#ViVE2022 panel addresses opioid epidemic

The new ViVE 2022 healthcare information technology conference now taking place in Miami Beach is a giddy whirlwind of delegates taking maskless selfies after surviving 2-years of COVID-19 lockdown.

This merger of meetings from the College of Health Information Management Executives (CHIME) and the HLTH digital marketplace offers fluorescent colours and images, breathless pitches from healthcare start-ups and seemingly endless repetitions of health IT’s current favourite buzz words and phrases (‘transformation’, ‘value-based care’ and ‘equity’ ranking high on the list).

But it also offers sessions where respected clinicians discuss how digital health can be brought to bear on some of North America’s most significant healthcare issues – the opioid epidemic being a prime example.

On the first day of ViVE, a panel of five experts provided an update from the front-lines on an epidemic which took 100,000 lives in the US in the last year, an increase of 28.5% over the previous year. One of the panelists, Dr. Scott Weiner, chief of health policy and public health at Brigham and Women’s Hospital, Boston noted the number of overdoses associated with opioids has risen over the last two years even though the number opioids being prescribed has actually dropped significantly – pointing to the impact of the COVID-19 pandemic – and mental health issues associated with being isolated.

While acknowledging the role fentanyl and the illicit supply of synethic opioids is currently playing in the pandemic, much of the presentation at ViVE focused on how digital health is helping encourage and monitor appropriate prescribing in acute-care settings post-surgery.

Patricia Lavely, VP and Chief Information and Digital Officer in the Health District of Palm Beach County, described reported results from a CHIME survey of these opioid-use reduction technologies and strategies.

The results from 2021 showed that:

  • 100% of organizations had electronic prescribing of controlled substances
  • 92% had order set maintenance to offer non-opioid options
  • 90% had an eprescribing modules connected to the State or regional Prescription Drug Monitoring Program (PDMP)

Other data from the survey showed organizations reported that this eprescribing connectivity had the highest impact on opioid-use reduction. It was also noted that CHIME has an Opioid Task Force to offer resources for its members but many hospitals were not yet taking advantage of all the health IT tools available and doing all the “easy things” they could do to help deal with this issue.

Lavely said despite the use of technology and electronic health records, opioid overdose deaths continue to rise at a “horrific pace” and that much more needs to be done to identify at-risk patients and those with an opioid use disorder.

Panelist Dr. Matt Sullivan, chief information officer at Atrium Health, noted that while health informatics specialists have huge amounts of data on patients in association with opioid use more needs to be done to analyze and share what can be learned from this information.

A discussion of existing patient risk scores concluded their usefulness was limited because they depend on patients giving honest answers and also fail to take into account many other variables besides prescription drug use associated with the risk of having a substance use disorder.

Panelists acknowledged the importance of harm reduction and especially the use of naloxone to reduce opioid deaths and also said more must be done in healthcare institutions to reduce the stigma against drug use.

“One thing we can take away from this session (on the opioid epidemic) is that harm reduction and naloxone will save lives,” said Dr. Sean Kelly, chief medical officer of WELL Heath and moderator of the session.

It was acknowledged at the start of the session that many patients need adequate pain relief and may fail to obtain it. But as panelist Dr. Greg Polston, chief informaticist and associate medical director UC San Diego Health noted more than once, misprescribing opioids is something that can lead to a clinician losing their license.

Overall it was noted that while clinicians and those working in health IT are doing a lot to help deal with the opioid epidemic more can be done even though many of the variables involved remain out of their control.

Opioid Panel at ViVE 2022

Privacy vs. the public good: The delicate health data balance (#HIMSSEurope20 – Day 2)

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“Trust and transparency.”

One couldn’t write a summary of the second day of proceedings at the virtual HIMSS Europe 2020 conference without starting with those words. The phrase was used repeatedly by speakers during keynote sessions of the day which focused squarely on health data and how it needs to be shared to support population health and improve health outcomes.

Much of the unspoken framework for the discussion was provided by legislation specific to the European Union governing the collection and sharing of patient data, especially the General Data Protection Regulation adopted in 2018. But common themes of the need for governments and health organizations to have the trust of patients and be transparent in their planned uses of personal health data would certainly resonate with North American audiences.

“Trust is not something you can change in weeks or months. You must show again and again that health data is protected and will be used judiciously,” said Dr. Ran Balicer, professor of public health and founder of the Clalit Institute in Israel.

While all sessions stressed this theme it was clear the sentiment of this particular conference audience favoured data-sharing for secondary purposes. Polled on whether to enable efficient global data collaborations, privacy regulations should be temporarily adjusted and lowered in times of pandemics and health crises, 46% of respondents replied positively, with others evenly split between disagreeing and not knowing.

“Our new world in the use of data … really depends on the free availability and interchange of data between different organizations” said Dr. Charles Alessi, chief clinical officer for HIMSS. “Data is the fuel for change in our health care system and we want to make sure we have good access to that data,” reiterated Petra Wilson, European program director for the Personal Connected Health Alliance.

Sessions on population health and precision health demonstrated the scope of health data has broadened significantly in recent years to incorporate not just lifestyle data but also information on the social determinants of health. Dr. Mahmood Adil, medical director of Public Health Scotland, gave a brief but compelling presentation about how Scotland is gathering these data regionally and using it to improve health outcomes.

While a discussion on precision health and the use of algorithms to support personally driven decision support and provide proactive care sounded futuristic, Dr. Balicer says this is already a reality.

As has been the case since the beginning of the week, the COVID-19 pandemic coloured the nature of proceedings. Once again, the emphasis was on the positive impact of the pandemic – in this instance, evidence that public willingness to share their personal health data appears to have increased since the onset of the pandemic to speed tracking and help in vaccine development.

Mary Harney, former minister of health and children in Ireland, said people should view the sharing of their personal health data as an investment in themselves as it would contribute to initiatives resulting in better health.

Following another day once again very short on direct patient participation, the sessions ended on a positive note for patients.

“Keep fighting for your data,” said Dr. Erwin Böttinger, professor and chair of the Digital Health Center, Hasso Plattner Institute, reiterating a point made earlier by Dr. Mark Davis, chief medical officer for IBM Watson Health who said it was fundamentally important for individuals to have control of their own health data.

(Photo: Helsinki Central Station – in honour of the city where this conference was to be held)

Patient portals – windows to health care

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Patient portals that offer the ability to access information from a hospital or physician provide a valuable window to at least part of a person’s health and care. But such portals remain unavailable to many and often fall short of being comprehensive.

Those were conclusions that could be drawn from a lively chat on Twitter that I helped coordinate on behalf of Health Quality Ontario (HQO) on March 20. Hosted by HQO Interim President and CEO Anna Greenberg (@AnnaGreenbergON) and respected patient advisor Alies Maybee (@amaybee), at #HQOchat the discussion saw more than 500 tweets from almost 100 participants over the course of an hour.

However, that’s just part of the story as tweets on the topic continue to be seen on the @HQOntario Twitter account days after the chat. The topic of configuring patient portals also promoted a lively exchange between a largely Ontario-based group of participants on Twitter earlier this year.

Greenberg and Maybee set the stage for the chat in a background blog that also framed the debate by asking about people’s experiences with portals, the scope of portals and their functionality. The portal discussion inevitably overlapped a discussion on electronic access to one’s health record even though this is often not a function of hospital-based portals.

The chat involved many patients, physicians, representatives from one of largest patient portals in the province (@MyUHNPatientPortal), Canada Health Infoway (@Infoway), other senior HQO staff, and others including representatives of quality care organizations and the @MyOpenNotes initiative.

As Ontario currently has no province-wide patient portal initiative (unlike Quebec, Nova Scotia and Alberta) it was not surprising that patients described a wide range of experiences with the portals. While some people talked of having up to six different portals, others said they had no access to such a portal.

Many expressed thanks for having access to what a patient portal has to offer. One of the most positively received tweets came from a specialist at the hepatology clinic at UHN who stated:

Our staff have embraced it (clinicians and support staff): fewer calls: patients happier: less printing of results for patients: patients pointing out errors. Overall very positive

Others felt the experience fell short of expectations. To quote one comment:

I have had access to a patient portal and while the concept is very exciting, I have been disappointed with the reality. The patient portal I have used has a limited # of parts of my record and lacks notes and referrals etc. so it is not a complete picture 

And Maybee commented:

I found that the hospital needs to update appointments right away. I went for an appointment listed on the portal, waited 45 mins until someone told me “Oh, that was cancelled but we are behind a lot on updating the portal.” Way to discourage us! 

The chat closed with a discussion of whether patients should be able to access their own laboratory or other test results before these have been discussed with their physician and the response was – with a few dissenters and caveats – an overwhelming ‘yes’. The same was true on the issue of whether patients should have access to their physician’s notes.

Dr. Irfan Dhalla (@IrfanDhalla), a general internist and VP at HQO commented:

Good news is that overwhelming majority of physicians are supportive of patients having access to their own notes. Some express nervousness, but usually this goes away after some experience.

It is clear that recent efforts to improve the availability and functionality of patient portals are paying dividends. But while they are useful tools, these portals managed by hospitals, clinics or medical record vendors are no answer for patients who seek a complete record of their health and care that they control.

And as another Canadian-lead discussion on Twitter a week ago makes quite clear, the numerous barriers facing patients who want to easily correct errors in their own medical record show how far the culture and environment need to change to truly make the new digital health environment patient-centred.

As Maybee commented:

We need to see the great stuff in portals all in one place — perhaps an aggregator?

To which another participant commented:

Bingo – I’m going to go one step further (sorry) but what I really want is one record, regardless of hospital, organization or discipline. If I go to 6 hospitals, I want to have a portal with the complete picture and full record. Call me a dreamer! 

And two other comments which summarize this point:

Allow patients to control their own data – we’ve spoken to thousands that want to share and export to their circle of care. System level change takes time re: connectivity, but empowering patients to share can be done sooner. Patient control = patient centred. 

While most of Canada have no access, some of us here in the know have several portals. That’s great! And it’s confusing. With @access2022 & @infoway talking to vendors now about creating the #digitalhealth highway for HC data in Canada we need #interoperability #HQOChat

 

 

Canada Health Infoway (@Infoway): Back to the Future again

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How you greeted the news last week of Canada Health Infoway’s rebranding and new campaign to mobilize support for digital health will probably depend very much on how you have viewed the success of this pan-Canadian federally funded health organization to date.

Over its 17 years of existence, Infoway has had more than its share of detractors for either failing to do enough with hundreds of millions of dollars it was charged with co-coordinating to bring digital health to Canada, or for focusing on the wrong things at the wrong times. Or take electronic prescribing: That Infoway’s PrescribeIT initiative has now spread to three provinces will be viewed as a major success by supporters of the organization. However, detractors will point out Canadian is many years behind other countries in ePrescribing, PrescribeIT involves few physician practices,  and at least one major national pharmacy chain has evidently failed to endorse Infoway’s funding model.

Part of the conflicting views of Infoway can perhaps be traced to the way it has radically reinvented itself over the years.  In his address to the Infoway Partnership Conference in Montreal last week, Infoway President and CEO Michael Green acknowledged that over the course of its existence, Infoway’s role has radically shifted focus; from building the infrastructure to support digital health, to providing clinician tools, and most recently to driving access for Canadians to digital health.

The latest iteration of the driving force behind Infoway – ACCESS 2022 sees the organization firmly positioning itself as an advocate for building a coalition committed to promoting “a future where all Canadians have access to their health information through the availability and use of digital health tools and services, which will empower patients and improve health outcomes.”

“ACCESS 2022 will bring together the collective expertise of an agile technology sector, the knowledge base of health system experts, and the insights and experiences of patients and caregivers, to ultimately meet and exceed the demands of Canadians in the 21st century…We are asking all Canadians to join us in this movement,” Green said.

Unveiled with touques for all and the music of Stompin Tom Connors at the Montreal conference, it was all very archetypically Canadian – and once again was doubtless viewed with either enthusiasm or cynicism depending on how you view Infoway.

We actually have a credible objective assessment of the organization presented in Fit for Purpose, a report published in March by two highly respected health policy experts Drs. Danielle Martin and Pierre-Gerlier Forest.  At the request of the federal health minister, Martin and Forest assessed all 8 federal pan-Canadian health agencies including Infoway.

They noted that Infoway has had several signature successes, including:

  • Driving the digital health agenda in Canada by creating pan-Canadian leadership
  • Parnering with all jurisdictions to achieve “close to” the 2004 federal/provincial/territorial health accord goal of 100% availability of electronic health records thereby resulting in $19.2 billion in cost savings and efficiencies since 2007
  • Initiating a patient engagement framework that “provides Canadians with access to their health information and digital health solutions that empower them to be more active members of their care team.”

However, while not criticizing Infoway directly the report goes on to identify significant shortfalls in how Canada is doing with digital health:

Data currently exists that could be used to improve care in hospitals, primary care environments, community settings, and health regions across the country. Unfortunately, the underlying architecture to support this meaningful use and enable continuous improvement across health systems does not yet exist in Canada. Infrastructure has been built and electronic health record systems purchased across the country, but two key outcomes are still missing: an inter-operable set of electronic systems and a “single” accessible electronic record for every Canadian patient as a critical means to achieving coordinated, integrated care.

How successful Infoway is in addressing this – and it is clearly committed to doing so  – will very much determine how it is viewed in future years.

(Image from Access2022.ca website)

Something is happening here … #HIMSSEurope18

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You try so hard but you don’t understand
Just what you will say when you get home
Because something is happening here but you don’t know what it is
Do you, Mr. Jones?

                                             Ballad of a Thin Man: Bob Dylan

The problem with a Health Information Management Systems Society (HIMSS) meeting – any HIMSS meeting – is that there is so much going on at one time that it is impossible to craft it into one coherent narrative.

That is the challenge with HIMSS Europe 18 currently underway here in Sitges near Barcelona, Spain as hundreds gather to discuss the latest in digital health and health information technology and to network, network, network. And it’s doubly challenging as this meeting is being held in conjunction with Health 2.0, the health innovation conference recently purchased by HIMSS.

(Now wait a minute, wait a minute you say – you get to go all the way to a resort hotel in Spain, with a clothing optional beach within 5 minutes walk, where they serve wine at the some conference buffet luncheons, only to cop out and say you can’t write coherently about it. Patience please).

As a social media ambassador here and lively live tweeter I can supply you with an endless number of insightful tweets or sound bites from just the first 24 hours. For example:

“We have gone from a paper world to a digital world in a short period of time”: Dr. Robert Wachter

“There is a lot of tokenism in health(care) innovation, and some think you can change or even fix health(care) overnight. It is not about technology, nor about the process, it is about changing the culture of an organization”: Lucien Engelen

“Pay patients and value them as the experts that they are”: Marie Ennis-O’Connor

But while I think these tweets provide a useful running commentary of the meeting they – and even the twin meeting hashtags #HIMSSEurope18 and #health2con – provide only a partial and episodic picture of what is going on.

Individual presentations or sessions are also noteworthy. For instance I have never heard as passionate a presentation supporting the role of nurses in the future digital world as that given by Angelien Seiben and Shawna Butler from Radboud University Medical Center. And Dr. Jordi Sorreno Pons a GP and CEO of the Universal Doctor app jammed so many ideas into his 8 minute presentation on future developments in medical innovation that it was almost incomprehensible.

The big subject areas – patient engagement, big data, artificial intelligence – are all given their own sessions or streams here.  But in the time available they tend to focus on specific projects or regional initiatives.

Certain things have changed from HIMSS or eHealth meetings held 15 or 20 years ago. The digitization of patient records is now a reality and not a vision and patients are not only discussed but included (#patientsincluded) as presenters in their own right.

But as to what all of this means for the future of digital health in Europe or worldwide – we are too much in the moment to have a clear picture given the complex nature of health systems and the endless number of variables that impact such systems.

For the numerous people here with an start-up to promote or an niche application to profile the meeting is a far simpler place.

(This is the first of what we hope will be a series of posts from Sitges)

#Ehealth2016 – inquiring minds want to know

 

ehealth_ambassadors_badge_300x300Canada’s premier conference on health information technology – #ehealth2016 – is now less than a month away.

That means it’s a good time to start to contemplate some of the big questions facing the health IT community in Canada and wondering whether this mega-meeting hosted in Vancouver.\, courtesy of COACH, Infoway and CIHI will provide any answers to these questions.

At its worst, this annual meeting can be an annoying combination of sometimes irrelevant keynote speakers and simultaneous sessions that do not live up to their titles/abstracts. But over the past decade e-health (however one chooses to write the name – hyphen, no hyphen, capital on ‘e’ or no capital on ‘e’ etc.) has become THE meeting for those interested in health IT to network, hear leaders in the field and gain insights into really interesting work going on at local/regional and provincial/territorial levels.

As an observer, I would suggest a few interesting questions this conference may help to provide answers for:

  • With the death or evolution of the big dinosaur programs for funding physician EMRs (POSP, PITO etc.) what is being done to continue to involve and engage physicians in improving how they use electronic records to improve care?
  • What is Infoway planning on doing with its new infusion of funding courtesy of the last federal budget?
  • Is patient engagement a thing in Canada in health IT and if so what does it mean?
  • Is the vendor space for EMRs and EHRs going to continue to consolidate ?
  • And that interoperability issue – is anything substantive happening to better connect physicians and hospitals.
  • Big data. (enough said).
  • Are hospitals and practitioners adapting to the mobile revolution in health?
  • Are these the correct questions to be asking? At HIMSS this year there was a big shift towards discussing digital connectivity beyond the electronic record and major discussions about data security in health. Should Canada be having those discussions too.

Inquiring minds want to know.

 

To the EMR … and beyond

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For a conference that was about health information technology, it was all about health IT.

Allow me to explain.

The annual meeting of the Canadian Agency for Drugs and Technology in Health (@CADTH_ACMTS) is a showcase for health technology assessment (HTA) and the mission of the organization is to provide credible, impartial advice and evidence-based information about the effectiveness and cost-effectiveness of drugs and other health technologies.

What was noteworthy about this year’s meeting in Ottawa –  the largest yet for the organization with about 750 attendees – was the number of times electronic records (either EMRs or EHRs) were referenced as an essential feature for both gathering and for disseminating credible information to support evidence-based medicine.

Physician speakers repeatedly noted the need to have easy, point-of-care access at the time of the patient encounter, and to all of them this meant embedding that information in the electronic record.

More than one family doctor talked about being overwhelmed with guidelines and best practices and the need to integrate this information into the physician workflow to be useful – and EMRs as the natural place to do this.

The Canadian Association of Radiologists creates world-class clinical practice guidelines, but as Dr. Martin Reed, a pediatric radiologist from Edmonton told the meeting, one of the problems with these guidelines is that it is very hard to get people to use them.

He said there is now a feeling in the medical imaging community that the best way to do this is to integrate the guidelines into CPOE (computerized physician order entry) systems.

Given that some Canadian physicians still do not use EMRs and some (many?) hospitals are not using CPOE this could raise concerns about the quality of care being delivered.

On this information gathering front, the new focus on real-world data has placed an increased emphasis on the value of EMRs or EHRs to gather useful information to evaluate the effectiveness of drugs and technologies, the meeting was told.

“The starting point is having an EHR covering all of the caregivers. At that point the world is your oyster,” said Dr. Murray Ross (@murrayrossphd), leader of the Kaiser Institute for Health Policy in Oakland, CA.

Dr. C. Bernie Good (@CBGood23) who holds numerous roles with the US Department of Veterans Affairs gave numerous examples of how the extensive database gathered on VA patients through EHRs has helped support evidence-based drug prescribing.

And it does not end there.

As Anil Arora, assistant deputy minister in the Health Products and Food Branch, of Health Canada told the meeting it is not just the information being gathered in patient records that will need to be taken into consideration in the future – but also the wealth of patient data now being collected through wearables and other devices as well as through social media.

Given that we have by no means maximized the value of EMRs to gather this information in Canada, the challenges of extending the information sources to other digital repositories of patient information is currently problematic to say the least.

(Picture – Anil Arora. Courtesy CADTH)

From #HIMSS16 to #ehealth2016 – new work, new roles and a new language

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“We need the Intelligence Augmenter, stat!

“The diagnostic algorithm’s out of whack and the Transition Specialist wants to know how the interface outflow is correlating the patient’s Fitbit data into the Director of Decentralized Asset Management’s new discharge interface. And we can’t reach the Business Analyst for Patient Workflow.”

The above is not a conversation you are likely to have heard in your hospital lately.

But if you listen to Mark Casselman (@markcasselman), the CEO of COACH (@COACH_HI), Canada’s Health Informatics Association, it is the type of exchange that could be a reality in the not too distant future.

In a recent address at the #HIMSS16 conference in Las Vegas, Casselman gave a thoughtful overview of how the changing landscape around how digital health care is going to fundamentally change not only how care is provided to patients but also the roles and responsibilities of those providing that care.

Casselman noted we are currently in an environment where we have two distinct health care delivery ecosystems working simultaneously – the traditional health care delivery system based on face-to-face interactions between provider and patient in either an office or hospital setting, and the new and evolving consumer-based digital health system – the world of virtual care, apps, engaged patients and the quantified self.

“The traditional health care delivery ecosystem is mostly operating distinctly and differently from these fantastic innovations. They’re operating at different clock speeds.”

He notes that virtual care is evolving along the whole continuum from the traditional clinician/patient interface through team-based care to the new personalized patient-centred approach to care.

“It’s almost impossible for these things to be embedded in the traditional system because they’re changing so quickly,” he said.

These evolving forms of digital care and the underlying beliefs and concepts that support them are creating dynamic tension for those used to working in the traditional health care environment.

In part, he said, this is because the traditional evidence-based model of care which relies on the randomized controlled trial as the gold standard, cannot adapt quickly enough to assess and absorb the changes being brought about by digital health innovations.

To Casselman – and seemingly to the 42,000 delegates to the Vegas meeting – the new reality is one Canadian physicians, hospital administrators and all others employed in the system must start to acknowledge.

“Health care professionals, teams, and organizations must consider what novel skills and capabilities are needed to deliver virtual care effectively,” he said.

Casselman’s organization – COACH (one of the main sponsoring bodies of the upcoming #ehealth2016 conference in Vancouver) has done much to define the 65 existing roles and responsibilities involved in health informatics in Canada today and as developed a professional skills matrix for those roles.

But with the emerging digital health world, he said, there is now a need to re-examine this and determine the new roles that will be needed to provide care in the new world of health delivery.

Using artificial intelligence to augment care with algorithms, harvesting big data for insight, precision medicine, and digital care provided through mobile in the home and the community will require many different skills sets and roles –the type of currently fictitious roles noted by Casselman in my introductory vignette.

But Casselman goes beyond this onto more dangerous ground when he questions whether the patient electronic record of the future will even be the primary point around which patient care will be focused

“We’re digitizing our physiological indicators, we’re sharing them and its creating a real tension in the world of health informatics,” he noted.

Maybe the physician-owned patient record in the EMR is only a segment of what will really be needed to deliver care in the future as the patient tracks his or her own indicators and brings this to the table.

Much to think about and we can only be thankful that Canadian informatics leaders such as Casselman are giving it some thought, especially when he prefixes it all by stating “At the end of the day, it’s all about the care.”

(The summary sides from Casselman’s full presentation can be accessed here).