By John R. Dayton, MD in conjunction with NODE.Health
The Emergency Department (ED) is the entryway to the healthcare system for one-third of Americans every year. Digital tools can be used to improve healthcare before, during, and after an ED visit. On May 20th, NODE.health hosted a webinar, moderated by Dr. Rosner, a Physician and digital health researcher, with three Emergency Physicians on how digital health can be used in the context of COVID-19 to improve clinical decision making, and address public health issues. This article is a summary of the webinar.
Dr. Megan Ranney
As the Emergency Department serves as the front door to the American healthcare system, with over 130 million patient visits per year, she notes that these encounters represent an opportunity to deliver digital health interventions. She breaks these down into three time periods to emphasize opportunities at each stage of care:
Dr. Ranney is an Emergency Physician and the Founding Director of Emergency Digital Health Innovation (EHDI) at Brown University. She is focused on using digital tools in the Emergency Department.
- Pre-arrival and Triage: summarize symptoms, use predictive risk analytics, and screen for public health concerns
- ED Treatment: diagnose and educate, and engage patient and family in the treatment plan
- Post-ED: utilize feasible and effective treatment programs and give links to resources
Emergency Digital Health Innovation program goals:
At EHDI, Dr. Ranney focuses on identifying and addressing public health issues during the ED visit. Her group’s work includes COVID symptom trackers, text-message-based mental health and violence prevention, opioid use education, and wearables for fall prevention. Her goals at EHDI include gathering evidence for ED-based digital health solutions, emphasizing the essential role of ED to prevent worsening of long-term health conditions, and increasing education and collaboration with NODE.health and other academic centers.
Current research projects include the following:
- Smartphone application addressing medication adherence for high-risk HIV+ patients
- Smartphone application addressing violence prevention in adolescents focused on decreasing fights and improving mood
- Crisis text line for patients dealing with emergent mental health concerns
- Digital symptom checkers using predictive analytics with patient-reported symptoms to guide medical care of patients
EHDI is also focused on scaling digital health solutions through private and public partnerships:
- The Prevent Overdose RI platform uses data from the ED to show which communities are most at risk for opioid overdose, guides resource allocation, and develops predictive scores for which patients might be at risk
- Partnership with Marigold Health to create online peer support groups for opioid use
During the Question and Answer portion of the webinar, Dr. Ranney discussed utilizing randomized control trials and emphasized that evidence for digital health solutions can be obtained through trial designs and research. She also stressed that it is important to evaluate potential harms of digital health tools from both a privacy and ethics framework.
For example, the data from COVID19-specific symptom trackers, or self-triage applications, is variable, so there’s a major risk of mis-triage. If someone is told they’re fine, when they actually have COVID-19, they could be falsely reassured, spend time in close proximity with uninfected people, and transmit the infection. Also, if the symptom checkers are too sensitive, the system will be inundated by people asking for tests that they may not have. There are a few symptom checkers with encouraging data, including the one being used by Rhode Island, created by Diagnostic Robotics, but this is an area that needs more validation research.
Dr. Ranney also spoke about the changes to the regulatory environment for digital health tools brought about by the pandemic. For example, there has been a relaxation of HIPAA requirements surrounding telehealth and related interactions. This has sped the integration and deployment of both applications and the expansion of payment for telehealth.
You can follow Megan on twitter at @meganranney and Brown’s Emergency Digital Health Innovation at their website.
Dr. Joseph Habboushe
Dr. Habboushe is an Emergency Physician at NYU Langone Health and Bellevue Medical Center in New York. He is also the CEO and Founder of MDCalc. Their mission is to support clinical decision making with medical calculators, evidence-based scoring systems, and algorithms. MDCalc currently has over 550 of these tools that are used by 65% of physicians.
To illustrate the value of clinical support tools featured on MDCalc, Dr. Habboushe discussed the Canadian CT Head Injury/Trauma Rule, developed by Dr. Ian Stiell. Although patients frequently request these CT scans of their heads after injury, research has shown that up to 70% of these studies are unnecessary. Dr. Stiell researched which risk factors correlate with major head injury and created this scoring algorithm to determine which patients benefit most from a head CT. This scoring tool can be used to allocate healthcare resources, prevent unnecessary spending, and avoid unnecessary radiation exposure.
Although many patients initially request a head CT, this clinical decision tool can be used to discuss why the study may be unnecessary. Using this decision tool, along with shared decision making, can help prevent unnecessary costs and radiation exposure.
Clinical Decision Tools and Integrations with EHRs:
In addition to their free app and web-based platform, MDCalc is currently partnering with academic centers like Yale and the University of Utah to integrate these clinical decision tools into Electronic Health Records (EHRs). Using EHR software-driven suggestions and auto-fill features, they have been able to enhance patient care:
- University of Utah Cardiologists use auto-populated data from their EHR to check the CHADS VASC score and evaluate the stroke risk for patients with atrial fibrillation.
- Yale Emergency Physicians use the Emergency Department-Initiated Buprenorphine for Opioid Use Disorder (EMBED) to assess opioid use disorder, opioid withdrawal, and treatment-readiness for ED-initiated Buprenorphine treatment.
MDCalc and COVID-19 To address COVID-19, MDCalc has a dedicated page with clinical decision tools related to ICU care, intubation, and resource allocation. Dr. Habboushe recommends using scoring tools especially for COVID-19 patients because this is a novel disease with huge variability in practice. Treatment practices need to become more standardized, especially in low-resource areas. Their Epic EHR-integrated COVID-19 Toolkit meets requirements for FEMA and 75-90% of those cases are eligible for federal reimbursement
During the Q&A session, Dr. Habboushe spoke about how calculators require strong evidence before they can be used for patient care. He noted it is also important for physicians to understand how the research was designed and to be familiar with their recommendations. For example, some tools, like the Canadian CT Head Rule, are sensitive, but not specific. Because tests with high sensitivity help “rule in” pathology, and tests with high specificity help “rule out” pathology, misapplication of this rule could actually result in a higher rate of CT scans. Familiar with research related to scoring tools will enhance physician practice and facilitate better conversations with patients.
If you want more information about MDCalc, EHR integration, and their COVID-19 Toolkit, contact Dr. Habboushe at [email protected].
Dr. Brian Blaufeux
Dr. Blaufeux is an Emergency Physician and the Regional Chief Medical Information Officer for Northwell Health. Northwell is the largest healthcare system in New York, employs 72,000 workers, and Dr. Blaufeux oversees Westchester County. Northwell uses an internal Health Information Exchange (HIE) that compiles data from their hospitals, ambulatory practices, urgent cares, labs, and care coordination department. Northwell Health has developed 3 different informatics solutions in response to COVID-19:
NORA Chatbot: Data from Northwell’s HIE can be viewed by any provider in their system, supports workflows for their patients, and feeds NORA, their internally-developed AI tool. NORA provides physicians with lab results and vital signs pertinent to COVID-19 and other pathologies. Physicians also use NORA to receive alerts when lab results are available.
Automated ‘treat and release’ protocols: Many patients get COVID testing in the ED and these tests are sent to the Northwell core lab. Patients who are stable enough to be discharged home can consent to receive automated test results via text, email or call (via Telavox) after they are discharged from the ED. If two automated call attempts fail, the patient is then moved to a manual call list managed by Northwell’s call center.
Also, Some ED patients are discharged with pulse oximeters. Oxygen saturation readings are transmitted to Northwell’s Health Information Exchange (HIE) and the patient is enrolled into an automated communication solution. Low oxygen saturation readings trigger follow-up calls.
Northwell COVID Survival Calculator (NOCOS): The NOCOS calculator was trialed on over 5,000 patients in 13 hospitals. Multivariate regression was used to determine predictive factors for COVID survival. The manuscript under review can be found here. The COVID survival short list includes: age, Emergency Severity Index, and lab results. Once NOCOCS is fully validated, Northwell intends on using scale to help determine who is safe to go home.
During the Q&A session, Dr. Blaufeux highlighted the importance of digital health tools being integrated into the clinical workflow. For example, this includes integration into the EHR and easily-accessible mobile apps. An ideal solution is available, simple and uses EHR features like auto-populate to pull data for quick access for a busy physician. He also stressed that we need to make sure that these digital tools are followed and validated by rigorous science.
To contact Dr. Blaufeux about his work with Northwell and addressing COVID-19, you can reach him at [email protected]
- Emerging resources include medical calculators and clinical decision tools, chatbots, and symptom checkers
- Healthcare data can be used to improve patient care and treatment outcomes
- Digital tools can be used in the Emergency Department to improve care before, during, and after Emergency Department visits
- Innovative use of digital tools like clinical decision tools, EHRs, telehealth, apps, and wearables may improve resource allocation and treatment decisions for COVID-19
- Digital tools can produce the best results when they are backed by research and used properly
About the Author
John R. Dayton, MD, is an Emergency Physician, educator, and entrepreneur. He is an Adjunct Faculty member at the University of Utah, Past President of the Utah College of Emergency Physicians, and a NODE.health Scholar Mentor. John writes about medical innovation for Emergency Physicians Monthly, advises healthcare startups, and is the founder of MedForums.com, a ‘yelp’ for medical education. He can be reached on Twitter at @drjohnnyd and at [email protected].
NODE.Health Foundation is a 501(c)(3) non-profit organization dedicated to education, validation and dissemination of evidence based digital medicine. As the largest professional association in digital medicine, NODE.Health empowers societies, executives and NODES from health systems, payers, life sciences, venture capital, startups and the public sector involved in healthcare digital transformation. NODE.Health does not endorse any specific products or services.
NODE.Health is pleased to cross post this summary of the webinar by highlighting expert opinions and examples of digital health tools used in the emergency department, especially during COVID times. NODE.Health encourages its readers to be diligent with selecting such tools and understand the evidence. As more evidence comes out on the use of such tools for COVID-19 and beyond, NODE.Health will keep its readers informed about the latest developments. Interested in learning more about the Network of Digital Evidence (NODE.Health)? Click here