UCSF Health examines its algorithms and more to address health inequities related to patient no-show processes, telehealth, and vaccinations.
As the coronavirus pandemic revealed significant disparities in health equity, executives at the University of California San Francisco turned to an interesting place to address this issue: technology. And what they discovered was fascinating. Bias built into algorithms, predictive models, and processes could be the root of some problems.
As other organizations seek to address this issue, "Plan to evaluate all healthcare initiatives or tools used to drive healthcare with the equity lens," said Sara Murray, associate chief medical information officer at UCSF Health.
At The Quest for Health Equity, a recent virtual event organized by the health IT association, Workgroup for Electronic Data Interchange (WEDI), Murray described how work that began before the pandemic to evaluate equity at UCSF Health was able to influence the healthcare organization's response to COVID-19.
Two initiatives underway at the pandemic's start helped to set the stage for UCSF Health's equity push. One reached fruition just as the pandemic started, and the other took shape last April.
Predictive Algorithms Can Get Blamed for Ensuing Discrimination
Predictive models can be guilty of explicit discrimination when personal characteristics such as ethnicity, financial class, religion, and body mass index are used to predict which patients are more likely to be no-shows for health-related appointments.
Certainly, no-shows are a major source of waste in U.S. healthcare. "We lose about a quarter of a million appointment slots annually, with really profound revenue impacts," Murray told the WEDI audience.
"If used for overbooking, [these characteristics] could result in healthcare resources being systematically diverted from individuals who are already marginalized," the blog stated.
To minimize the financial impact of no-shows, UCSF Health had been considering using an algorithm provided by its EHR vendor, Epic, to overbook appointments on a random basis, using some of the personal characteristics mentioned above, as well as other variables.
Yet overbooking also can lead to problems. "Say both patients show up," Murray said. "Now they're slotted into the same usually short time slot, and they're seen by an overworked and rushed provider. One might argue the appointment quality could decrease."
So UCSF Health decided to build an overbooking algorithm to simply include features of the appointment itself, such as time of day, day of week, and average lead time, as well as the patient's prior history of no-shows.
"By excluding all these sensitive features [such as ethnicity, financial class, religion, and body mass index], we were able to improve the model and basically perform identical to Epic," Murray said.
UCSF Health's data science team "has spent a fair amount of time evaluating commercial tools such as predictive models or artificial intelligence for trustworthiness," Murray said.
UCSF Prioritizes Patient-Positive Interventions
Ultimately, UCSF Health decided it would be best to use the no-show algorithm only for patient-positive interventions—"things we could do to help the patient make it to the appointment—reminders, outreach, sending them a Lyft," Murray said. "We weren't going to use it for booking. We piloted this in 12 departments, and had a modest improvement [a mean reduction of 9%] in no-shows."
Since this work took place, Epic has also made improvements in their overbooking model as well, Murray noted.
"We are not arguing that demographic features should never be represented in a model, as they can be critical predictors of health and access to healthcare," states the Health Affairs blog post. "The question is whether it is tolerable for demographic bias to be represented in a model, not just explicitly (as in the race/ethnicity input) but also implicitly (as in the prior no-show input), if that model may lead to action that negatively affects an individual patient."
Overbooking intervention "risks withdrawing resources from vulnerable patients" and is "ethically problematic," the blog post states. Instead, it recommends "patient-positive" interventions that may increase the likelihood a patient keeps a scheduled appointment, such as flexible appointment times, telehealth visits, or even assistance with transportation or childcare.
As Telehealth Use Surges, UCSF Health Addresses More Equity Issues
Speaking of telehealth, UCSF Health has also measured equity of telehealth utilization. In April 2020, the health system, like many others, saw a dramatic overall increase in telehealth utilization—a 16-fold increase in UCSF Health's case.
"We built health equity analytics in a dashboard that unfortunately illustrates disparities that we were concerned might exist," Murray said. "Telehealth is not being equitably used among non-English speaking patients, or among black patients in comparison with white patients, and there are some disparities related to age as well."
UCSF Health is taking action on these telehealth disparities. "This data is driving action," Murray said. "Our organization has said this is a key area of focus. And work is underway to establish the best interventions to start to close some of these access disparities."
COVID-19 Vaccination Process Highlights Additional Work Underway to Reduce Disparities
The current push to administer COVID-19 vaccinations is yet another focus currently at UCSF Health. Using their own employees as an initial group to study, "we noticed that disparities existed at every step of the process," said Sana Sweis, MS, director of analytics strategy at UCSF Health.
The largest disparity was gaps in rates of individuals scheduling their initial vaccination appointments, with persons of American Indian, Alaskan native, and Black ancestry trailing the Caucasian group.
A related disparity during vaccinations: individuals who failed to register for a patient portal account because they did not own a computer, or lacked necessary technical knowledge to use it properly, Sweis said.
"We targeted interventions that included phone call outreach, with a targeted focus, as well as education and assistance," she said. "In addition, we've set up walk-in clinics where patients can still come in to get vaccinated even if they do not have a patient portal account."
At the 60-day mark in the immunization process, UCSF Health executives noticed an increase in scheduling rates among all race ethnicity groups, but the largest increase was among American Indian, Alaska native, and Black groups.
"This illustrates the impact of the interventions on the initial process," Sweis said.
EU Uses Regulatory Oversight to Address Inequities
In places beyond the United States, regulatory oversight is being considered as a solution to address inequities. For example, the European Union has laid down seven requirements for lawful, ethical, and robust trustworthy AI. These requirements are:
Human agency and oversight
Technical robustness and safety
Privacy and data governance
Transparency
Diversity, non-discrimination, and fairness
Societal and environmental well-being
Accountability
Because much of this technology is not subject to regulation in this country, Murray said it is important for U.S. providers to evaluate technology for bias right now.
The Journal of AHIMA, the American Health Information Management Association, recently published a helpful guide to the eight exceptions to the information blocking rule incorporated into the Cures Act final rule.
These exceptions were necessary to allow the final rule to comply with other privacy laws and, in certain circumstances, to guard the integrity and security of electronic health record (her) systems, according to the guide's authors, Sharon Slivochka, RHIA, Cleveland Clinic director of electronic health record in health information management, and Diana Warner, MS, RHIA, CHPS, CPHI, FAHIMA, director of account management at security provider MRO.
The authors recommend steps for setting up an enterprise-wide information governance framework for a structured approach to compliance.
The eight exceptions explained in detail in the guide are:
Preventing harm
Privacy
Security
Infeasibility
Health IT performance
Content and manner
Fees
Licensing
The preventing harm exception recognizes, in ONC's words, "that the public interest in protecting patients and other persons against unreasonable risks of harm can justify practices that are likely to interfere with access, exchange, or use of EHI [electronic health information]." But such exceptions, if used, must be appropriately documented.
The content and manner exception provides clear and flexible direction to organizations regarding the scope of a request to access, exchange, or use of EHI.
The guide recommends one approach to develop and implement policies related to requests for EHI. The guide also offers definitions of key terms in the final rule: EHI, access, exchange, use, information blocking, and the United States Core Data for Interoperability. Finally, it includes sample documentation of an EHI request denial, and a list of resources.
Infectious Disease Connect helps clinicians choose the best antimicrobial therapies.
A company dedicated to bettering treatment of infectious diseases and antimicrobial stewardship, which also happens to be backed by a major academic medical center, has garnered top scores from KLAS Research, which judged the company based on service quality and superior high customer satisfaction in its category.
ID Connect, which recently combined with ILÚM Health Solutions decision support technology from Merck, gives hospitals timely, telemedicine-enabled consultations with infectious disease experts. ID Connect also offers ILÚM Insight to assist clinicians in choosing the most appropriate antimicrobial therapy while managing toxicity, price, resistance to drugs, and infection transmission. Assisted by machine learning algorithms, this technology associates a patient’s demographics, history of medication use and hospitalizations, as well as other data to generate treatment recommendations tailored to individual patients.
"Antimicrobial stewardship is now required by the Centers for Medicare and Medicaid Services," said Tyson Mehlhoff, research director of emerging technologies at KLAS, in a news release. KLAS measures more than 400 vendors and 750 products and services. "In our early conversations with provider organizations," said Mehlhoff, the key outcomes they look for in antimicrobial stewardship and ID specialist partners are improvements in clinical outcomes, time savings, and safety, while remaining financially viable."
"In the face of a global pandemic and a growing shortage of infectious disease experts nationwide, ID Connect has never been a more important partner to the hospitals and patients we serve,” said ID Connect President and CEO David Zynn.
Having been deployed in more than 30 medical sites in seven states, ID Connect calculates that with its help, its customers have reduced patient transfers by up to 40%, cut antibiotic use by 30%, and reduced days of treatment per 1,000 patients by 40%.
In a recent KLAS report, using scores based entirely on customer opinions, ratings, and experience, ID Connect gained an overall score of 96.9 for service, with 80% of its customers sharing that they were “highly satisfied” and 20% “satisfied.” ILÚM Insight's platform had an overall score of 96, with 80% of those surveyed “highly satisfied” and 20% “satisfied.”
Devices enable LifeBridge to move scanning closer to COVID-19 patients, limit their movement, and accelerate diagnoses.
Point-of-care ultrasound has found an important place in the toolkit of clinicians fighting the spread and effects of COVID-19, according to the chief innovation officer of Baltimore-based LifeBridge Health.
A new generation of handheld ultrasound devices, including the Butterfly iQ, allows faster assessment of pulmonary symptoms of the disease, while minimizing the spread of COVID-19 by reducing the need to move patients and equipment during the treatment process.
LifeBridge Health physicians are now using this ultrasound technology in the ICU to confirm COVID-related conditions such as pleural effusion, a build-up of excess fluid between the layers of the pleura outside the lungs, says Daniel J. Durand, MD, chief innovation officer and chair of radiology at the health system.
A handheld probe delivers images directly to the physician's phone or tablet through a wired connection. No additional equipment is used. "It puts the technology in the hands of a doctor that can make a difference for the patient," Durand says.
LifeBridge has more than 20 such devices in use across its four hospitals. "We've done thousands of exams at this point," he says.
Handheld Devices Replace More Expensive Options
Ultrasound use cases can be thought of as falling into two broad categories—conventional machines that allow a radiologist to render a broad range of final diagnoses, and "point of care" devices that allow a frontline clinician to perform a procedure or to initially investigate a potential diagnosis they suspect. The pandemic highlighted the usefulness of the latter category, Durand says.
"We were going to have to buy certain types of point-of-care ultrasound devices to target at specific uses," he says. "You always have to have those around for certain types of procedures, or triage-type things."
By incorporating these devices into the mix, LifeBridge was able to replace older, more expensive units for less money, and gain extra capabilities and uses.
"We're really thinking about democratizing imaging technology and bringing it closer to the patient," Durand says. "If that means that a non-radiologist is doing the imaging, that's fine. What matters is that we're getting more high-quality information and images on the patient quicker, improving diagnosis, and improving their care."
Prior to the arrival of point-of-care ultrasound, clinicians were using more expensive and outdated technology to assist in tasks such as inserting an IV or central line. "Frontline physicians are looking a lot more at the human body than they were before," Durand says.
ICUs in particular are one location where point-of-care ultrasound has thrived during the pandemic at LifeBridge.
Rather than asking another department to bring in imaging equipment and waiting for a diagnosis, Durand says the hand-held device enables clinicians to act in real time,
"It's difficult to quantify the potential impact of Butterfly-type devices on lowering COVID-19 mortality," he says. "You can do it with things that have been studied forever, like mammograms, but it takes [something] like 10 to 20 years."
Despite that, the pandemic demanded new approaches to care. "We all had to think outside the box, and we didn't always have time to design an elegant study, because we were all literally fighting for our lives," Durand says.
"There's plenty of information that shows that ultrasound technology can save lives in the right setting," he says. One such study at Temple University found that point-of-care ultrasound was more sensitive than chest x-rays at identifying COVID-19.
Still, "It's more about the access and the democratization [of ultrasound] and less about being able to say, 'It saved X number of lives,' for better or worse," Durand says.
"How Could This Transform Care?"
Compared to the cost of previous ultrasound gear, the new generation is "extremely low, which almost made us suspicious," Durand says.
Anticipating pushback from cardiologists, anesthesiologists, and ICU personnel, LifeBridge briefed and consulted with them well in advance of deploying the handheld ultrasound devices, Durand says.
"We all thought together, how could this transform care?" he says. "We all agreed and were enthusiastic. A couple of physicians had just purchased them on their own, and were using them at ambulatory offices outside of LifeBridge."
Part of the distinction with this new approach is that it utilizes the screen of the tablet or mobile phone that clinicians already carry and utilize, he adds.
Another cost-cutting measure is in the way the hardware is built, being entirely solid-state complementary metal oxide semiconductor, making it much less susceptible to breakage.
"Ultrasound probes get dropped all the time," Durand says. "There are many instances where the probes in other machines are prone to breaking and actually cost more than the entire Butterfly device."
Although even silicon-based probes are susceptible to breakage, they are much hardier than older, crystal-based ultrasound probes, Durand says.
One other less tangible benefit of Butterfly is its intuitive user interface, Durand says.
"It's from that sort of Steve Jobs school of thought that clearly sat down and reinvented something from scratch and then had a lot of human factors and engineers and designers in on it," he says.
Could Hand-Held Ultrasounds Become as Ubiquitous as Stethoscopes?
Eventually, point-of-care ultrasound will incorporate artificial intelligence algorithms that can provide ever more sophisticated analyses of the ultrasound, Durand says.
"It can do all that in a way that's far more standardized than just us listening to something through some headphones," he says. Plus, the chaotic conditions of COVID-19-era hospitals increased the noise interfering with using a traditional stethoscope.
"There's absolutely no reason that every doctor shouldn't know how to use these at some point in the future," Durand says.
Despite this, LifeBridge has no plans to deploy a point-of-care ultrasound to every doctor—yet. "Certainly, people have talked about it," Durand says. "But that's a big price tag. Medical schools are thinking in the right direction." More study over time will help make the case for it to be standard issue, he adds.
Potential Impact on the Radiology Profession
These portable devices have some wondering about their potential impact on the future of the radiology profession. Similar concerns arose when teleradiology became popular, and Durand points out that other professions have faced similar apprehensions due to innovation.
"A lot of people said that accountants were going to be out of business once TurboTax came out," Durand says. "In fact, accountants make more money today than they did in the mid-1980s, and are happier today."
In addition, says Durand, radiologists have had better wage growth and lower rates of burnout than other physicians, because they work more as consultants to physicians, Durand says. As point-of care ultrasound becomes more popular, "I think you might see a similar phenomenon."
Editor's note: This story was revised on Feb. 23 to clarify the FDA's definition of diagnostic quality and on Feb. 24 to further clarify the different types of ultrasound devices.
Individual and population health improvements is the aim of new Consortium for State and Regional Interoperability, offering a new way to share health information.
Offering a new way for health information exchange providers to share information, the Consortium for State and Regional Interoperability (CSRI) is the newest organization dedicated to robust electronic health data interoperability.
CSRI members include:
CRISP, with member organizations from Maryland, the District of Columbia, and West Virginia
Colorado Regional Health Information Organization (CORHIO)
CyncHealth, with member organizations from Nebraska and Iowa
Health Current, serving Arizona
Indiana Health Information Exchange (IHIE)
Manifest MedEx, serving California
The recent announcement of CSRI described these organizations as successful nonprofit HIEs with robust technology infrastructure, data stewardship expertise, and far-reaching data networks.
"CSRI is well-positioned to leverage economies of scale on projects that have the potential to move the interoperability needle in a big way," said Morgan Honea, CEO of CORHIO. "I … look forward to developing and delivering HIT that can help solve significant data problems."
CSRI aims to strengthen data exchange capabilities in several ways:
Develop solutions that providers, health plans, Medicaid programs, and public health departments can use across state lines and federal initiatives
Advance initiatives promoting robust, scalable health data exchange nationwide
Deliver insights so that federal agencies may advise HIEs on critical decisions, relieve administrative burden, and accelerate innovation.
Among the services and data its member organizations already provide during the current pandemic are supporting ordering and scheduling of tests, identification of high-risk patients, hospital bed capacity prediction, and dashboards bringing together test results, mortality, and hospitalization data. Other services help match test results with patient data to support contact tracing.
Expanding public-private partnerships, greater data interoperability, more robust supply chains, and streamlining regulations are among the suggestions.
A blue-ribbon panel of experts from all sectors of healthcare recommended a coordinated national response to the COVID-19 crisis, including making permanent certain measures adopted during the pandemic, including allowing providers to practice medicine where they are needed most, without burdensome concerns about state licensure.
"The COVID-19 pandemic and immediate response has exposed vulnerabilities in the nation's ability to handle a national-scale crisis," said Mark McClellan, MD, PhD, founding director of the Robert J. Margolis Center for Health Policy at Duke University. "A positive sign was the organizations and people in the healthcare space who typically are competitors showing willingness to work together for the good of all Americans."
The study originated before the pandemic began, and was focused on responding better to disasters and catastrophes in general. Once the pandemic struck, "we realized that we needed to expand the scope of what we were doing, and to bring in even more expert voices," said Mary R. Grealey, president of the HLC.
In response, HLC launched a partnership with the Duke-Margolis Center for Health Policy to assess lessons learned from COVID-19 in 2020, which led to the new initiative and report.
Starting in the summer, initiative leaders created three specific work streams on care delivery, data and evidence generation, and supply chain innovation, according to Calvin Schmidt, MBA, senior vice president and worldwide leader of government affairs and policy at Johnson & Johnson, who chaired this initiative for HLC.
"What we are trying to do is lay out a framework in which we will be less reliant on the extraordinary and the heroic in times of crisis, because we will be better prepared for the unthinkable in the future," Schmidt said during a press briefing.
"We should never again have a situation where states and healthcare providers are feverishly competing against each other for the critical supplies that they need," Schmidt said.
Health Inequities Faced During Crisis 'Must Never Reoccur'
Schmidt also said the report makes clear that the healthcare inequities exacerbated during the COVID-19 crisis must never occur again, and that healthcare systems must be equipped with metrics and a commitment to direct resources where they are needed the most.
Another goal of the report is to promote real-time data collection, reporting, and sharing. In addition, the report recommends leveraging interoperability of health information technology and public health data systems.
Judy Faulkner, founder and CEO of Epic and co-chair of the initiative's workgroup on data and evidence generation, expressed concern about hospitals that are on outdated versions of their electronic health record software. "It is the responsibility of that system, as well as the vendors, to make sure that they too can be able to interoperate," Faulkner said. She added that public health organizations need to be "much more modernized" to be able to interoperate with other healthcare organizations.
The report also recommends creation of an ongoing funding stream to support needed data systems in federal, state, tribal, territorial, and local public health systems, such as immunization systems, including supporting staff who maintain and update these systems, and who make decisions informed by these data systems.
Yet another objective is to strengthen capacity and transparency of the U.S. healthcare supply chain. "Fragile supply chains that depend on single sources outside the country, those were a challenge in many parts of the pandemic response," McClellan said.
As part of this recommendation, the report advocates strengthening stockpiles and preventing supply shocks by creating standards for what should be stored in stockpiles, both in quantity and how long particular supplies should be stockpiled before being replaced.
Supply shocks can be minimized by developing mechanisms for collecting supply chain information to identify vulnerabilities in a manner that protects confidential commercial information and trade secrets, the report said.
Strengthening Public-Private Collaborations
Many of the steps described in the report require public funding, McClellan said. Others will be privately funded, and "a lot of them are shared," he added. For example, telehealth requires some public investments such as improving infrastructure, but the report also describes many ways the private sector is taking steps, and with federal collaboration could take more, to support new care models, such as alternative payment mechanisms.
Other recommendations would create regulatory streamlining and reforms and uniform waivers to enable all levels of government to respond to emergencies with fewer regulatory impediments.
Antitrust laws that prohibit providers sharing information with other providers about the fact that they need 10 times as many diagnostic testing supplies, or 1,000 times as much protective equipment, must be waived during times of crisis, McClellan said.
"Information that wouldn't be [normally] shared needs to be shared with the federal government," he added.
Among the contributors and participants in the report are Aetna, the American College of Emergency Physicians, the American Medical Association, America's Health Insurance Plans, Anthem, Ascension, Baxter, BlueCross BlueShield of North Carolina, BlueCross BlueShield of Tennessee, Bristol Myers Squibb, Business Roundtable, the Centers for Disease Control and Prevention, Cleveland Clinic, Epic, Federation of American Hospitals, HCA Healthcare, Johnson & Johnson, Labcorp, Mayo Clinic, McKesson, Merck, Mount Sinai Health System, the National Governors Association, New York‒Presbyterian Hospital, NorthShore University HealthSystem, SSM Health, Surescripts, The Joint Commission, The Sequoia Project, the U.S. Department of Health and Human Services, and numerous others, totaling 106 organizations.
Agency hasn't received reports of adverse events during emergency use, but risks remain.
Use of ventilator splitters, a lifesaver during a pandemic that overtaxed existing ventilator supplies, remains a concern of the U.S. Food and Drug Administration (FDA), according to an agency advisory issued last week.
So far, the FDA has not received any reports of adverse events related to use of ventilator splitters. The FDA sanctioned their use during the COVID-19 pandemic due to a general shortage of ventilators.
"Recent literature describes risks that may be associated with using certain ventilator splitters," the FDA advisory stated. Challenges include the need to continually balance differences in respiratory mechanics of both co-vented patients, the need for paralysis and deep sedation to prevent asynchrony, and possible lung injury when swinging air from one co-vented patient to another, among other issues.
The FDA urged providers to consider non-invasive ventilation, such as high-flow nasal oxygen or non-invasive positive pressure ventilation, as a first option, prior to using an authorized ventilator splitter.
In the event that invasive ventilation with such splitters is the only option, the FDA offered the following recommendations:
Limit sharing of ventilation to two patients
Try to match patients based on similar ventilatory requirements
Limit duration of sharing ventilation to 48 hours
If possible, reserve at least one single patient ventilator for emergencies, or to wean a patient off ventilation support
Ventilator splitters divide the gas flow from one mechanical ventilator to deliver a tidal volume to more than one patient, and collect expiration from these patients.
During the pandemic, clinicians gained experience with shared ventilators, and along with research conducted on this sharing, the FDA said much knowledge has been gained over this short time on potential risks and benefits of shared use.
Patient records, including x-rays, pathology reports, and full PHI are vulnerable to these attacks.
Each of 30 popular mobile health applications are vulnerable to attacks via their application program interfaces (APIs), according to findings released last week by a security hacker and author, working with a threat protection technology company.
The study, All That We Let In, raises concerns that increasing reliance on mobile health apps during the pandemic is drawing threat actors to mobile health applications as their preferred attack surface.
The attacks described can permit unauthorized access to full patient records, including protected health information (PHI) and personally identifiable information.
"There will always be vulnerabilities in code so long as humans are writing it," said Alissa Knight, researcher and author of the report. "Humans are fallible. But I didn't expect…all of the APIs to be vulnerable to broken object level authorization vulnerabilities, allowing me to access patient reports, x-rays, pathology repots, and full PHI records in their database. The problem is clearly systemic."
The study examined 30 popular mobile health apps. Each app has been downloaded an average of 772,619 times, and Knight estimates that the 30 apps examined expose at least 23 million mobile health users.
Of the 30 popular apps Knight tested, 77% contained hardcoded API keys, some of which do not expire, and 7% contained hardcoded usernames and passwords. The study found that 7% of the API keys belonged to third-party payment processors that warn against hardcoding their secret keys in plain text.
The total number of users exposed by the 318,000 mobile health apps now available on major app stores is likely far greater, according to Knight.
Mobile health platform developers, and all those using these applications, should recognize that synthetic traffic to mobile APIs is an issue, secure the development process, and protect against so-called "machine in the middle attacks" via certificate pinning, the report recommends.
Half of the records accessed by such attacks contained names, social security numbers, addresses, birthdates, allergies, medications, and other sensitive data for patients, the report stated.
The publisher of the report is Approov, which provides a multi-factor, end-to-end mobile API security solution that complements identity management, endpoint, and device protection to lock down proper API usage.
Pandemic-boosted telehealth will persist and provide a reliable revenue stream to rural health systems, yet infrastructure investment is needed to boost Internet access.
The last few weeks have brought good news and bad news for the health of rural America. On a positive note, the Federal Communications Commission (FCC) awarded $9.2 billion to expand broadband access to more than 10 million rural Americans to close the digital divide. At the same time, rural Americans may be among the last to receive the COVID-19 vaccine due to logistical challenges, underfunded and overburdened hospitals, and skepticism among rural populations.
Azalea Health is a cloud-based electronic health records provider serving over 800 clinics and critical access hospitals across rural America. CEO Baha Zeidan recently answered some questions from HealthLeaders about what needs to happen next to move rural broadband closer to the top of the priority list to improve rural health in America as the pandemic continues.
HealthLeaders: Since the shortfall of infrastructure certainly is some multiple of $9.2 billion, how much difference can this current FCC initiative make?
Zeidan: The recent FCC initiative will deliver high-speed broadband to 5.2 million. However, this still leaves around 35 million without coverage. So while it’s an important step forward, it’s clearly not enough to ensure everybody has equal access to the Internet.
HL: How will this FCC funding impact healthcare delivery in rural America?
Zeidan: A connected community is a healthier community. Internet access allows people to educate themselves on their health and connect with doctors when they need to. Of course, online health misinformation is still a challenge, but at least people can contact their doctors for clarity, or research the side effects of their medications. Broadband can also help rural health providers with recruiting, many of whom suffer from staffing shortages. Finally, it’s worth noting that telehealth will likely remain a staple of care following the pandemic. Telehealth allows healthcare providers to reach patients that would otherwise have to drive long distances to reach a clinic, saving time and energy and lowering a critical barrier to care. It also gives providers a reliable revenue stream as they recover from the financial fallout of suspending elective procedures during the pandemic. This FCC funding will help make telehealth access equitable.
Baha Zeidan, CEO, Azalea Health (Photo courtesy of Azalea Health)
HL: What do you think of the FCC’s plans to expand rural broadband in general?
Zeidan: I applaud the FCC for taking steps to expand rural broadband access, which couldn’t come at a more critical time. Telehealth has been a lifeline through the pandemic, but far too many lack the connectivity to take advantage of this technology. Moving forward, telehealth will be a vital source of healthcare for patients who would otherwise have to travel for a half hour of more to visit a hospital or clinic, enabling these patients to be more engaged in their health. It will also be a way for rural hospitals, many of whom were already struggling financially before the pandemic, to reach new patients and boost their revenues to stay open and continue serving their often vulnerable communities.
HL: Given the renewed push to satellite-based broadband, such as SpaceX’s Starlink, does the current mix of wired and wireless broadband make sense? Can systems such as Starlink provide meaningful, affordable Internet access to rural communities?
Zeidan: The FCC certainly thinks satellite systems like Starlink can work—they gave SpaceX almost $900 million. But it’s not a sure bet. Space-based Internet has been attempted and failed in the past, so there’s no guarantee it will work this time. Assuming they can successfully deploy the thousands of satellites needed to provide reliable Internet, you would still need to install expensive devices across rural America to receive and transmit the data to the satellites. That said, I think it’s important that we encourage innovations for people that have been left behind. Satellites can be part of the solution, but I don’t think we should give up on tried-and-true broadband technologies that haven’t made it to rural American due to lack of investment.
HL: To what degree does this FCC funding provide solutions for both healthcare services and patients? What is the mix of this funding, relative to both stakeholders?
Zeidan: The FCC’s funding announcement doesn’t specify the locations that will receive broadband coverage through the funding. But regardless of where the broadband is expanded to, both patients and healthcare providers stand to benefit as more people will be able to stay connected with their doctors via telehealth.
HL: Urban ISPs (Internet Service Providers) are doing VERY well. (For example, Comcast had net income of more than $13 billion in 2019.) To what degree is the failure of rural broadband's promise an inability of regulators to compel mega-profitable urban ISPs to invest in rural markets?
Zeidan: The government absolutely needs to step in and subsidize ISPs to serve rural areas. And there’s precedent for this too. In the past, the government subsidized energy companies to install power lines in rural areas. The problem is that rural telecommunications infrastructure is inherently unprofitable. There is simply too much space to cover and not enough users to pay for the miles and miles of wires that need to be laid. However, it’s in the government’s own interest to invest in rural broadband. In the digital age, economies depend on broadband access. With remote work now viable following the pandemic, broadband access could attract people from busy urban areas to the quiet solitude of rural areas. And, as more rural businesses are enabled to thrive, governments will see increased tax revenue as a result.
HL: How should health IT address the challenges of vaccine distribution in rural America?
Zeidan: Rural America cannot afford to be an afterthought for vaccination. These communities have high rates of comorbidities that increase their risk of life-threatening illness from Covid-19, and their hospitals are being overwhelmed by Covid-19 patients. The health system is fragile, and the longer hospitals need to delay elective procedures and routine care to save capacity, the more hospitals will be forced to close. While it’s true that rural areas pose unique challenges for vaccination, health IT can be part of the solution. Data sharing on health information exchanges can help state-level public health officials track who has been vaccinated, who should be prioritized for vaccination, and which hospitals serve higher numbers of vulnerable patients. Telehealth and mobile health apps can support outreach to at-risk patients and dispel misinformation about vaccines. And cloud-based access to electronic health records can support the deployment of mobile, pop-up vaccination clinics.”
UPMC CIO juggles priorities with vaccination rollout and April 5 info blocking rule deadline.
As new rules take effect April 5 to prevent information blocking by hospitals, University of Pittsburgh Medical Center (UPMC), a $21 billion nonprofit headquartered in Pittsburgh, will be one of the larger health systems scrutinized early on for compliance. Like other organizations, UPMC has had to juggle multiple IT priorities to meet the changing healthcare landscape.
Ed McCallister, senior vice president and chief information officer of UPMC, leads a team of more than 2,000 professionals in UPMC's Information Services Division. HealthLeaders spoke with McAllister about UPMC's preparedness for the April 5 information blocking deadline, vaccination scheduling, and the eventual migration of its data centers to the cloud.
Following are excerpts from the interview, lightly edited for space and clarity. We invite you to read Part 1 of this interview, where McCallister explores how remote working and telehealth have forever changed IT dynamics.
HealthLeaders: How much work have you had to do to get ready for the information blocking rule?
Ed McCallister: The pandemic definitely created a challenge around it because of resources and priorities. We were preparing for it, we were taking the steps, and I'm comfortable that we'll be able to meet the requirements set forth around access to information. But it absolutely presented a challenge. When the rules were set, I didn't think that we'd have a development team working on a vaccine scheduling system, a vast tracking system. But I'm not uncomfortable that we won't be ready for it. Again, we have some time. And I think we've been thinking about it for a long time. It's that balance between providing our patients and our members of our health plan information that's necessary for them to be able to best manage their care with the HIPAA rules, and the privacy rules, as well as it's an ever-challenging world around cybersecurity.
Ed McCallister, senior vice president and chief information officer, UPMC (Photo courtesy of UPMC)
HL: How is vaccination scheduling going?
McCallister: You build when you need to, but you buy when you need to. So we partnered with a company to do biometrics called CERTIFY Global, and we collected over 1 million fingerprints, pre-pandemic, and it was going very smoothly. You walk in, you register yourself, you have a seat, and it worked out very well. We're using that vendor right now for the platform on our vaccine scheduling system.
HL: More providers are moving much of their IT infrastructure into the cloud—not just Microsoft 365—but also for electronic health record (EHR) infrastructure. Where are you on that journey?
McCallister: We're not there. We're not EHR in the cloud right now. What we have invested in is our clinical analytics platform. Traditionally, it was called a data warehouse, and we approached it more as a vault for data. We're using the cloud extensively around our data analytics efforts.
Our clinicians stick the patient directly in the middle. [Chief Health Care Data and Analytics Officer Oscar Marroquin, MD, FAAC] is doing some really great things around our clinical analytics. My job is to make sure that he has the platform and the information, [so] that he can do what he needs to do. And again, a majority of it is done in the cloud. It's around EHRs. It's around, how do we proactively treat patients? Eventually, we'll have that as part of the care where the AI and the analytics are coming into play, and they're going to drive more and more in medicine. Oscar's at the forefront of doing that for us.
HL: Do you think cloud data centers are the inevitable future? A lot of hospitals seem to be interested in getting out of the business of running data centers.
McCallister: I'm at the front of the line leading us out of the data center business. I would envision that the Googles, the AWSs [Amazon Web Services], the Amazons, the Microsofts, that's the business that they're in, running data centers. We actually moved out of our [old] data center. We had some aging data centers. Our primary data center was 22 years old. Our backup data center was 30 years old. Not only that, they were only a couple miles apart.
I guess it's been five years, we moved to a colocation arrangement with a company called Involta, and they’ve been a very good partner in what we're doing, so that will be our primary data center. Our data center here in Pittsburgh will be our backup site. But again, it's a hybrid model where we have the data centers, we don't own the data center. We lease the data center space. They help us manage the data center. We can get back to the business of taking care of patients, because that's what we do at UPMC. So I absolutely would 100% agree with being out of the data center business is where we're headed, and it is a good thing.
HL: How do you see information technology rising to the challenge of the next phase of the pandemic?
McCallister: The traditional IT model was to receive the specifications requirements from a business leader, and then you enable that great business strategy. Now, not only have we sat shoulder-to-shoulder with the business leaders, we've actually taken the lead in many areas and been able to educate the business leaders and given them options on how do we best do something. Before, we were more an enabler of a strategy; we now create the strategy, and in the future, technology will be able to lead versus follow. This accelerated a process that was happening for a long period of time.
