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Stanford Children’s Health CMIO Takes Advantage of Silicon Valley Location

April 2, 2017
by David Raths
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Natalie Pageler, M.D., describes partnerships, both on and off the Stanford campus
Stanford Children's Health's Natalie Pageler, M.D.

Natalie Pageler, M.D., chief medical information officer at Stanford Children’s Health, realizes that her clinical informatics team is lucky to be located in the heart of Silicon Valley, where digital health innovation is thriving.

In a recent interview, Pageler said the 312-bed Lucile Packard Children's Hospital Stanford is ideally situated to partner closely with the university’s biomedical informatics experts and the School of Engineering on big data projects and new tools. In one example, a clinical informatics fellow looked at patterns in vital sign data in the data warehouse to revise vital sign alarm thresholds over time.

“Because we live in Silicon Valley, we also have the opportunity to work with companies such as Apple,” she said. A few years ago the health system announced that it was using Apple’s HealthKit to get continuous blood glucose monitoring from a patient’s home glucose monitor uploaded through their iPhones into MyChart, the patient portal, and then into Stanford’s EHR. “Then we created a data visualization tool called GluVue, an API-enabled app that displays all that data for clinicians,” she said.

“Now we are working with Apple again to do something similar with congenital heart disease,” Pageler added. “This concept involves some of our most fragile congenital heart patients and continually uploading their parameters” to guide caregivers.

She said Stanford Children’s Health is looking at several options to get the pool of data needed to enable care for diabetic patients, including data from insulin pumps. “With this digital health rollout, for our diabetic patients in particular, they won’t need to come into an academic medical center all the time for frequent appointments. They could do a lot of those appointments via virtual visits, and we pair those with home monitoring data uploaded to the EMR,” Pageler explained. “Then you stop disrupting their lives as much. You can provide care at home and prevent them from having significant deterioration. You are really flipping the entire model of healthcare delivery.”

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Pageler has been CMIO at Stanford Children’s for a little over a year. She succeeded Christopher Longhurst, who left to become CIO at UC San Diego Health.

She said that like most physicians who get into informatics, there was a lot of serendipity involved. “I do have an engineering undergraduate degree, so I definitely have a bent toward technology and science and engineering,” she said. During her fellowship, she was getting a master’s degree in medical education and did her thesis work on clinical decision support as a form of just-in-time education and a way to change physician attitudes. “That is where I got involved in informatics,” she said.

CMIOs at pediatric hospitals deal with the same issues generally as their counterparts at adult hospitals, but there are some regulatory differences, Pageler noted. For instance, the early markers for Meaningful Use were very adult-focused. “So we find ourselves constantly uniting as a pediatric group and saying, ‘don’t forget us’ and trying to figure out how we can make the measures make sense for a pediatric population.” She added that because pediatrics involves a smaller population, there is less evidence for evidence-based medicine and fewer randomized clinical trials to participate in.

Pageler reports to CIO Ed Kopetsky. She has been involved in two EHR implementations, the second time helping lead implementation of Epic a few years ago. “I work very closely with the IS department, and within IS, I have a clinical informatics team and an EHR training team reporting directly to me,” she said.

Stanford Children’s Health has an enterprise data warehouse and participates in multiple registries around specific diseases. It participates in four pediatric cardiology registries and two national diabetes registries, for example. Also, Epic has recently launched a program called Cosmos that allows Epic sites to contribute their data for research. Stanford Children’s has contributed all its pediatric asthma data to that site.

Pageler’s interest in clinical decision support continues to this day. Her team’s focus is EMR-integrated web-based clinical decision support tools. “We have been working on this for a while,” she said. Previous CMIO Chris Longhurst was involved in developing BiliTool, a web-based decision support tool designed to help clinicians assess the risks toward the development of hyperbilirubinemia or "jaundice" in newborns over 35 weeks gestational age.

Stanford Children’s has continued that work with development of a premature infant bilirubin decision support tool. “There are not a lot of randomized controlled trials for our populations,” she explained. “High bilirubin levels are very dangerous for newborn infants and pre-term babies, but we don’t have a lot of data about that. We have created a tool using the best evidence we have that takes the age and bilirubin levels from the EMR and provides guidance on what the physician should do based on current evidence. The tool then looks at the outcomes of that guidance and uses that information to continually improve the tool.”

Another Stanford neonatologist is working with a Bay Area startup, InsightRX, to create a clinical decision support tool for the dosing of the antibiotic vancomycin. Dosing can be very challenging, particularly in pediatric patients because the way they metabolize the product changes and the dosing should change based on their weight, she said. They have created a tool that takes information from the EMR and uses an algorithm to recommend a new dosing strategy. It feeds information back into the EMR to see how levels ended up being after that recommendation, so it is following that concept of a learning health system, where you are both recommending something and then learning from practice, she said.

I asked Pageler if such tools could be easily shared between pediatric hospitals on different EHRs. “That is definitely the ideal,” she said. “We are well resourced as an academic institution. We have physicians pursuing these tools as part of their research, but not every organization is so blessed. There is definitely a desire to share. With the FHIR standard, there is the possibility of creating these web-based tools that could sit on top of other EHRs, for more people to take advantage of them,” she said. “There are lots of challenges with that. If you are going to make a tool widely available, you need a really strict process around updates and maintenance and accuracy. But that will be the wave of the future. FHIR is opening the doors widely to allow the development of this type of tool that can sit on top of other EHRs.”

 


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The Modern Healthcare CIO, CMO, and CTO

December 10, 2018
by Lori Williams, Industry Voice, vice president of fulfillment, Gigster
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Disruption in the healthcare space comes primarily from the expansion of data’s role in the industry, and the healthcare C-suite’s familiarity with that expansion will help drive company and industry success

For the healthcare C-suite executive, the industry has never been more complex—nor has it ever contained so much potential. Emerging technologies mixed with political uncertainty has created an environment where incredible amounts of healthcare data are revolutionizing how patient care is handled, but patients remain uncertain about the future of their own health. With better data and the means to draw insights from it, healthcare CIOs, CMOs and CTOs are in a position to help address patients’ uncertainties and make hospitals and clinics more accessible and effective than ever before.

Here’s a look at how the role of the modern healthcare CIO, CMO and CTO is changing:

The Modern Healthcare CIO
The modern healthcare CIO’s role has evolved to become more innovative. No longer a title reserved strictly for engineers and IT professionals, today’s healthcare CIOs are focused on information science instead of simply setting up network infrastructure or providing back-end support. The trend towards a more data-centric role began as hospitals rolled out electronic health records, equipping individuals with better access to healthcare provider data. Through enterprise data warehousing, CIOs are becoming masters of data management, governance and predictive analytics, and passing along the many benefits of those knowledge bases to patients.

The Modern Healthcare CMO
The confusing healthcare landscape makes the role of a healthcare CMO more necessary than ever before. Thanks to ongoing regulatory changes, uncertainty surrounding the Affordable Care Act, and shifting consumer expectations for on-demand services, healthcare CMOs are responsible for helping patients navigate their way through a complex and opaque industry. As patients continue to assume the role of consumers, carrying out comparison shopping as they would for any other industry, CMOs must be adept in crafting a healthcare provider’s brand and messaging.

At the same time, CMOs must also ensure that healthcare providers offer a modern online experience, ensuring websites are mobile-optimized and social media accounts are generating engagement. This also means CMOs need to help move marketing efforts into the 21st century, transitioning away from direct mail or billboards towards digital marketing and CRM tools. Because if they don’t, there are plenty of med tech startups that will promptly eat into their market share.

The Modern Healthcare CTO
Unlike healthcare CTOs of the past who remained siloed off from the rest of the organization, today’s modern healthcare CTO is fully engaged with healthcare providers and their technology stacks, utilizing new software and hardware to improve daily workflows. The CTO is enabling the transition to patient-oriented self-service operations, enabling patients to carry out administrative tasks like scheduling appointments or refilling prescriptions over the internet. Because medical data is often stored in a variety of different sources, it’s critical for the CTO to be able to keep these systems interoperable with one another. For hospitals riddled with legacy software, CTOs should expect to continue employing middleware solutions to bridge the gap between old and new.

Members of the healthcare industry C-suite have the power to transform lives, and the CIO, CMO and CTO have roles that directly affect a provider’s ability to carry out positive change. With better data from the CTO’s tech stack, the CIO can use better analytics to help providers determine the best solutions for their patients, marketed to consumers by the CMO through modern platforms in clear, easy-to-understand language.

Lori Williams currently serves as Gigster’s vice president of fulfillment. Prior to joining Gigster, Lori was the general manager for Appririo.


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What Does Your Magnum Opus Look Like? A Few Operatic Thoughts

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I was given the privilege and pleasure recently of presenting, for the second year in a row, a lecture on Richard Wagner’s “Ring” cycle, as the leading opera company in my city, a world-class opera house, has been putting on, in yearly succession, the four operas of the “Ring of the Nibelung” cycle by German composer Richard Wagner (1813-1883). Last year, the second opera in the tetratology, “Die Walküre,” was performed; this year, the third opera, “Siegfried.” After the concluding opera, “Götterdämmerung,” is performed, the entire cycle will be presented in festival format, always a major cultural event. I spoke on “Siegfried.”

I’ve been fortunate to have seen six complete “Ring” cycles in live opera houses in different cities, and I can tell you, it’s a life-changing experience, as this four-opera work (16 hours of music altogether), sits at the absolute summit of western art. Richard Wagner was a hideous human being himself, but spent numerous years working on something that changed the course of classical music and redefined opera.

What’s more, from the summer of 1848, when Wagner wrote a first sketch of the libretti, or texts, of the operas, until their true compositional completion in 1871, more than 23 years were to pass; and it would be another five years before the tetralogy was fully presented, in a purpose-built new opera house in the Bavarian town of Bayreuth. It was a herculean feat to create the entire text of these four long operas, and compose 16 hours of music that would completely redefine the concept of opera. Indeed, when the crowned heads of Europe, the great living composers, and the 19th-century European intelligentsia and glitterati, gathered at the new Festspielhaus in Bayreuth in 1876, many were so overwhelmed by what they saw and heard, that they were rendered speechless. Even now, 142 years later, first time Ring-goers are overwhelmed by the breadth and sweep, the musical and dramatic audacity, and uniqueness of the “Ring” operas, with their story of gods, giants, dwarves, flying Valkyries, Rhinemaidens, one huge dragon, humans, gold mined from a river, magic swords and spears, and of course, a gold ring whose possessor can control the world and its fate.

Even just looking at the third opera, “Siegfried,” Wagner struggled mightily. For one thing, being essentially a grifter and a cad, Wagner borrowed/took money from everyone who would lend/give it, and often had affairs with the wives of the patrons bankrolling his compositional work, leaving his life in constant chaos, as he fled from one city to the next. One such wife, Mathilde Wesendonck, inspired the opera “Tristan und Isolde,” groundbreaking operas that Wagner wrote during a 12-year hiatus in his composition of “Siegfried.” And “Tristan” itself changed the entirety of classical music, its tonality-challenging chromaticism.

Well, no one is expecting anyone to match the unique creativity of Wagner’s “Ring” cycle. But the leaders of U.S. patient care organizations are doing a lot of important things these days, including using formal continuous improvement methodologies to rework core patient care delivery processes in order to transition into value-based healthcare. What’s more, as our Special Report on Leadership outlines, the entire role of the CIO is being rethought now, as the demands for leadership and strategic capabilities are catapulting that role forward; and patient care organizations are beginning to make real headway in advancing equality for women and people of color among the ranks of healthcare IT leaders and managers.

So while no one is expecting anyone to create an operatic tetralogy that will change the face of music, there are plenty of heroic endeavors open to anyone willing to envision the healthcare system of the future. The opportunities are as limitless as the imagination.

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Using Performance Management to Scale

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Performance management is so much more than just a year-end performance review
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Performance management and goal setting have always been part of my DNA. It’s like a compass that tells us we are steering the ship in the right direction or gives us a chance to course correct if we wander off track. It’s hard for any organization to determine how they are doing unless there are clear measurable objectives. CIOs and their leaders need monthly, quarterly and annual goals to measure how you and your team are doing against the plan. I also firmly believe they should be S.M.A.R.T. goals: Specific, Measurable, Achievable, Relevant and Time-based.

Once the goals have been established, you need a written plan. I like three-year rolling plans so you can look into the future and describe your vision of what your organization will look like 36 months out. Then you can work back to the second year, and eventually the first year, to give you the framework for what you need to accomplish in the next 12 months. I suggest you do it with your managers. It makes them accountable to the organization since they are involved in the formation of the plan.

Your plan must be a living document to be used frequently during team meetings throughout the year to see how you are performing as a team and individually. This is not a process you invest in to review at year-end to see how you performed. By then it’s too late. It must be reviewed on a consistent basis to make sure everyone is on track. Performance management is so much more than just a year-end performance review. If there are individuals who are not performing against the plan, you can use the plan as a tool to performance manage them to re-engage as an important member of the team. 

I just returned from the Scale-up Conference in Denver and learned so much about taking goal setting and performance management to a whole new level by adopting the "Rockefeller Habits," as written by Verne Harnish. After reading the book, everything changed for me in the way we will be doing our planning, goal setting and performance management forever. It’s so brilliant and easy to understand. Here they are:

Rockefeller Habit #1: The executive team is healthy and aligned

Rockefeller Habit #2: Everyone is aligned with the #1 thing that needs to be accomplished this quarter to move the organization forward

Rockefeller Habit #3: Communication rhythm is established and information moves through the organization accurately and quickly

Rockefeller Habit #4: Every facet of the organization has a person assigned with accountability for ensuring goals are met

Rockefeller Habit #5: Ongoing employee input is collected to identify obstacles and opportunities

Rockefeller Habit #6: Reporting and analysis of customer feedback data is as frequent and accurate as financial data

Rockefeller Habit #7: Core values and purpose are “alive” in the organization

Rockefeller Habit #8: Employees can articulate the key components of the company’s strategy accurately

Rockefeller Habit #9: All employees can answer quantitatively whether they had a good day or week

Rockefeller Habit #10: The company’s plans and performance are visible to everyone

Accountability is no longer hard to measure since the entire plan is visible to everyone throughout the organization. Each part of your team should have key people accountable for every functional part of your organization. No more guessing is required. I’ve read countless books about leadership, performance management and goal setting, as I’ve been an avid student on the subject for decades.

These ten habits, once adopted and measured regularly, can change any organization that wants to grow and scale, and keep everyone accountable along the way.

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