Datasets still contain bias and hold back the ability of machine learning to improve healthcare.
Artificial intelligence (AI)–driven healthcare is widely expected to transform medical decision-making and treatment, but AI algorithms must be thoroughly tested and continuously monitored to avoid unintended consequences, including bias, to patients.
In a commentary published in JAMA Network Open, Regenstrief Institute President Peter Embí, MD, calls for algorithmovigilance—a term he coined for scientific methods and activities relating to evaluation, monitoring, understanding, and prevention of adverse effects of algorithms in healthcare—to address inherent biases in healthcare algorithms and their deployment.
HealthLeaders spoke with Dr. Embí to understand this new concept. This interview has been edited for brevity and clarity.
HealthLeaders: Is this just about detecting bias in algorithms?
Peter Embí, MD: Algorithms learn from existing data, which have inherent biases in them, because they come from a biased system, where we have disparities in care. There's a risk that you can build into these algorithms that same bias, and then you essentially operationalize something that is skewed, because it was based on skewed data. When we start to have predictions made by these algorithms that guide therapy, guide diagnosis, or provide advice, we have to make sure that they're having the right effects, or the effects that we expect.
One of the key elements of algorithmovigilance is to say—much like we do with drugs—just because we've done some initial studies doesn't mean it's going to perform the same way when we put it out into the world. And we need to be monitoring [predictions made by algorithms], to make sure that they're going to have the intended effect. It's already been demonstrated that if you don't do that, you can have unintended consequences, like worse care for certain vulnerable populations and the like. The analogy that I made with algorithmovigilance to pharmacovigilance, which has existed for quite some time, is apropos in the sense that you have in pharmacovigilance. We get FDA approval for a particular drug, we put it out into the marketplace. But once it starts to be used much more widely, we often find effects that we weren't expecting, and the only way to know about that is to look for them. So that's a core piece of it.
Peter Embí, MD, is the President of Regenstrief Institute. Courtesy of Regenstrief Institute.
HealthLeaders: The pharma world is filled with trade secrets. We know a lot of the science behind how some drugs are produced. Science then tests them and report the results. All of that is public. But there are concerns that AI is the same way, in the sense that we have all these black boxes, and a problem with oversight is that we're just not working with an innovation system that offers any incentive for somebody to tell you how their black box works.
Embí: Even those who develop them don't really know why they're giving the output that they are giving, because these are machine learning approaches. Oftentimes, when you do dig in, and you look at what are the parameters that are leading to the recommendations, they don't make logical sense all the time. The fact that someone has a certain characteristic, why should that lead to a prediction that they're going to have a worse outcome, and should be treated a certain way? It doesn't always make sense, except there's some multi-step correlation that we don't fully understand. And yet, that is the parameter that is predictive. As we continue to use these algorithms in practice, … I think it would be important to continue to call for that level of transparency, at least for those who are regulating them, if not for the rest of us. Whether it's a black box or not, you're determining what's happening in the real world.
And I think that's the most important piece of this. We can't presume that it's going to have the effect we expect it to have. We have to check for that. It's an ethical imperative that we do. And then I think, to your point, regulations need to follow. Even as the FDA and others grapple with how they're going to monitor and evaluate and certify these things, that ongoing piece of post-market surveillance is going to be critical.
HealthLeaders: So, what do I do as a technology provider to do the corrective action needed?
Embí: It's going to become increasingly important that some symbiotic relationship between the technology company and the end user or customer needs to exist, where there is ongoing monitoring, to ensure how it's deployed, how it's used, what the outcomes are, and are fitting within the expected parameters of what we anticipate would happen. I am not advocating that we don't use algorithms. In fact, I want the use of algorithms to be advanced for good. But if we aren't aware that they can have unintended consequences, we may not identify the downsides. So, I think [technology providers] have to build that in.
HealthLeaders: What's the road to bias-free data sets? How do we get there?
Embí: I don't know that I have the full answer to that, except to say that we know that our current datasets, and probably for some time, are going to have inherent biases in them. Pulling from other experiences, it may not be that we can achieve nirvana of completely bias-free datasets. But until we get there, we should work hard on that, to include a more representative sample of individuals and experiences in those data sets. The first step is to understand that we have a problem, that we do have bias, and characterize what those biases are. Because the better we understand and can characterize what the existing and current biases are in our existing datasets, the better we're going to be able to understand what we need to be correcting.
Hospitals have thousands of such devices connected to their networks, capable of accessing EHR records.
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued a report last week finding that the Centers for Medicare & Medicaid Services' (CMS) survey protocol does not include requirements for networked device cybersecurity.
Further, the report stated that CMS' accreditation organizations (AO) do not use powers they possess to require hospitals to have such cybersecurity plans.
The OIG stated that hospitals that identify networked device cybersecurity as part of their emergency preparedness risk assessments can get their mitigation plans reviewed by AOs.
In practice, however, hospitals frequently fail to identify device cybersecurity in these risk assessments, the AOs told the OIG. Assessing hospital safeguards for the privacy of medical records may prompt AOs to examine networked devices.
The OIG also reported that CMS and the AOs do not plan to update their survey requirements to address networked devices or general cybersecurity.
"As hospitals continue to face cyberattacks that risk patient harm, it is important to know whether and how AOs hold hospitals accountable for cybersecurity of their devices," the OIG stated in an issue brief on its report.
The OIG gathered findings for the report by conducting structured telephone interviews with leadership at the four AOs, and by sending written questions to CMS.
AOs direct their requirements from the Conditions of Participation and oversee most hospitals that participate in Medicare. The OIG says AOs rarely use their discretion to examine the cybersecurity of networked devices during their surveys of hospitals.
"We recommend that CMS identify and implement an appropriate way to address cybersecurity of networked medical devices in its quality oversight of hospitals in consultation with HHS partners and others," the OIG stated.
CMS stated that it agreed to consider additional ways to appropriately highlight the importance of cybersecurity of networked medical devices for providers, consulting with its HHS partners having specific oversight authority regarding cybersecurity.
The report stated that one expert estimates that a large hospital may have around 85,000 medical devices connected to its network and capable of being connected to hospital EHR systems.
Incentives remain unaligned with the use of health IT, but 21st Century Cures Act implementation is one tool in ONC's arsenal.
Lock-in of all sorts, ranging from the geographic lock-in of hospital consolidation to the vendor lock-in of electronic health records, was on the minds of former national coordinators of health IT during a panel last week at the virtual CHIME21 Summer Forum.
"I see telehealth as the next positive disrupter for improving care," said Rob Kolodner, MD, vice president and chief medical officer of ViTel Net, who served as national coordinator from 2007 to 2009 under former President George W. Bush.
Kolodner said he hopes telehealth can empower individuals to have provider choice and thus spur competition within the healthcare system, "rather than a geography lock." The COVID-19 pandemic shattered many of the barriers to telehealth adoption "and hopefully won't be reinstated," Kolodner said.
But competition extends to the very EHR systems that the federal meaningful use program funded, he added.
"Having spent over 30 years in the federal government, believing that vendors should compete on value and not on vendor lock, in order to do that, we need to get beyond the monolithic-type systems that we sometimes have to a platform-based type of approach, with modules and optional components, and be able to adapt easily and rapidly over time, and not have an 18-month cycle to get new things into place," Kolodner said.
Don Rucker MD, professor of clinical emergency medicine and biomedical informatics at Ohio State University and the immediate past national coordinator under former President Donald Trump, echoed the need for ONC to enable more choice for healthcare consumers.
"We can't, as an industry, look and say, we're providing great value for the American public and healthcare," Rucker said.
"Ultimately, the role of ONC and of any federal agency head is to be, in part, the voice for the people, the vast majority of America who's not at the table, but who has, frankly, gotten a raw deal in healthcare," he added.
Still, Rucker shares the hope of all former coordinators that new tools, including the FHIR application programming interface (API), will spur competition at all levels, including health information exchanges.
The daunting challenge of data blocking exasperated all national coordinators, leading ultimately to language in the 21st Century Cures Act, passed in the final months of the Obama administration in 2016.
"That would allow us to have a more modern approach…to achieving interoperability with an API FHIR-based system, and then addressing this increasingly important challenge of data blocking," said Karen DeSalvo, MD, chief health officer at Google, who was national coordinator from 2014 to 2016 under former President Barack Obama.
All the technology in the world won't help unless incentives are aligned to share data, said David Blumenthal, MD, president of the Commonwealth Fund, who was national coordinator from 2009 to 2011 under Obama as well.
"The implementation and use of electronic health records, and all the applications that build on them, is fundamentally a human activity," Blumenthal said. "If we don't motivate the users of those technologies to make the most of them, they won't."
The frustration of Blumenthal and his successor, Farzad Mostashari, MD, founder and CEO of Aledade, created a sense of inevitability that interoperability would happen, Blumenthal said, affording the political opportunities DeSalvo and Rucker used to pass and implement the Cures Act.
Although Mostashari's term saw the implementation rate of certified EHRs rise from 9% of hospitals to 90%, "the test of success was not functional enough, and it wasn't tied to payment models enough," Mostashari said. "It wasn't tied to the real business model. It was more compliance-oriented."
EHRs were able to meet ONC's certification standards but "you can't calculate a darn quality measure," Mostashari said. Instead, ONC would be better off "focusing more on functional tests" that demonstrate the ability of the EHR to perform a given function, he added.
The Power of Listening
Listening to public concerns about proposed ONC regulations emerged as another key topic at the CHIME forum.
"We did a lot of listening sessions with CMS," said Vindell Washington, MD, chief executive officer of Alphabet/Google Verily subsidiary Onduo, who was national coordinator from mid-2016 to early 2017. "There's no substitution for getting out, having sessions, and talking with folks that are going to be participating."
"I learned at ONC that listening is one of the most powerful policymaking and management tools that any leader in any organization can exert," Blumenthal said. "Some of my most productive meetings were meetings in which I didn't say a thing."
"Every single comment gets heard," added Micky Tripathi, the current national coordinator. "Sometimes you don't see it in a direct response, but I can assure you it's taken very seriously."
Mostashari cautioned the CHIME CIO audience that "astroturf doesn't work" in the regulation feedback process.
"If a vendor says to send in your version of this form letter, that's counted basically once," he said. "Speak in your own voice, be specific and granular about your own experiences, and be grounded in your reality."
Both public health and hospital staff received accolades for handling the COVID-19 outbreak, and a few former coordinators said that things would have gone worse without the widespread rollout of EHRs in American healthcare. Still, the leaders cautioned that more must be done.
"For years, we've been saying public health is underfunded," Tripathi said. "Public health is too fragmented. Public health has too many jurisdictional issues. We invested $40 billion in EHR systems that sent a firehose on the public health system with one-way flows of data that the public health system was not prepared to do anything with."
Despite this, "we also saw tremendous and heroic efforts to stand up stuff to help to solve that problem," Tripathi added.
Efforts to implement vaccination scheduling at a state level, exposed through EHR vendors such as Epic, and major pharmacy chains, have been a bright spot, based on an FHIR-based protocol, Tripathi said.
"It shows how, with the new technologies that we have available to us…you have the ability to say we can do things on a short cycle in the way that the rest of the internet economy works," he said.
"I do think our traditional public health organizations were in much better shape than they possibly would have been without those public health provisions that we did put in place," Mostashari said.
The proliferation of APIs enabling data exchange will lead to many new healthcare apps that won't necessarily be based upon EHRs, he added.
The rule aims to free data from silos to promote interoperability between payers and providers.
On July 1, a final rule by the Centers for Medicare & Medicaid Services (CMS) takes effect, and aims to continue, as CMS says, "to build on its roadmap to improve interoperability and health information access for patients, providers, and payers." When implemented effectively, health information exchange (interoperability) can also reduce the burden of certain administrative processes, such as prior authorization. We have issued regulations that will drive change in how clinical and administrative information is exchanged between payers, providers and patients, and will support more efficient care coordination."
To understand the impact of the rule, HealthLeaders reached out to two technology companies working on enabling healthcare organizations to meet the requirements of the rule. We posed identical questions in separate interviews to Don Searing, PhD, vice president of solutions architecture at HGS Healthcare Technology, a consulting organization deploying people, process, and technology platform improvements; and Minal Patel, president and CEO of Abacus Insights, which provides a data integration and interoperability platform that enables health plans and their providers to create a more personalized healthcare experience for consumers
HealthLeaders: What does the CMS mandate beginning in July mean for payers, providers, and patients?
Don Searing: At its root, the new rule means data should be released from its current proprietary silos to facilitate the healthcare journeys of members and patients.
Today, most patients are familiar with going from one provider to the next (e.g., from your PCP to a specialist or lab), and having to: 1) carry information from one doctor to the other, 2) explain their symptoms repeatedly, and 3) be responsible for coordinating their own care across the providers. Additionally, many have health or wellness apps that do not have access to their provider health data and that cannot provide data to their doctor.
The goal of the rule is to knock down these barriers—some technical, some regulatory, some procedural—and to provide a system for providers and applications to communicate with each other and allow data to move seamlessly between all the tools and providers a patient or member interacts with.
For patients, this is great news. But with this power comes a lot of additional responsibility, as each member must manage the access to their data as it moves through this system.
The payers and providers will have a heavier initial lift as they modify or upgrade existing systems to ensure the APIs (FHIR, etc.) are enabled and provide a way for their members and patients to authorize the usage of their data in a secure and auditable way. Most payers and providers are focused on opening these gateways right now and have not even scratched the surface of what they plan to do with the data they may now gain access to.
Minal Patel: The Centers for Medicare & Medicaid Services mandate gives consumers free electronic access to their structured and unstructured healthcare information by requiring health plans to make that data interoperable and shareable with consumers, providers, and other health plans.
For patients, the mandate represents a step forward in being able to access insightful, actionable healthcare data in a timely fashion, so they can make better decisions about their health. Patients can also incorporate new sources of data, for example from wearable devices, into their health history for a more comprehensive picture. They will also be able to learn more about the healthcare providers in their area so their choices will be better informed.
Providers, with the necessary patient consent, will be able to access claims data, electronic health records, and other information that can better inform treatment decisions for their patients leading to better health outcomes.
Payers can use the trove of valuable information they have about patients, physicians, and the efficacy of various treatment courses to improve the member experience and help improve health outcomes. Healthcare data—if analyzed and used properly—can help insurers keep their membership healthier, better understand risk, and run their businesses more efficiently and cost-effectively.
HL: What new obligations or responsibilities does this place on each party?
Searing: Patients are now the owners of all their data and are responsible for providing access to it. Groups like the CARIN Alliance have been working to try to standardize this process and make it easier to provide access to various providers and health applications. I foresee this will be an area of confusion for patients as they understand their new role.
Payers and providers will have to update or even rebuild their systems to ensure they are compliant with the specified access rules and the required APIs. However, just making these ports accessible and open does not mean that anyone will know what to do with the new data and access. That will come down the road as those of us in the industry develop the use cases.
Payers have a unique opportunity to play the role of data aggregator as they currently have the best view of member health due to all the claims they receive from providers and pharmacies. Look to insurers expanding their care management services to incorporate more health and wellness/fitness data as some of their first forays into expanding capabilities.
Patel: Health plans must make data available to patients in a form that is easy to use. Health plans need to also ensure that the data is protected, secure, and in an environment that is essentially direct-to-consumer. Individuals that decide to use third-party applications to access their health data or connect it to other third-party applications, such as wellness applications, need to understand the privacy and security rules of those applications so that they are not unknowingly distributing their health data to outside sources.
HL: Consent rules vary by state. How does this affect the ability of the new regulation to perform as lawmakers intended?
Searing: I think that as patients—and the apps that represent them—start to run into challenges in varying consent rules, we will see further guidance from CMS. We will either see the industry move quickly to set a common denominator and reduce variation in the system (like how California’s more stringent privacy laws have become the common approach across all states), or we will see organizations lobbying CMS to push for a federal consent standard.
Patel: Health plans that operate in multiple states will need to be knowledgeable about the possible, and likely, differing rules for consent. The onus is on the health plan to ensure that health data is protected, and this adds a layer of complexity that goes well beyond the addition of a FHIR server. Health plans will need to have a strategy in place to meet various state requirements, appropriate security safeguards, and technical expertise to ensure that PHI is not released to unauthorized entities.
HL: If agencies merely comply with the mandate, without matching its spirit of improving appropriate data sharing and disclosure, will anything really change?
Searing: Previously, CMS was very specific in putting all industry players on notice that a) this data was the property of the patient and 2) no barriers could be put in the way of patient access to it. These statements were directed at companies who traditionally limited access to the data within their systems. CMS has made clear that these principles are not negotiable, and that information blocking will not be allowed.
Many of these organizations struggle to even share information between their internal departments. So, while the information may be available, I would not expect it to be of very high quality.
Patel: Patients will have access to their data, but the real change comes when plans use the mandate to transform their businesses.
At Abacus Insights, we believe this will be transformational across our industry. The mandate requires investment in strong data infrastructure platforms. A strong data infrastructure is rapidly followed by the adoption of analytics. Health plans today can use compliance with federal data-sharing requirements to transform their operations and improve health outcomes. By fully upgrading their systems for analyzing and sharing data, plans can make data available to doctor’s offices, hospitals, urgent care clinics, pharmacies, dialysis centers, and labs along with digital health innovators. With a complete health picture and access to data, providers and patients can make better decisions, leading to better health outcomes.
HL: What are the crucial standardized interfaces (such as FHIR) enabling this interoperability, and what role do they play in giving all participants measurable results?
Searing: Any rule demanding interoperability that is going to have a chance at implementation must have a set of APIs and an underlying, open technical architecture that all participants can buy into. FHIR is a fantastic start at laying the groundwork for these kinds of services, making it easy for developers and product companies to add them to their standard integration libraries. It is critical that these remain open and active as we move forward and start to iterate on the new solutions that will come to market. Just as EDI allowed many companies to standardize a lot of transactions (enrollment, purchasing, payment, etc.), I expect that the FHIR standard, and the HL7 it is based upon, will be critical to implementing this rule—just as standards have created entire other industries like Wi-Fi and the internet.
Patel: Until a few months ago, the standard for how data would be shared among healthcare entities was not established. As a result, health plans were building to a moving target. Earlier this year, ONC issued guidance that FHIR would be the describing data formats and elements and a standard API for sharing data. FHIR builds on previous data format standards from HL7. Even with the FHIR standard in place, health plans and other entities need to ensure that they are implemented in a standard way. This has been one of the most challenging aspects of meeting the mandate. If the APIs are not aligned, it’s possible that data will not be able to be shared with patients as well as posing possible security risks.
The FHIR standards are foundational to how data is accessed and shared among entities. Taking the guesswork out of what to expect means that organizations can now focus on data quality and data analytics to drive better insights and outcomes.
American Telemedicine Association applauds the introduction of the Telemental Health Care Access Act.
A bipartisan Senate bill that would eliminate a federal requirement for mental health services to be delivered in person was introduced last week and was immediately welcomed by telehealth advocates.
The Telemental Health Care Access Act of 2021 was introduced by Senators Bill Cassidy (R-LA), Tina Smith (D-MN), Ben Cardin (D-MD), and John Thune (R-SD). The proposed law would repeal the in-person requirement for telemental services signed into law as part of the end-of-year Congressional reconciliation package last December.
"Our highest praise and gratitude to Senators Cassidy, Smith, Cardin and Thune for their steady leadership and clear priority to bring telehealth services to the American people, including those in rural and underserved communities," said Ann Mond Johnson, CEO of the American Telemedicine Association (ATA). "The Telemental Health Care Access Act is a critical piece of legislation that would repeal the telemental health in-person requirement. Passing this legislation, and ensuring this unnecessary requirement is not repeated for other services, along with other pieces of legislation that make the telehealth waivers permanent, could not be a higher priority for the ATA and our members."
In a statement, ATA noted that no clinical evidence exists to support an in-person requirement before patients can access telehealth services. ATA officials say evidence demonstrates that telemental health services such as telepsychology are as effective as in-person visits.
The ATA stated that it had also published a new brief on in-person requirements for telehealth, describing the obstacles to care created by what it termed "this arbitrary law that are contrary to clinical consensus, exacerbate provider shortages, worsens health inequities, and unnecessarily preempt state laws."
"The ATA strongly opposes statutory in-person requirements as they create arbitrary and clinically unsupported barriers to accessing affordable, quality health care," Mond Johnson said. "Requirements such as these could negatively impact those in underserved communities who may not be able to have an in-person exam. We simply cannot ignore the importance of providing all Americans, regardless of whether they have an established relationship with a medical provider, the opportunity to access life-saving health care."
"Telehealth has been essential for maintaining and expanding access to healthcare services during the COVID-19 pandemic," said Senator Cardin in a statement. "This is especially true for those seeking mental health counseling and medical management, as we have seen spikes in anxiety, depression, substance abuse, domestic violence and suicide resulting from social isolation. This legislation provides additional flexibility to increase access for Medicare beneficiaries needing mental health services."
Tech showed caregiver's faces to kids during pandemic, while protecting clinicians and specialists.
As the COVID-19 pandemic raged, a new autonomous robot rolled its way into the favor of providers and patients alike at Children's National Hospital in Washington, D.C.
The robot, acquired with funds made available by the Federal Communications Commission COVID-19 Telehealth Program, also helped solidify the hospital's role as a regional tertiary telemedicine hub for surrounding primary and secondary healthcare institutions.
In the first days of the pandemic, the robot permitted stricter separation of possibly COVID-infected patients in the hospital's emergency department from some hospital staff, and then was able to play a more focused role as patients were treated for any suspicion of infectious disease.
With help from staff engineers, the robot understands the layout of the emergency department. Staff are able to instruct the robot to move from location to location, and while getting there, the robot is able to negotiate getting there under its own control, through autonomous programming, giving people and other objects in its path plenty of room while it makes its way to its destination.
Staff can also control the movements of the robot via a mobile app on their phones when it arrives at each emergency treatment station. For example, not only can they have the robot take the vitals, staff can even make the robot wiggle and wave, amusing children, many of whom seem more at ease with the robot than they are with traditional staff care.
"I would recommend this to be used and to become part of the new standard of care," says Alejandro Jose Lopez-Magallon, MD, medical director of telemedicine at Children's National.
"We had three objectives in mind—to protect patients, protect families, and protect our staff," Lopez-Magallon says.
The robot's supplier, Teladoc Health, Inc., acquired InTouch Health, which originally created the robot (sold under the name Vita), in a company acquisition in early 2020. The robot joins a number of other telemedicine devices at the hospital, including two other autonomous robots, and telemedicine carts that lack autonomous movement, and hence must be moved from location to location by staff. Two of the three Teladoc Vitas there were acquired through the FCC program.
The robots act as eyes, ears, and more for clinicians on the other end of the connection. Clinicians are spared from having to change their personal protective equipment (PPE), which saves time and gives them the ability to move on to the next patient, while nurses and staff continue to provide bedside care.
"I sometimes can hear better than I could in person," referring to the robot's digital stethoscope, especially compared to the disposable plastic stethoscopes required for in-person exams during the pandemic, says Shireen Atabaki, MD, MPH, FAAP, FACEP, associate medical director of telemedicine and emergency medicine physician at Children's National. "It's very good for heart and lung sounds."
In addition to its video camera, the robot's instruments can be wielded by an onsite staff member to reveal to the remote physician or nurse conditions of the ear (otoscope), skin (magnifying dermatoscope), and circulatory system (blood pressure cuff).
"You can't examine the stomach and see if somebody's belly is tender," sums up the type of limits of such a remote examination, Atabaki adds. In that case, a nurse on site can conduct such exams.
And yet, there are other benefits. "Sometimes, the interaction is better," Atabaki says. "You see more of the child. They're moving around, they're not shy, they're talking, complaining to their mother, they're much more comfortable" than if the physician is there in person, particularly when decked out in PPE, she notes.
And to patients, the robot's screen shows them the human face of the clinician—as opposed to an in-person face swathed in PPE. "Showing your face and being able to interact with kids and families makes for a more amenable interaction than just a cold machine," Lopez-Magallon says.
Children's National was also awarded a large grant to create a regional telemedicine consortium across 15 health systems in the D.C. region. "The goal is to provide seamless pediatric specialty care and primary care across the region in light of the COVID pandemic," Atabaki says.
When a pediatric patient presents at a remote hospital, and Children's sends an ambulance to pick the patient up for transport to Children's, a Children's provider can be virtually on board during the trip, Atabaki says.
Children's also has a telemedicine-based COVID-19 follow-up clinic, and the hospital has already scheduled more than 500 visits there, Atabaki says.
"And we can invite a subspecialist, let's say a cardiologist, an endocrinologist, or dermatologists, to join us and provide subspecialty care in the emergency department to a patient," she says.
"Pediatric specialists are a scarce resource in the United States and around the world, even in our own region," Atabaki says. "Telehealth really helps overcome that."
Another area of focus for the regional telemedicine initiative has been providing mental health services between Children's National and its campus in generally underserved Wards 7 and 8 of the District of Columbia, employing telemedicine carts and iPads, Atabaki says.
In addition, a newly deployed family presence program dedicates an iPad and Zoom to each patient room in the hospital, and other hospital resources to allow families lacking Wi-Fi or adequate data plans to be able to communicate with patients from outside the hospital, she adds.
"If you're restricting the number of people that come into an ER with a child, this allows the family member who's out in the car waiting, or at home waiting anxiously to have communication, both with their child who's in the hospital in the ER, and also with the care team," Atabaki says.
Children's National will seek funding to continue the program even as existing funding to run the system sunsets.
"There will be other pandemics," Lopez-Magallon says.
Also, to protect against obsolescence, Children's National leases the Teladoc robot, instead of purchasing it.
"Technology is fluid, and we wanted freedom from having to do a lot of maintenance," he says. "It looks flashy initially, but in three to five years, then it just becomes some funky-looking old [tech]. And it always gets better. And that was a good arrangement."
Nurse leader rounding software on iPad Minis raises HCAHPS scores, but will need to be carefully integrated with the EHR.
Realizing that the typical electronic health record, despite vendor slogans to the contrary, is far from patient-centered, Northwell Health'sLenox Hill Hospital found breakthrough HCAHPS scores by adding a second piece of technology to tell the story of inpatients' point of view.
Utilizing software from CipherHealth, Lenox Hill nurse leaders improved patient care handoffs between shifts, ultimately improving patient experience scores as reflected by HCAHPS.
"We redesigned and reimagined the role of our unit ward clerks, transitioning them to patient service facilitators, and giving them Cipher," says Joe Leggio, associate executive director and vice president of experience at the hospital, which employs 4,200, including up to 1,900 nurses.
The transition began two to three years ago, when leadership was trying to find ways to improve the way nurses rounded among inpatients.
"We all have HCAHPS data, which is great, but it's not helpful to know that someone eight weeks ago was upset," Leggio says. "It's very hard to fix that experience."
Instead, leaders wanted real-time information on patient experience that they could aggregate, and then apply process improvement measures quickly.
"We made the round be at the center of what we do, so that we were patient-focused," Leggio says.
Joe Leggio is the associate executive director and vice president of experience at Northwell Health’s Lenox Hill Hospital. Photo courtesy of Lenox Hill Hospital.
Patient engagement software is linked to ADT data
The CipherHealth technology is linked to admission, discharge and transfer (ADT) feeds generated at the hospital. "It knows where patients are, when they're there," Leggio says. The technology lets clinicians build scripts tailored to each patient, include checking on nursing's "5 Ps"—potty, pain, position, possessions, and peaceful environment.
The technology also allows nurses to capture notes in free text "to have an organic conversation with the patient as to what matters to them," according to Leggio.
Also present in the technology is what Leggio calls a communication and escalation algorithm. For example, a nurse making rounds may see that garbage needs to be taken out. Nurse leaders can take a photo with the CipherHealth mobile app, which they carry on iPad Minis, and send the photo to the hospital's environmental services according to their preference (via text message or email).
"It's all timestamped, so it gives us a sense of what our response times are, and it allows the person who's trying to solve that problem know what they're looking for when they get into that room."
Patient satisfaction isn't the only beneficiary of this round-centered tech. Pain management is a big area of focus, Leggio says.
Patients have been able to get an increased frequency of pain consults with clinicians, plus different therapies such as music therapy, art therapy, and pet therapy, all preferred alternatives to reduce reliance on opioids, he adds.
"So much of what happens is sometimes patients' expectation of zero pain, and sometimes we can't get to zero," Leggio says. With that in mind, clear communication between providers is crucial, he adds.
"There's so many people walking in and out of that [patient] room, between physicians, pain management, [and] nursing," he says. "This tool has given us insight into that communication clarity."
Another piece of insight comes from understanding what is happening at the other end of the patient's call button.
"Right now, most hospitals don't have a piece of technology built into a call bell system that says, 'I'm calling for pain' or 'I'm calling for ice.' We've been able to improve workflow efficiencies because we were able to see what patients are asking, by unit and by service."
Tasks like these often resulted in nurses jotting and pocketing handwritten notes, records of which aren't retained after the shift is done.
"It's nothing against our nurse leaders," Leggio says. "They were working with the technology they had. But now I've got a tool that aggregates this data, and proactively sends it to me on a weekly, monthly, and quarterly basis with the trends built into it."
Currently, only Lenox Hill nurse leaders (as opposed to all nurses) use the CipherHealth technology, and it is in use at nine other Northwell hospitals.
But the narrative that emerges is something previously unavailable to nurse leaders.
"In a 48-hour stay, the patient will come in contact with over 65 of our employees," Leggio says. "It just starts adding up. The key is that communication."
Lenox Hill's HCAHPS scores for responsiveness have improved dramatically, rising from the 19th percentile in 2018 to the 32nd in 2019, 44th in 2020, and 93rd so far in 2021. Patients' likelihood to recommend the hospital rose from the 49th percentile in 2018 to 95th so far in 2021.
EHR integration challenge remains
All this improvement has, however, left a formidable task for Lenox Hill and other users of this technology. For decades, EHRs have been sold to them as the "single source of truth," but now, technology such as CipherHealth's represents a second "unofficial medical record," as Leggio puts it.
"We're not there yet, fully integrated where we want to be," he says. "But we are working on it. Making a change like this was a very large shift. What we don't want to do is just throw another piece of technology in front of us, thinking it's going to solve all the problems.
"We are now on the journey to figuring out, how do we link this to the medical record? We're figuring out those steps right now."
The COVID-19 pandemic also played a role in the timing of the rollout of the CipherHealth technology. "March, April, and May [2020] were our three biggest months for the pandemic," Leggio says. "We put the tablets down and reprogrammed them to help with patient and family communication. I knew our nurse leaders were rounding on every patient."
After the first pandemic wave, "we felt it was important to go back to the [CipherHealth] technology again, because it's about structuring our process with the round, and using information in real time."
And as long as the feedback remains positive, Lenox Hill will keep the initiative going. "Our latest CMS Star rating came out in early May, and we went from a three-star to a four-star hospital," Leggio says.
One lesson learned: build more custom scripts for each specialty from the outset, Leggio says.
"We're doing this now, by service line, a bit [more] of a crafted, individualized script," he says.
Editor's note: This story has been updated 6/9/21 at 1:39pm.
App-based inpatient access rose more than 50% between 2018 and 2019.
More and more hospitals are enabling patients to access their electronic health records via online portals and mobile apps, according to the Office of the National Coordinator for Health Information Technology (ONC).
Seven in 10 hospitals now permit such access, according to a new ONC data brief evaluating conditions at the end of 2019.
Also that year, nearly every hospital enabled patients to electronically view their health information using a portal, ONC reported.
Three out of four hospitals allowed inpatients to view their clinical notes in the hospital's patient portal.
Small, rural, independent, and critical access hospitals had lower rates of access to this information, ONC said.
Rates of technology adoption were also highlighted in the report.
App-based inpatient access to information increased by more than 50% between 2018 and 2019, and the proportion of hospitals that let inpatients view their clinical notes increased by more than 30% between 2018 and 2019, ONC reported.
Among hospitals providing outpatient care, 97% let outpatients view their health information via a patient portal, 95% let them download their health information, and 75% enabled them to transmit their health information to a third party, according to the report.
Patients in outpatient settings can view their clinical notes at 82% of hospitals. Hospitals reported that 73% of patients in outpatient settings can access health information via apps.
Some variability on patient access exists within hospitals. Nine in 10 hospitals let patients view their health information across all outpatient care sites, and less than one in 10 hospitals enabled access across some outpatient sites.
The brand of EHR also varies within some hospitals. Three in 10 reported that they use different EHRs across practice sites. But the use of different EHRs yielded similar patient access to their data via apps as at hospitals that used the same EHR across outpatient sites.
But hospitals that used different EHRs across outpatient sites saw lower rates (3 in 4) of ability for patients to view their health information in a portal. Those hospitals that use the same EHR across outpatient sites saw all patients being able to access their health information via portals.
The challenge: How to take advantage of the data while ensuring ethical use, managing security, and protecting individual rights.
"COVID-19 was our wake-up call." So begins a new 46-page report from MITRE, a nonprofit research organization and think tank advising federal and state governments.
The report recommends a national strategy for digital health while assuring equity of new digitally powered services. The report is broken into six broad goals, supported by recommended objectives outlining actions to realize each goal.
Access, affordability, and utilization of universal broadband for everyone.
A sustainable health workforce that is prepared to use new technologies to deliver person-centered, integrated quality care.
Digital technologies empower individuals to safety and securely manage their health and well-being.
Data exchange architectures, application interfaces, and standards that put data, information, and education into the hands of those who need it, when they need it, reliably and securely.
A digital health ecosystem that delivers timely access to information to inform public health decision-making and action.
Integrated governance designed for the challenges of a digital health ecosystem.
While digital technologies can transform healthcare, they are opening up the promise of more equitable care for underrepresented and vulnerable populations, "little is known as yet about the quality of individual care" as healthcare has shifted to remote services, according to the report.
"What is known is that the health impacts of the pandemic were experienced quite unevenly, with the negative impact borne disproportionately by people of color and those with lower incomes," the report states. "The sets of systems for detecting and responding to what became a pandemic were shown to be vulnerable. It seems clear that more data can and should be available for use across various stakeholders—the individual, care providers, public health professionals, community-based organizations, and researchers. We now need to give attention to major considerations that may have been given lower priority during the pandemic, such as how to take advantage of the data while ensuring ethical use, managing security, and protecting individual rights."
MITRE also outlined seven guiding principles for its proposed strategy:
Empower the individual.
Every community, every person is important.
Collaborate and connect.
The end is improved health and well-being.
The system must learn and adapt.
Ensure privacy, security, and accountability.
Be bold.
"Prompt, decisive, strategic action is needed to ensure the resulting ecosystem is robust, efficient, and equitable," the report states. "If we let this opportunity pass, we risk worsening disparities in health by creating solutions that are only available to the privileged few."
'Strong magnetic forces' are pulling care back into brick-and-mortar, in-person settings, said telehealth champion Joseph Kvedar.
With pandemic case rates plummeting, telehealth has reached a fork in the road, and one of the industry's leaders is worried about it.
"The choices we make in the next few months, all around the industry, are going to pave the way for the next decade," said Joseph Kvedar, MD, chair of the American Telemedicine Association (ATA), who is also a professor of dermatology at Harvard Medical School.
"We might not be able to resist that strong magnetic force that draws us back to in-person, brick and mortar," Kvedar said, as his keynote address opened the 25th annual ATA conference, being held virtually throughout June.
"I keep hearing themes of things that are drawing [providers] back into brick and mortar," Kvedar said. "I constantly hear about things like 'our folks want to charge facility fees, or we have beds to fill.
"We are like hotels. We have to fill our beds to make a living.' And that's challenging us to think about how we go into this two-channel hybrid world."
Already, data Kvedar cited show a pullback from the rich mix of virtual visits that peaked during the height of the COVID-19 pandemic. From March to June 2020, 30% of all U.S. outpatient activity was conducted via telehealth, in contrast to 0.8% in the same time period during 2019, according to FAIR Health, an independent nonprofit that collects data for and manages the nation's largest database of privately billed health insurance claims and is entrusted with Medicare Parts A, B, and D claims data for 2013 to the present.
By August 2020, that activity had declined to 6%, and it remains at 5.9% as of February, Kvedar said. "So there does appear to be a leveling off, or a slight decrease" in such telehealth use, he added.
According to a different source, The Commonwealth Fund, 14% of outpatient visits were telehealth in April 2020, then leveled off at 7% in August 2020, a figure that has remained stable since then.
Kvedar said physician mindsets are part of that pullback to in-person care.
"I'm a dermatologist, so I see my share of acne patients," he said. "Acne is a perfectly great use case for telehealth. If I see a patient on telehealth, I'll offer them telehealth as a follow-up. If they come to me in the office with the same condition, and I'm not thinking about it, I probably offer them office-based care as a follow-up, because that's just the way my brain's working in the middle of a busy day."
Looming behind these statistics is the continuing doubt that payers will continue to cover the cost of telehealth visits. "The reimbursement future is uncertain," Kvedar said.
(Joseph Kvedar, MD, is the chair of the American Telemedicine Association. Photo courtesy of American Telemedicine Association.)
"This is a Medicare law that requires that Medicare patients be in a health profession shortage area to access healthcare via telehealth," Kvedar said. "If we don't get that changed, that will create an ice age for telehealth reimbursement."
If value-based reimbursement models expand, that will boost telehealth's prospects as well, he added.
Another concern of providers is that consumer tech companies will come in and "take over primary care," Kvedar said. "But yet I hear that [providers] are pulling back to brick and mortar, so how do we deal with that conundrum?"
Kvedar said telehealth advocates "need to be much more blunt and come up with financial reasons for providers to take the risks of going big, and telehealth going big in hybrid [settings], because right now there's this tendency to pull back."
In that vacuum of traditional provider leadership on the issue, national telehealth providers, such as Teladoc and Amwell, may become the dominant players in telehealth, Kvedar said. He cited data showing that telehealth care from local providers surged during the pandemic but has since swung back toward these national telehealth providers.
"It may very well be that you see the provider side to a brick-and-mortar dominant way of providing care," he said.
Kvedar urged ATA attendees to "advocate, advocate, advocate," writing letters to legislators calling for more access to telehealth. He also urged employees to similarly advocate to their employers, and for health plan members to encourage health plans "to reimburse in a straightforward, thoughtful way that isn't confusing telehealth."
He also urged telehealth technology suppliers to "double down on any innovation that increases our efficiency, whether it be symptom checkers, chatbots, home devices, social robots, anything that enables us to take a human being and use that individual's time across multiple patients or populations." He also reiterated the ATA's call for universal broadband service.
