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Digital Medicine TransformationThe New Skill for CIOs

Session # 145, Feb 13th 2019, Room W304A

Ashish Atreja, Mount Sinai Health System and Shafiq Rab, Rush Health System

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Shafiq Rab, MD, MPH, CHCIO, FCHIME

No Conflicts of Interest

Ashish Atreja, MD, MPH, FACP

Scientific Founder, Rx.Health (Stocks, Board seat)

Conflict of Interest

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• Value based health care transformation

• Potential for Digital Medicine and Digital Therapeutics

• Platform approach to unify and transform health systems

• Aligning Strategy with IT for Digital Transformation

Agenda

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Learning Objectives

1. Describe how value based care is making business

case for a new wave of digital health technologies

2. Assess successful case studies of digital medicine

adoption by patients and providers

3. Identify ways in which digital transformation can

become sustainable and scalable through a platform

approach

Dr. Shafiq RabSVP & CIO

HIMSS 2019

Things That Haven’t Changed

• The problem we are trying to solve• The value of IT• Improving daily efficiency• Getting consensus to adopt which has

become more important as technology transforms

So What’s Changed?• Connectivity• Machine learning and AI is there• Mobility • Contextual facial recognition• Crisper• Genomics itself• All the tools to profile a patient• Augmented reality• Use technology to increase business and retain patients

Blue ButtonInteroperability

Hospitals & Clinics

Analytics

Proteomics

Genomics

IoT & Wearables

Location Spending

HabitsNutrition Social

Determinants &Mental Health

Rx Network

EHRMy Life

BankPersonalProfile

Cardiologist

Ap

po

intm

ent

sER

Vis

its

Patient & Family

Care Coordinator

Oracle

Power BI

Caradigm Azure MachineLearning

AzureStream

PopulationHealth

Systems

DiseaseRegistries

What Makes Us - Us

TheCare

Continuum

Thank You

Discussion

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Ashish Atreja

Chief Innovation Officer, Medicine

Icahn School of Medicine, Mount Sinai

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Mount Sinai Health System

Founded in 1852

Not-for-profit Academic Medical Center

7 Hospitals, 1 Medical School, 15 Institutes

3500+ beds, 135 operating rooms

12+ Ambulatory Surgical Centers

200+ community location around New York

36,000 employees

~ 7000 Physicians

2.6 million outpatient visits

500 thousand ER visits

170 thousand inpatient visits

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Provider Organizations are Unprepared for

Value Based Care

Value based care has

arrived

50% of unprepared for bundles and

MACRA

76% of hospitals face

readmissions penalties

http://khn.org/

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This is our Burning Platform

Courtesy Mike Berger, Mount Sinai

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Accenture, 2016

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http://blog.tauedu.org/medical-jokes-doctor-and-patient

We need tools to

address

triple whammy!!!

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CIOs New Responsibility

Going beyond the EHRs to enable digital transformation

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Emergence of the new field of Digital Medicine

265,000 Mhealth Apps

Telemedicine

Linked Wearables

AI/Machine Learning

Secure Messaging

Augmentic/ Virtual Reality

Voice commands/ Alexa

Chat Bots

Biomarkers, CRISPR

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In RCT, patients using BlueStar saw a greater mean A1c

decline than those receiving usual care: 1.2% (1.9% vs

0.7%) over a 12 month period

Quinn, C et al, Diabetes Care, 2011

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From: Effect of Lifestyle-Focused Text Messaging on Risk Factor Modification in Patients With Coronary Heart

Disease: A Randomized Clinical Trial

JAMA. 2015;314(12):1255-1263. doi:10.1001/jama.2015.10945

Enrollment of Participants in the TEXT-ME Randomized Clinical TrialLDL-C indicates low-density lipoprotein cholesterol.

At 6 months, levels of LDL-C were significantly

lower in intervention participants (mean

difference, −5 mg/dL with reductions in systolic

blood pressure (−7.6 mm Hg) and BMI (−1.3),,

and a significant reduction in smoking (26% vs

44%; relative risk, 0.61 [95% CI, 0.48 to

0.76]; P < .001).

The majority reported the text-message

program to be useful (91%), easy to understand

(97%), and appropriate in frequency (86%).

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Government Support for Digital Health and Evidence

What

• Startup Days

• FDA – Pre-Certification Program

• CMS – new CPT codes

• 21st Century Cures Act

• AHRQ – Set Up App Challenge

Significance

Support for innovation,

telehealth and reducing

regulatory barriers

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Google AI Retinopathy

• 9963 images from 4997 patients

• Algorithm based on deep machine learning had high sensitivity and specificity for detecting referable diabetic retinopathy

• Could lead to improved care and outcomes, especially in areas with access issues to ophthalmologic assessment

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Envisioning digital care in year 2020

Virtual care (telemedicine and messaging)

24/7 tracking (remote monitoring)

Population health (AI,predictive analytics)

Empowerment (SDH, AR, peer networking)

Prescribing Apps (digital therapeutics)

@ Fraction of Cost and Time

Paul Sonnier, Storyofdigitalhealth.com

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Digital Health: Problem of Plenty with Point and Click Solutions

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• “In the wake of reports that question the accuracy and effectiveness of [Theranos’] technology… health-tech companies will now face a greater burden of proof to demonstrate that their technology is effective.”

The ‘Burden of Proof’

Future generations of startup founders should ensure they are working with

venture capital firms that have ample experience in health care. These

investors will understand that it takes time to build a successful and long-

lasting company.”

- Christina Farr, Fast Company

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Evidence-Based Digital Medicine

(EBDM)

RIGOR

Evidence-based

Medicine

INNOVATION

Digital

Technologies

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NODE Health: Network of Digital Medicine

20+ Health Systems: HIMSS, AMA, ACC, Academy Health

Learning Network of

Digital Transformation

To become the

Largest Validation NetworkHospital

System &

Patients

Startup

Grant

Agency

Industry

Pharma

Payer

VC

and

Angel

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Digital Medicine Conference

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03nd Annual

Digital Medicine Conference

Thurs, Dec 4- 6th

New York City

Innovation, Evidence and Transformation

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Digital Prescription Platform to Support

Scalable Transformation by CIOs

INNOVATION

EVIDENCE

Transformation

EHR for fee for service care

Digital Prescription Platform for Value based care

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“The Digital Daisy to Unify Fragmented Digital

Medicine”

Digital

Experience

Digital

Gateway

Telemedicine

mHealthData

Analytics

Innovation

Courtesy Bruce Darrow and Digital

Medicine Team, Mount Sinai, NY

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Creation of First Digital Prescription Platform to

Prescribe Digital Assets, Right Within EHR

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Digital Toolkits Deliver Value

Multiple validated use-cases developed and delivered through Digital Medicine Platform

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Heart Failure Readmission Reduction

Quality improvement trial monitoring CHF

patients 30 days post discharge. Patients

prescribed app + devices

40% 73%

Readmission

Rate reductionActive Patients

Chronic Disease Management

NIH sponsored, 2-year pragmatic

randomized trial collecting electronic patient

reported outcomes in IBD Patients

3x 75%

Quality of Life

ImprovementActive Patients

After 2 Years

Provider Acceptance

Within 8 weeks, more than 2000 digital

app prescriptions by providers

96% 92%

System Usability

ScoreActivated

Patients

Digital Toolkits Deliver Value

Multiple validated use-cases developed and delivered through Rx.Health’s platform

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Heart Failure Readmission ReductionQuality improvement trial monitoring

CHF patients 30 days post discharge.

Patients prescribed app + devices

40% 73%

Readmission Rate reduction

Active Patients

Chronic Disease Management

NIH sponsored, 2-year pragmatic

randomized trial collecting electronic

patient reported outcomes in IBD Patients

3x 75%

Quality of Life Improvement

Active Patients After 2 Years

Provider Acceptance

Within 8 weeks, more than 2000 digital

app prescriptions by providers

96% 92%

System Usability Score

Activated Patients

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Digital Prescription Platform:

Increased Patient Activation to

92%

Patient activation:

92% patient engagement during in-person prescription

Provider Validation:

96th percentile rank in System Usability Scale for provider

Usability and 90% ile for Learnability

Makhni S et al. AMIA Annual

Symposium 2017, 9 Nov. 2017

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Validated Use-Case- Apps (MIPS) Long Term Patient Engagement and QI

Atreja A, et al. Impact of the Mobile HealthPROMISE Platform on the Quality of Care and Quality of Life in Patients With

Inflammatory Bowel Disease: JMIR Res Protoc 2015;4(1):e23

In a pragmatic randomized trial at Mount Sinai

Medical Center (MSMC), patients using Health-

PROMISE could update their e-PRO information

and receive a disease summary.

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Validated Use-Case- wearablesTransitions of Care and Readmission

ReductionThrough the use of the mobile application,

HeartHealth, healthcare providers are able to

remotely monitor their patients’ blood

pressure and weight in the 30 day high risk

period post discharge.

Pinney S, et al. | Use of Electronic Patient Reported Outcomes and Automated Devices for Heart Failure Disease Management |

iproc 2017;3(1):e24 and ACC 2018 (to be presented)

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• Paper based nurse assessment not scalable

• Using Structured and Unstructured Data in EHR

• Prescribing SDH Assessment directly to patients and caregivers Smartphones

– Actionable data directly from patients or caregivers

– Cellphone numbers accuracy

– iOS, Android

– Empty fields- hold value

Fast Tracking Assessment of SDH using SDH Prescription

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Integration with EHRs and Care Management Systems

Allowed Bulk Prescribing for Pop Health and

Replicate Success Stories with other Health Systems

Traditional ADT,

HL7

Ubiquitous

But Inefficient

Data Warehouse Stored Procedures

EHR Reports Reporting Workbench

2005s

APIFHIR

Automate data export through

stored procedures

Capability and access vary by

individual site

One click upload of reports

through Secure FTP

Low technical skills required

Most advanced and efficient

Not widely available yet

1990s 2000s 2016-

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CASE STUDY

14%

Engagement Rate In 12 Hours

Within 12 hours of the initial

message being sent, 14% of

patients replied with more

replying over the next 48 hours

Opt-out rate

Only 2.6% of patients opted out

of the Asthma Care Plan,

showing that digital engagement

can be high when done in the

right way

2.6% 100%

ACT Completion Rate

Every patient that started the

ACT survey, completed the ACT

survey showing that a 5 question

survey isn’t burdensome for

patients

SBH Health: Bulk Prescription of Care

Plans

For DSRIP Asthma Pop Health InitiativeCurated Digital

Solutions Digital

Toolkits

Care PathwaysIntegrated Clinical

Workflow

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Yale Experience: Enterprise

wide PHR Onboarding with bulk

prescription

A recurring report of patients offered activation code but who

had not yet registered was uploaded to RxUniverse

Patient List

Provided by Yale

New Haven

23450

Digital Rx Sent

1488 (6.33%)

not cellphones

21909

Clicked in 24 hrs

Within 24 hours,

2170 (9.86%)

Clicked

2170

Clicked in 7 days

10.81% Clicked

by end of 7 days

2378

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Real Time Clinical Trial Recruitment and Engagement

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ROI by decreasing no-shows and better pre-

rehab through digital care plans for

Procedures and Surgeries

20%

Good to Excellent Bowel Prep Reduction in inadequate prep

58% 92%

Useful or very Useful

Colonoscopy and Surgeries: Major source

of revenue leaks

Percentage of patients with missed or delayed appointment

(~6%, 15%)

Percentage of patients with poor preparation (15-25%)

Percentage of patients with ER after procedures (2-8%)

Patients not coming back at recommended intervals (30-

70%)

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Stitch Different Assets in Digital

Toolkit Together and deliver them on

demand throughout patient journey

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• There is an urgent need for CIOs to support Digital Transformation

• By unifying different solutions under one EHR connected platform, one can solve the problem of plenty and fragmentation created by point and click solutions

• Strategic deployment of platforms can yield exponential ROI for pop health as well as fee for service care, while enhance patient experience and outcomes

• Through sharing and learning networks, health systems can fast track their transformation journey

In Summary: Digital Medicine is new Health IT

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Questions

@cioshafiq @atreja