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Arcadia University

Data as "ATP" Fuel for


Intellectually Fearless Leaders

Daniel J. Vreeman, PT, DPT, MS, FACMI


Regenstrief-McDonald Scholar in Data Standards
Indiana University School of Medicine

Director, LOINC and Health Data Standards


@djvreeman Regenstrief Center for Biomedical Informatics

© 2018 © 2019
Arcadia University’s pioneering,
global, integrated, liberal arts, and
professional learning experience
cultivates leaders who are
intellectually fearless and uniquely
prepared for life and work.
ATP
Wait. Is this a biochem quiz?
ATP
Power for virtually every cell activity

! Transport work moving substances across cell membranes.

" Mechanical work supplying the energy needed for muscle


contraction, chromosomes, and flagella.

# Chemical work supplying energy to synthesize the multi-


thousands of types of macromolecules that cells need.
📷 CNX OpenStax | cc-by
For as long as I have wanted to
be a clinician, I have also loved
science and computers.
Info…what?
Biomedical informaticians collect important
health information. We organize, analyze, and
convert data into knowledge, and then we use
technology to apply that knowledge to improve
health and health care.
Info…what?
Biomedical informaticians collect important
health information. We organize, analyze, and
convert data into knowledge, and then we use
technology to apply that knowledge to improve
health and health care.

Ok, what about this “Data Science” thing…


Clem McDonald, MD in the Regenstrief computer terminal room
(Circa 1974)

McDonald CJ. Protocol-based computer reminders, the quality of care


and the non-perfectability of man. N Engl J Med 1976;295:1351–5
It appears that prospective reminders do reduce errors, and
that many of these errors are probably due to man’s
limitations as a data processor rather than to correctable
human deficiencies.

Clem McDonald, MD in the Regenstrief computer terminal room


(Circa 1974)

McDonald CJ. Protocol-based computer reminders, the quality of care


and the non-perfectability of man. N Engl J Med 1976;295:1351–5
Were MC, Nyandiko WM, Huang KT, et al. Computer-generated reminders and quality of pediatric HIV care in a resource-limited setting. Pediatrics. 2013 Mar;
131(3):e789-96. Epub 2013 Feb 25. PubMed PMID: 23439898.
Were MC, Nyandiko WM, Huang KT, et al. Computer-generated reminders and quality of pediatric HIV care in a resource-limited setting. Pediatrics. 2013 Mar;
131(3):e789-96. Epub 2013 Feb 25. PubMed PMID: 23439898.
4x
improvement of overdue clinical tasks!
(68% vs 18%)

Were MC, Nyandiko WM, Huang KT, et al. Computer-generated reminders and quality of pediatric HIV care in a resource-limited setting. Pediatrics. 2013 Mar;
131(3):e789-96. Epub 2013 Feb 25. PubMed PMID: 23439898.
Central Premise
Intellectually fearless leaders need a great data metabolism
What we (mostly) do today

!
Interpret

Focus
Analyze data
Area

Coalesce data

Go Decision
🌐 Adapted From: Learning Health Care Project
What we (mostly) do today

!
Interpret Publish journal article
Hold inservice

Focus
Analyze data
Area

Coalesce data

Go Decision
🌐 Adapted From: Learning Health Care Project
What we need: Continuous Learning

!
Interpret Deliver Tailored Messages

Focus
Analyze data
Area

Coalesce data Take Action!

Go Decision
🌐 Adapted From: Learning Health Care Project
What we need: Continuous Learning

!
Interpret Deliver Tailored Messages
Persistent and sharable Right time, place, audience, format
knowledge

Focus
Analyze data
Area
Data Science Methods

Coalesce data Take Action!


Data policies, standards Capture changed practice
Go Decision
🌐 Adapted From: Learning Health Care Project Forming Communities of Interest
University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps 2017. www.countyhealthrankings.org. Used with permission.
People with smart Health IT systems, informed by
comprehensive data, can drive transformative change
Inform shared clinical decision making

Computer-assisted diagnosis and predictions

“Whole person” view integrated into care pathways

Expand health system’s ability to tailor to its population needs

Fuel for investigations into the clinical utility of contextual data

Adler NE, Stead WW. Patients in context--EHR capture of social and behavioral determinants of health. N Engl J Med. 2015 Feb 19;372(8):698-701. doi: 10.1056/NEJMp1413945. PubMed PMID: 25693009.

Hossein Estiri, Chirag J Patel, Shawn N Murphy; Informatics can help providers incorporate context into care, JAMIA Open, Volume 1, Issue 1, 1 July 2018, Pages 3–6, https://doi.org/10.1093/jamiaopen/ooy025
Fundamental Challenge
The help from Health IT systems is limited by the data within their purview.
Connecting Many Data Sources
Social and community determinants
Lifestyle and behavioral
Health history
Patient-generated
EHR/clinical
Genetics
Basic science
Great leadership needs to draw from a wide breadth of information
However, many forces today are converging
on the need for interoperable health data
📰 Source: POLITICO
Electronic Health Record
vendor adoption of
Application Programming
Interfaces
In Fall 2018, almost 87% of hospitals and
69% of MIPS eligible clinicians are served by
health IT developers with product(s) certified
to the FHIR API standard.

https://www.healthit.gov/buzz-blog/interoperability/heat-wave-the-u-s-is-poised-to-catch-fhir-in-2019
Apple Health Records
Uses Argonaut FHIR API

🌐 Sources: Apple and Apple


📰 Source: Healthcare Innovation
https://apps.smarthealthit.org
📰 Source: FierceHealthcare
Standardized Health Data
searchable with BigQuery:
cloud data warehouse with
built-in machine learning

Eyal Oren
PM, Google
📷 duncan | cc-by-nc
Bright TJ, Wong A, et al. Effect of clinical decision-support systems: a systematic review. Ann Intern Med. 2012 Jul 3;157(1):29-43. PubMed PMID: 22751758.
Rajkomar A, Oren E, Chen K, et al. Scalable and accurate deep learning with electronic health records. npj Digital Medicine 2018;1:18. doi:10.1038/s41746-018-0029-1
Our central insight is that rather than explicitly
harmonizing EHR data, mapping it into a highly curated set
of structured predictors variables and then feeding those
variables into a statistical model, we can instead learn to
simultaneously harmonize inputs and predict medical events
through direct feature learning.

Rajkomar A, Oren E, Chen K, et al. Scalable and accurate deep learning with electronic health records. npj Digital Medicine 2018;1:18. doi:10.1038/s41746-018-0029-1
Rajkomar A, Oren E, Chen K, et al. Scalable and accurate deep learning with electronic health records. npj Digital Medicine 2018;1:18. doi:10.1038/s41746-018-0029-1
A deep learning approach that incorporated the entire
electronic health record, including free-text notes,
produced predictions for a wide range of clinical problems
and outcomes that outperformed state-of-the-art traditional
predictive models.

Because we were interested in understanding whether deep


learning could scale to produce valid predictions across
divergent healthcare domains, we used a single data
structure to make predictions for an important clinical
outcome (death), a standard measure of quality of care
(readmissions), a measure of resource utilization (length of
stay), and a measure of understanding of a patient’s
problems (diagnoses).
Rajkomar A, Oren E, Chen K, et al. Scalable and accurate deep learning with electronic health records. npj Digital Medicine 2018;1:18. doi:10.1038/s41746-018-0029-1
Rajkomar A, Oren E, Chen K, et al. Scalable and accurate deep learning with electronic health records. npj Digital Medicine 2018;1:18. doi:10.1038/s41746-018-0029-1
Spears GV, Roth CP, Miake-Lye IM, Saliba D, Shekelle PG, Ganz DA. Redesign of an electronic clinical reminder to prevent falls in older adults. Med Care. 2013 Mar;51(3 Suppl 1):S37-43. PubMed PMID: 23407009.
Implementing a fall prevention program
that adheres to clinical guidelines,
however, requires addressing the
significant logistical barriers that
impede the integration of fall prevention
activities into primary care.

Spears GV, Roth CP, Miake-Lye IM, Saliba D, Shekelle PG, Ganz DA. Redesign of an electronic clinical reminder to prevent falls in older adults. Med Care. 2013 Mar;51(3 Suppl 1):S37-43. PubMed PMID: 23407009.
Spears GV, Roth CP, Miake-Lye IM, Saliba D, Shekelle PG, Ganz DA. Redesign of an electronic clinical reminder to prevent falls in older adults. Med Care. 2013 Mar;51(3 Suppl 1):S37-43. PubMed PMID: 23407009.
…tailor the reminder to existing clinic
setups and workflows.

Spears GV, Roth CP, Miake-Lye IM, Saliba D, Shekelle PG, Ganz DA. Redesign of an electronic clinical reminder to prevent falls in older adults. Med Care. 2013 Mar;51(3 Suppl 1):S37-43. PubMed PMID: 23407009.
Spears GV, Roth CP, Miake-Lye IM, Saliba D, Shekelle PG, Ganz DA. Redesign of an electronic clinical reminder to prevent falls in older adults. Med Care. 2013 Mar;51(3 Suppl 1):S37-43. PubMed PMID: 23407009.
My Summary:
Computers can you help implement EBP, but
changing practice (people) is hard!

Spears GV, Roth CP, Miake-Lye IM, Saliba D, Shekelle PG, Ganz DA. Redesign of an electronic clinical reminder to prevent falls in older adults. Med Care. 2013 Mar;51(3 Suppl 1):S37-43. PubMed PMID: 23407009.
Some words of caution
📰 Source: STAT
Medical information that is revealed to health
care providers is protected by privacy laws such
as the Health Information Portability and
Accountability Act (HIPAA).

In contrast, emergent medical data receives


virtually no legal protection. By mining it,
companies sidestep privacy and anti-discrimination
laws to obtain information most people would
rather not disclose.

📰 Source: STAT
HIPAA
HIPAA Right of Access
Accepts requests by email or fax: Providers may not create a barrier to access
by requiring patients to submit requests in person or by mail.

Sent in format requested to the patient’s designated recipient: Provider sends


the records in the format the patient requests, which is in digital form by email for
text, CD for images, and sends it to the third party designated by the patient.

Sent within 30 days: Provider responds to the request within 30 days of receipt.

No unreasonable fees: Providers may only charge reasonable, cost-based (i.e.,


minimal) fees to cover labor costs of copying and supplies.
https://www.ciitizen.com/scorecard/
continuous glucose monitor
+

insulin pump
+
computerized control system

📰 Source: NEO.LIFE
Putting it all Together
Data is fuel for leaders who
want to make a difference
Human 

+

Computer
" Human

Friedman CP. A "fundamental theorem" of biomedical informatics. J Am Med Inform Assoc. 2009 Mar-Apr;16(2):169-70.PubMed PMID: 19074294;
Stead WW, Searle JR, Fessler HE, Smith JW, Shortliffe EH. Biomedical informatics: changing what physicians need to know and how they learn. Acad Med. 2011 Apr;86(4):429-34. PMID: 20711055
Although most health
professionals use IT daily in
their work, few know how to
adapt their roles and work
processes to incorporate IT
for the greatest benefit.

Stead WW, Searle JR, Fessler HE, Smith JW, Shortliffe EH. Biomedical informatics: changing what physicians need to know and how they learn. Acad Med. 2011 Apr;86(4):429-34. PMID: 20711055
We have frequently heard the opinion from
both faculty and students that medical
students already possess all the basic
skills necessary to function effectively
in an information-rich environment.

Silverman H, Cohen T, Fridsma D. The evolution of a novel biomedical informatics curriculum for medical students. Acad Med. 2012 Jan;87(1):84-90. PubMed PMID: 22104049
We have frequently heard the opinion from
both faculty and students that medical
students already possess all the basic
skills necessary to function effectively
in an information-rich environment.

This is similar to assuming that a


student proficient in the use of a word
processing program knows how to write an
award-winning novel.
Silverman H, Cohen T, Fridsma D. The evolution of a novel biomedical informatics curriculum for medical students. Acad Med. 2012 Jan;87(1):84-90. PubMed PMID: 22104049
FEAR
FEAR
False Evidence Appearing Real
FEAR.
False Evidence Appearing Real
LESS.
How much pain have cost us, the evils
which have never happened?

🎙 Quote: Thomas Jefferson


Leaders go first.
Closing Thought
Tone is in your fingers.
📷 scragz | cc-by
📷 scragz | cc-by
Though Wooten's basses receive
much attention, his most
frequent and consistent
response when asked by his
fans about his equipment is
that "the instrument doesn't
make the music ... you do".
📷 scragz | cc-by
The instrument doesn’t
make the music … you do.