now, and some are non-discretionary.” He noted the investment in implementing and optimizing electronic health records (EHRs). “That’s going to provide the base for this next stage of digital health. That’s one example of a must-do, and there are others in the regulatory and compliance space that need to be done.”

Digital technology adoption requires a balanced approach in healthcare, Robson noted. “It’s not only about, is it convenient for the consumer, but in healthcare, it’s also about, is it going to provide the best outcome for them?” he said. The Walgreens app has been downloaded 55 million times and the company fills about 3 million prescriptions a day through digital refill services, he said. Walgreens also operates 9,500 retail stores. “When you have engagement that solves a need for a patient, it definitely gets adopted,” he noted.

Progress with Digital Innovation and Unlocking the Value of Disruption

Padilla noted that healthcare is ripe for disruption from consumer-facing startups and digital companies because the space has lacked a consumer focus, citing startups that have developed apps to triage patients. “It’s difficult for institutions and for long-established players in the industry to go beyond the innate barriers, or some of the incentive systems, to actually offer some of these services."

Healthcare providers often engage the "worried well," Landman said, "or the patients that will adopt the Fitbits and who have their records going to Apple Health, but not the really sick patients, the ones who need additional monitoring and care." He added, "That’s been a continued challenge, along with trying to align the incentives so that we focus more on sicker patients. And we have been working with behavioral economists, psychologists and the whole team to think of creative ways to truly engage patients who need care the most."

Bringing to the discussion his experience as both an IT leader on the health system side, including formerly chief medical information officer (CMIO) at Adventist Health Partners, and an execuive leader on the retail side, Walgreens' Robson said, “As health systems, we tend to look at patient engagement as a push, we’re going to push the patients towards what they need to do. Being on the retail side, we try to attract patients and we are looking at it as a pull; we’re trying to make it fun, easy and meaningful to them. Then it’s about trying to connect those things together, both from the outpatient side and the hospital side, I think that’s how we can help to move the curve.”

At Brigham Health, clinical and IT leaders have found that data and analytics can be used to develop personalized approaches and “direct the right tools to the patients that need them the most,” Landman said.

“What we also found is that technology alone is not an answer. An app is just one component of a larger program and you really need to invest in the people resources around that program, which is typically a nurse coordinator or a social worker,” he said. “You’re engaging the patient with the app, and you’re offering tech support and services to make sure they are up and running and know how to use it, but then you are interacting with them. A social worker or care coordinator is monitoring the feedback and engaging with the patient. I’ve seen very few [programs] that will succeed with digital alone; it’s a bigger program commitment.”

Landman added, “We found this model, and the general principle is that all of us need to work together to truly achieve the vision of the quadruple aim, or value-based care. We need technology, we need the insurers and payers, we need the providers, the pharmaceutical companies, to all come together and be open to collaborating and thinking about new things. And then we need to try things and for things that we do get up and running, then iterate on them, and when we do find success, scale them.”

The panelists also noted that new data sources, such as patient-reported outcomes data and data from consumer wearables and sensors, will play a key role in driving value-based care forward, but there is more work that needs to be done to make that data clinically meaningful.

“We haven’t scratched the surface with new data sources that we can pull together, things as simple as sensors detecting if a patient has moved,” Landman said. He cited Brigham Health’s ongoing Home Hospital program to bring acute care to the home for patients who would normally be admitted to an inpatient facility. As covered in a July 2017 Healthcare Informatics article, the Home Health program, which is overseen by David Levine, M.D., a practicing general internist and research fellow at Brigham and Women's Hospital and Harvard Medical School, entails placing patch wearables on patients at home to monitor patient vitals as well as steps taken.

Citing the results of that program, Landman said, “What’s most predictive of how well a patient is doing is actually how ambulatory they are, so a simple sensor and an accelerometer that’s measuring how often they are getting up and how many steps they are taking, that’s extremely predictive of how they are doing,” he says. “As we connect and link these data sources, we unleash a whole new world of possibility. If we can partner with our academic colleagues and do the rigorous scientific studies and validate them, I think we can start learning a whole lot more about how to better manage patients and how to measure surrogate markers of clinical outcomes.”

Walgreens is making headway to engage patients using digital tools, Robson said. For example, the company developed an online tool called Find Care Now that helps connect consumers with healthcare services—whether in-person at a pharmacy, via phone or virtual consultation—based on the individual’s location, by zip code. “The idea is, how do we begin to take that information about individuals and make it actionable to help connect people to the correct resources to address whatever issue they are having,” Robson said.

At Brigham Health, a multidisciplinary team has been using a texting tool, developed by a company called Medumo, to enhance colonoscopy screenings. The tool provides patients with a digital colonoscopy prep guide in advance of their procedure, through instructions sent via text messages. The tool also sends appointment reminders and links to Brigham’s digital wayfinding system on the day of the appointment. Patient feedback indicates that patients feel more prepared for the procedure.

“With this simple use case, which we piloted both at Brigham and Women’s colonoscopy and endoscopy clinics as well as MGH (Massachusetts General Hospital), we saw decreases in no-show rates of over 30 percent. That’s a significant ROI,” Landman says. “We have some very encouraging results and we’re starting to expand that tool to other procedural areas and use cases. This is an example of where it’s meeting a real need and there are some palpable ROI that resonates with our CFOs that lets us then build this platform out.”

Panelists also noted other examples of health systems providing services to patients to support their use of digital technology at home. Ochsner Health System in southeast Louisiana introduced an “O Bar” service, a health information “genius bar” concept, at its Center for Primary Care and Wellness. “We’re going to see more of that as these interventions gain traction,” Landman said. In fact, Robson said Walgreens is considering a “genius bar” concept at retail locations.

On the technology side, panelists also noted that no one digital technology company currently offers a consolidated platform that integrates with health systems while also providing patients the ability to seamlessly share their data. Right now, we’re in the fertile field stage of innovation where lots of best-of-breed solutions are popping up. But, I do think soon we need to see some consolidation. I hope over time that we’ll see some convergence of some of these great solutions into a true platform that you can buy that offers a seamless platform for both the system and the patients,” Landman said.

He also noted, “I think these aggregation tools that take sensor data, patient-reported outcome data, and pull that together and create displays for clinicians that are easy to access and layer clinical decision support on top of them, those tools are going to be quite powerful.”

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One Health Policy Researcher on the Current State of Blockchain in Healthcare, and its Potential Future

October 22, 2018
by Heather Landi, Associate Editor
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Blockchain technology is generating a lot of interest and excitement in healthcare because of its potential to improve transparency, relieve administrative burdens and reduce costly waste within the system. However, there are also those within the industry that caution about the realistic prospects for the adoption of blockchain technologies in U.S. healthcare as well as the challenges of implementing this still-emergent technology.

In August, a Deloitte survey found that most global executives see great value in blockchain’s potential to reinvent processes across the business value chain, while there is interest and investment in a wide range of use cases. The research revealed that 74 percent of all respondents reported that their organizations see a “compelling business case” for the use of blockchain—and many of these companies are moving forward with the technology.

As an academic researcher, Tim Ken Mackey, an associate professor of anesthesiology and global public health at UC San Diego School of Medicine, has been exploring the possibility of leveraging blockchain to enhance supply chain management in healthcare, as well as other use cases.

Mackey is the director of healthcare research and policy at UC San Diego – Extension, and he also is the director of the Global Health Policy Institute. He holds a Ph.D. in Global Public Health from the joint doctoral program at UC San Diego-San Diego State University. His work focuses on a broad array of multidisciplinary topics, including research in disciplines of public health, health technology and innovation, supply chain, pharmaceutical policy, and public policy and law.

Mackey will bring his blockchain expertise to the upcoming Convege2Xcelerate conference taking place Oct. 22 at Columbia University in New Yok City. The conference is sponsored by Partners in Digital Health, publisher of Blockchain in Healthcare Today and Telehealth and Medicine Today, and will feature sessions on transformational technologies including blockchain, telehealth and artificial intelligence (AI).

While Mackey is a proponent of exploring the use of blockchain in healthcare, and sees real-world applications for U.S. healthcare, he also sees a number of ethical, technical, regulatory and business issues that need to be resolved. Recently, Mackey spoke with Healthcare Informatics Associate Editor Heather Landi about blockchain’s potential and challenges in healthcare. Below are excerpts of that interview.

From an academic research perspective, what is your interest in blockchain and what use cases are you exploring?

I was first brought into it because we were exploring how it could relate to combatting counterfeit medication, so using blockchain in the context of supply chain, and seeing whether it’s a good tool to combat the illicit trade of counterfeit drugs. I originally came into blockchain from my public health experience, and from there, I’ve been looking at blockchain in a number of different use cases and different healthcare verticals. The primary one is drug supply chain, but that could be a lot of different things within the drug supply chain; it could be recall management, pharmacovigilance, and it could be track and trace.

Outside of supply chain, we also look at different design principles and different use cases of blockchain and how they are supposed to fit a particular healthcare challenge. Genomics is one area that looks more towards consumers sharing their data. That’s different from a supply chain blockchain, which is more for compliance purposes, versus also an EHR (electronic health record) blockchain, which is intended to share different healthcare records and improve different population health outcomes across different health systems, but at the same time, keeping the patient data within the health system and providing provenance to that data.

Also, medical devices might look at blockchain more for contractual issues like maintenance of products and making sure there is an audit log for recall. Medical devices oftentimes have blockchains to pull in data from other sources to get people to share data with their devices, so they can create more data to hopefully improve the continuity of care across that device. There’s a lot of different use cases out there, and the interesting thing is that a blockchain has to be malleable to whatever healthcare challenge it is trying to address, and the design principles, which are primarily—is it a permissions blockchain versus a non-permissions blockchain, is it a private blockchain versus a public blockchain, what’s the consensus mechanism? Those principles have to map to those use cases, and oftentimes, they don’t.

Could you expand on that idea of mapping blockchain to particular use cases?

A good example of blockchain adoption that is happening pretty rapidly, although it’s not fully into production, is in the clinical trial space. And let’s keep in mind those three principles—public versus private blockchain, permissions versus non-permissions, and consensus mechanism. For a clinical trial, you can have one component of that clinical trial process that is a public blockchain. What I mean by that is, if you want to recruit patients and you want to access patient registries, or you want verified information that patients have certain conditions, then a blockchain would be amenable to that, to match patients and make recruitment a lot more cost effective. That could be a very public blockchain that doesn’t really have any permission structure that allows people to share their data in a verifiable way.

But, once you enter those people into the clinical trial, you’re probably going to have some kind of private or hybrid blockchain where the data is only available to certain entities—the clinical sites, the physicians, and the researchers—that are involved in the study protocol. In that case, that public blockchain turns into a private blockchain, or a very specific permission-structured blockchain, which is really meant to drive the study protocol within the clinical trial. So even within one vertical, you may have different business cases for the structure of a blockchain. However, many people are very much against private blockchains; they want fully public blockchains. Those design principles have to be thought out first within the context of the healthcare use case before we even think of the technology, and that’s the disconnect we often have.

There are some in the industry who believe blockchain is overhyped or that the challenges of implementing it might outweigh the benefits. Do you believe blockchain is showing its potential?

It depends on the vertical, but that doesn’t mean that blockchain can’t work for a particular vertical or that it’s not a good technology for that vertical, but that there may be regulatory considerations, such as GDPR (General Data Protection Regulation) and HIPAA (Health Insurance Portability and Accountability Act), or business considerations that make it hard for more widespread adoption. Blockchain is really primed for proof of concept development, but often the hard part is translating a proof of concept into something that can go into production and can be used by multiple parties, and that’s where the most benefit comes from blockchain; if you are allowed to share data, but keep ownership of it and have provenance of the data and trust in that data. Getting to that phase is going to be harder.

As one example, in supply chain there is much discussion is about how much data are we going to share on the blockchain. This is a fundamental question that is not about the technology, it’s more about different trading partners and how much they want to share data. That issue is not about trust of the data, but it’s about proprietary information that may be contained in the data, and how we govern the sharing of data. Those things are outside technology but rather are core business considerations that are different for supply chain than they are for consumer health. That’s often the roadblock to more widescale blockchain adoption. Proof of concepts and prototypes are pretty easy to stand up, but when it gets to real-world testing, and also the regulatory framework and whether the regulatory framework will absorb that type of technology or incentivize it, those are separate issues.

Those are some of the barriers, and they are not technology-focused. I think that’s why there is a bit of a disconnect between people who are technologists and think, ‘It’s a great technology and we should just use it,’ versus the healthcare space where people say, ‘These are our processes, and blockchain may be good for those processes, but there are inherent regulatory, legal and business issues, that make it hard to adopt.”

The core principles of blockchain are that it is an immutable shared ledger and it establishes provenance and integrity of the data. Those core elements are things we want with health care data. There are a lot of healthcare challenges and issues that could benefit from a shared ledger, such as reining in misuse of healthcare data as it relates to healthcare fraud and abuse and for drug recalls. And then there’s simple things like medical licensure, where the use of blockchain for credentialing could make that process more efficient. Many healthcare use cases relate to some component of data provenance, some level of sharing of data, and also the security of data. But, from a pragmatic view, there are some healthcare challenges where you don’t need those underlying elements, you just need to improve a process. And, if that process doesn’t require those underlying data provenance elements, then maybe this discussion about blockchain is going to distract more than it adds.


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One-on-One with Bon Secours Mercy Health’s President of Health Innovation

October 22, 2018
by Rajiv Leventhal, Managing Editor
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G. Anton Decker, M.D., president of health innovation at Bon Secours Mercy Health (the Maryland-based Bon Secours Health System and Cincinnati-based Mercy Health finalized their merger in September, thus establishing one of the largest Catholic healthcare systems in the nation), has been “around the healthcare block,” one might say.

Prior to his new role as president of health innovation at Bon Secours Mercy Health, and before the merger, Decker was the chief clinical officer for Mercy Health, with system-wide oversight of clinical operations and value- based care. Before that, he served as the president of Mercy Health Physicians, a multi-specialty medical group of over 1,300 providers, and prior to that, he was the chief medical officer and chairman of the board for Banner Medical Group.

Decker brings his experience and expertise to the Convege2Xcelerate conference taking place Oct. 22 at Columbia University in New Yok City. The conference is sponsored by Partners in Digital Health, publisher of Blockchain in Healthcare Today and Telehealth and Medicine Today, and will feature sessions on transformational technologies including blockchain, telehealth and artificial intelligence (AI).

To preview the core health IT topics the conference will focus on, Healthcare Informatics interviewed Decker about how he, and his organization, take on innovation opportunities and how digital health plays a role in operational strategies. Below are excerpts from that discussion.  

Can you explain your role—president of health innovation?

I explore innovative partnerships with a focus on data and digital innovation.

Looking at some of the healthcare disrupters out there, non-traditional companies, what picture does that paint for the future?

One may argue that the U.S. health system ran out of money 20 years ago and it’s only catching up to us now. Because hospital reimbursement from commercial payers has still been favorable, health systems could survive. As commercial and governmental reimbursement declines, however, the only option will be for them to reinvent themselves or be disrupted. It’s not simply a light switch; it is happening to us right now, often without realizing it. I am an optimist and believe that the future is bright, although the journey to get there will be rocky.

Previously you have held roles such as chief clinical officer, overseeing clinical operations and value-based care. Can you talk about some of Bon Secours Mercy Health’s specific value-based care initiatives and how things are progressing?

We have a strong commitment to value-based care and are in many shared savings and risk sharing agreements with private and governmental payers.

 What advice can you give based on the lessons you have learned?

Be very careful before you go at risk. Many health systems have lost their shirts not realizing how difficult it is. I would advise to take it gradually; first do a shared-savings arrangement with a payer. Understand the nuances, succeed at that for a year or two, and then take on financial risk.

It’s critical to invest in physician leadership and the required infrastructure. Be careful of creating a “shadow health system.” Instead, utilize and improve on the existing system.

 From a digital health standpoint, be it products or services, what’s catching your eye these days?

Telemedicine is here to stay, but I don’t know if it will transform healthcare the way some may have hoped for. There are many digital solutions that are seeking to establish their place in the healthcare ecosystem. Ultimately, they will all face the same challenges: engaging consumers and maintaining their engagement; reimbursement; evidence of clinical effectiveness; acceptance by providers; and interoperability with electronic health records (EHRs).

This event is going to have a large blockchain focus. What’s your take on the blockchain “buzz” and if the hype is real or not?

Our health system is exploring the role of blockchain in healthcare. I think the possibilities are numerous, not only from the provider and vendor side, but also from the patient’s perspective. Yes, there is some hype, but that will settle down and blockchain and the application of a distributed ledger in healthcare is here to stay.


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