reprinted from Issue 22, Spring 2016 of Frontiers of Medicine (PDF)
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UCSF has long been a trailblazer in life sciences innovation – for example, faculty members founded Genentech, Chiron, and many other biotechnology companies. Now the UCSF Department of Medicine is poised to lead the way in digital health – a rapidly evolving field that harnesses the latest developments in health information systems, genomics, wireless devices, and other technologies to improve health care.
Rather than merely converting analog data into bits and bytes, the digital revolution is an opportunity for medicine to transform research, patient care and education. Following are a few highlights:
Center for Digital Health Innovation
To foster achievements in digital health, UCSF created the Center for Digital Health Innovation (CDHI) – a one-stop shop for faculty, staff, and students interested in advancing digital health concepts and prototypes, proving them in the clinical environment and commercially scaling them. Moreover, CDHI provides a front-door to Silicon Valley innovators who seek relationships with UCSF faculty for advice, research, and collaborations.
Established in 2013, CDHI welcomes everyone from expert coders to clinicians just looking for apps to help improve care, and serves as a match- maker for all things digital. "People might need funding, technology support, or commercial connections to scale up their idea, or introductions to licensing, contracting, and intellectual property resources on campus," said Michael Blum, MD, the center’s director, who is also associate vice chancellor for informatics for UCSF Health. "We have all these capabilities, and want to collaborate with UCSF faculty, staff, and students so they don’t have to figure these things out on their own."
"We want to collaborate with UCSF faculty, staff, and students so they don’t have to figure these things out on their own."
— Michael Blum, MD
The CDHI has four pillars:
In addition to connecting people with expertise, CDHI provides seed funding, cuts through red tape, and vets outside companies wanting to partner with UCSF. "External innovators are marching up from Silicon Valley, saying ‘We have this great idea that’s going to revolutionize health care,’" said Blum. However, most of these concepts and companies are unproven in the health care space, requiring vetting and validation. Hospitalist Priyanka Agarwal, MD, MBA, leads CDHI’s start-up partnership efforts and has assessed the feasibility of more than 150 startups, matching the best with potential faculty partners and protecting UCSF’s intellectual contributions. Also, Alvin Rajkomar, MD, is developing several partnerships scheduled to launch this year.
"If you’re going to have an impact on health care, you can’t just stand outside and say you’ll disrupt it," said Blum. "There needs to be coordination with existing processes." Russ Cucina, MD, MS, associate chief medical information officer for the UCSF Health System, and Aaron Neinstein, MD, an assistant professor in endocrinology, lead efforts to help new digital tools interface with UCSF Health’s electronic health record, APeX.
The tech world is full of new devices claiming to track everything from heart rate and blood pressure to sleep patterns and stress. "Unfortunately, many devices are completely unproven, and some don’t work as expected under real-world conditions," said Blum. "We need to know whether they measure things accurately, reliably, and in a way that improves health." Andy Auerbach, MD, MPH, a professor in hospital medicine, spearheads these efforts, partnering with organizations including the UCSF- Samsung Digital Health Innovation Lab, the UCSF Clinical and Translational Science Institute (CTSI), and the Clinical Innovation Center.
Chandler Mayfield executive director, technology enhanced education, from the School of Medicine Dean’s Office leads work to educate medical students about digital health and optimize ways to teach them the skills they will need, leveraging these powerful new tools.
CDHI incubates several projects, including CareWeb, the brainchild of Raman Khanna, MD, assistant professor of hospital medicine. CareWeb interfaces with APeX, allowing a patient’s entire care team to securely share communications via computer or mobile device using an interface that combines aspects of Facebook and Twitter. "Health care has moved beyond a point-to-point communication, such as a nurse paging a doctor, where no one else knows what is going on," said Blum. "This is a team- based, collaborative communications platform that is social and mobile."
CDHI helped develop CareWeb and integrate it with APeX. CareWeb has been piloted on the medicine and cardiology services for over a year, and was recently licensed to Voalte, a commercial software vendor, which will incorporate it into its technology platforms and bring the application to scale across the country. Khanna, with Blum and Department of Medicine Interim Chair Robert M. Wachter, MD, recently authored a piece in JAMA on the importance of reimagining communication technology in the post- pager era.
Led by Neinstein, CDHI also launched a collaboration with Cisco, the world’s leader in networking technology, to build a platform allowing patients to have centralized access to all their health- related data, including information from hospital stays, clinic visits, and devices like Fitbits and Apple watches. "This will allow an individual’s data to move around the health care system much more freely, rather than being locked up in a hospital’s electronic health record," said Blum. "It will also let developers write apps that access health care data, which is currently inaccessible. In five years, we’ll look back with amazement at the ‘Dark Ages,’ when patients couldn’t access their own health care data."
"There is a lot of activity in digital innovation at UCSF, and many people in the Department of Medicine are national leaders in this space," said Blum. "Our portfolio currently has a dozen projects, but we eventually want to have hundreds. We encourage anyone with an idea to come talk to us at CDHI."
Tideswell, Improving Care for Elders
"Oftentimes we ask older adults, ‘How does that medication affect your chronic pain? How does it impact your ability to think clearly?’ said Christine Ritchie, MD, MSPH, Harris Fishbon Distinguished Professor in Clinical Translational Research and Aging and director of Tides well at UCSF, an incubator in the Division of Geriatrics for geriatrics research, care models, and leadership training. "But these are very gross estimates. We wanted to do a more real-time assessment of people’s cognition and function, with much more granular data."
With support from the National Palliative Care Research Center, Ritchie and her colleagues are developing an app – called the Cognition-activity Assessment in Response to Rx Interventions (CARRI) tool – to accomplish this. Patients use an iPad to record their pain level and when they take their medication throughout the day.
Using tools developed by Kate Possin, PhD, assistant professor of neuropsychology, and colleagues at the UCSF Memory and Aging Center, the app also incorporates computer games to assess patients’ short-term memory, response time, and attention span. For example, with the Stargazer cognitive assessment tool, the screen may show nine blue stars and one green star, which then disappears; the patient is asked to touch the screen where the green star was. Instead of asking patients to self-assess their concentration and focus levels weeks later during a clinic visit, these tests measure those abilities several times a day and track whether a pain medication appears to impact their thinking.
Patients also wear a wristband accelerometer to track activity. "If someone says, ‘I don’t think that pain medication is helping me at all,’ but you look on their graph and see that their functional status improved profoundly, the provider might say, ‘Gosh, it looks like you are walking a lot more – could that be from your new medication?’" said Ritchie. "On the other hand, you could also see if their physical activity dropped or their sleep patterns changed, which also could be side effects from medicines used to treat pain."
"I’m always on the hunt for ways to utilize technology to help us live better lives," said Ritchie. "If I knew of someone else doing this, I would just use their assessment tool – but I haven’t found someone else who is, so we had to create our own. The development process has shown both how much promise there is, and also how challenging it is to create technology- supported tools that are relevant to the population we’re trying to help."
For example, her team originally thought they could design the app for a smartphone, which could combine the computer games, medication tracking, and accelerometer all in one device. "We realized that the phone is too small, and requires better eyesight and more manual dexterity than the iPad," said Ritchie.
"My hope is that we’ll be able to learn from the wearable technology and ‘quantified self’ community," said Ritchie, referring to the trend of self- tracking through technology. "We hope to creatively apply their innovation to clinical practice and research to help people who might not otherwise have access to these tools."
Redesigning Care through Telemedicine
George Su, MD, a pulmonologist at Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG), spent years studying lung cell biology in the laboratory of Dean Sheppard, MD. But after completing a biodesign externship at Stanford University, he began using design skills to improve care for vulnerable populations. In 2012, Su became medical director of telehealth for the San Francisco Health Network (SFHN) – the comprehensive health delivery system of the San Francisco Department of Public Health (SFDPH), which includes ZSFG and 26 community primary care clinics.
Telehealth is the practice of leveraging technology to provide care and medical expertise in ways that do not require face-to-face visits. "This was an incredible opportunity to apply design thinking to large health care problems," said Su, who also credits his experience studying complex molecular systems with helping him understand equally complex safety net care delivery systems. Rather than just inserting the latest gadget into clinics, Su and his colleague, Bruce Occeña, MPH, MBA, take a user-centered and needs-based approach – talking with stakeholders, understanding needs and capacities, mapping out existing processes, and thinking about how technology could help. Some examples include:
Until recently, patients with a puzzling skin problem had to wait several months for a ZSFG dermatology appointment. Now, primary care practitioners securely transmit photos to Toby Maurer, MD, chief of dermatology at ZSFG, and her colleagues, who review the images and provide recommendations within four days. More than 60 percent of the time, cases can be solved through images alone, eliminating the need for a face-to- face appointment. For cases requiring an in-person visit, appointment wait times have dropped to less than 30 days, largely because straightforward cases can now be handled without clinic visits.
The SFHN cares for over 8,000 diabetics, most of whom require screening for retinal eye disease at least every two years. Overwhelming demand and limited specialty access have resulted in poor screening rates. The SFHN Telehealth Program and ZSFG ophthalmologists Cynthia Chiu, MD, Jay Stewart, MD, and Jim Larson have designed a program that includes a walk-in service at ZSFG, embedded retinal imaging cameras at clinics with the staffing to operate them, and even a mobile camera on a van that visits clinics without dedicated cameras.
"Our primary care colleagues convinced us that rather than placing a high-maintenance camera in every clinic, a multipronged approach would be best," said Su. "We can leverage patients’ comfort level at their home clinics, while limiting the burden on clinics to maintain their own local eye imaging programs."
Spirometry is required to diagnose lung diseases such as asthma and emphysema. Unfortunately, wait times at the ZSFG Pulmonary Function Testing Laboratory have approached six months. Previously, due to the complexity of having the patients blow into the spirometer correctly, over three-quarters of spirometry studies conducted at SFHN clinics provided inaccurate results. Now, ZSFG respiratory therapist Eula Lewis, RRT, CTTS, uses transmitted spirometry data and real-time videoconferencing to provide quality control. "She can tell just by analyzing the spirometry wave forms whether a study is of adequate quality, and can instruct clinic personnel how to coach a patient to perform the test correctly," said Su. Lewis reviews the data and submits only high quality studies for interpretation by lung specialists.
These telehealth initiatives have received strong support from leaders of the SFHN, including Roland Pickens, chief operating officer, and Alice Hm Chen, MD, chief medical officer. "We’re also fortunate to work with an entire system of dedicated, mission-driven stakeholders who partner closely with us and tolerate a few bumps in order to implement new programs," said Su. "Our goal is to apply technology in creative ways that will best meet the needs of our patients, providers, and health care delivery system."
“Our goal is to apply technology in creative ways that will best meet the needs of our patients, providers, and health care delivery system.”
— George Su, MD
A Student Dashboard to Guide Improvement
Future doctors need to learn a dizzying array of skills during medical school – everything from how to do a physical exam to the latest advances in molecular biology and quality improvement. Yet it can be hard for medical students to know where they need to improve, since they receive test scores and teacher evaluations in bits and pieces.
A new tool developed by the UCSF School of Medicine called the iROCKET Student Dashboard pulls together many sources of feedback to provide a real-time, one-stop summary of each student’s strengths and growth opportunities.
"We are interested in promoting lifelong learning skills, and providing assessment information to students so that they can do evidence-based, data-driven self-assessment," said Karen Hauer, MD, PhD, associate dean for assessment for the UCSF School of Medicine.
Like a car dashboard, which shows drivers their speed, number of miles driven, and whether the gas tank is almost empty, the student dashboard presents a snapshot of performance, updated daily. Students can see how they are doing in each area compared to the class average, and can drill down for more detailed information. For example, they might see they excel in most areas of medical knowledge – indicated by green bars – but need to beef up their knowledge of the nervous system, pathology, and radiology, represented by yellow bars. The dashboard includes links to online resources and tutorials to help students improve in specific areas.
"We are moving toward a model of assessment for learning, rather than assessment of learning," said Hauer, who recently earned her doctorate in medical education from a joint program sponsored by UCSF and the University of Utrecht in the Netherlands. Her dissertation focused on the concept of trust, and how supervisors as well as educational programs effectively assess learners and determine when they trust learners to practice medicine more independently. "It’s infinitely better to help students identify early the areas where they are at risk, rather than having them fail and remediate."
Beginning this fall as part of the new School of Medicine Bridges Curriculum, each student will have a coach who teaches foundational clinical skills and systems improvement, and works intensively with them through all four years of medical school. "Students and faculty feel like advising is richer when they have shared information," said Hauer. "Lifelong learning requires good evidence and coaching, and we’re getting all the pieces in place."
The iROCKET Student Dashboard is still in its initial phase; next steps include expanding it from two to seven core competencies, training coaches how to use the dashboard, and enabling students to contribute narrative reflections on their performance, which coaches can read and comment on.
Hauer partnered with Bonnie Hellevig, Sandy Ng, MSN, RN-BC, and other colleagues at the School of Medicine and UCSF Health to model the iROCKET Student Dashboard on physician dashboards recently created by UCSF Health. The physician dashboards help clinicians track their care of patients and compare their performance to expected benchmarks and peer performance.
"We are moving toward a model of assessment for learning, rather than assessment of learning."
– Karen Hauer, MD, PhD
Part of creating the student dashboard included defining key performance indicators, as well as identifying milestones along the way. "We know what we want students to look like at the end of medical school, but it’s helpful for them to know what they should be like by the end of the first or second phase of the curriculum – and what to do if they need to make adjustments," said Hauer. "Helping people figure out, ‘What should I be working on?’ is part of cultivating a growth mindset, and how you’re going to get better."