Unexpected findings

It's fascinating to meet people in healthcare and hear them dismiss the potential value of a tool like Twitter. Despite an increasing amount of noise, I do find it a great place to listen and learn. For me personally, it's been a very powerful tool, and has taken me to places I've never imagined. One of those places is Cedars-Sinai Medical Center in Los Angeles, California. By chance, I'd come across Dr Brennan Spiegel on Twitter earlier this year, and through our online interactions, discovered that we had common interests in Digital Health, especially in the context of understanding whether these new digital tools and services being developed are actually having an impact in healthcare.

Dr Spiegel is Director of Health Services Research at Cedars-Sinai Health System, Director of the Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), and Professor of Medicine and Public Health in Residence at UCLA. I was particularly intrigued by the work he does at CS-CORE, where he oversees a team that investigates how Digital Health technologies, including wearable biosensors, smartphone applications, and social media, can be used to strengthen the patient-doctor bond, improve outcomes, and save money. So whilst I was out in California, I popped into Cedars-Sinai Medical Center to spend some time with him and his team to understand their journey so far in Digital Health.

With Dr Spiegel and the CS-CORE team - the picture was taken remotely using Dr Spiegel's Apple watch! 

With Dr Spiegel and the CS-CORE team - the picture was taken remotely using Dr Spiegel's Apple watch! 

To give you some context, Cedars-Sinai Medical Center is a non-profit, has 958 beds, over 2,000 doctors and 10,000 employees. It's also ranked among the top 15 hospitals in the United States, and is ranked first in Los Angeles by US News and World report. In addition to Dr Spiegel, I met with Dr Christopher Almario, Garth Fuller, and Bibiana Martinez

What follows is a summary of the Q&A that took place during my visit. 

1. What is the big vision for your team?
"The big vision is value of care. Value is our true north. It puts patients first while also reminding us to be judicious about the healthcare resources we use. Take Cedars-Sinai, a traditional volume based center of excellence. How do we transform our hospital, that has excelled in the fee-for-service healthcare environment for so long, and transform it into a value-based innovation center while maintain our top-notch quality of care? It seems like a magic trick to transform from volume to value in healthcare. How do we do it at scale, and how do we keep people out of hospitals when healthcare systems have  been designed to take people in? Our mission is to figure out how to do that. This could be a blueprint for how other health systems could do this and which doctors could do this. How do we align incentives? How do we create a Digital Health strategy that works within the existing clinical workflow? How might we use an E-coordination hub? These are all open questions ready for rigorous research. 

What does innovation mean at Cedars-Sinai? We see ourselves as a hub of innovation and are now developing a new 'Value Collaboratory' under the guidance of our visionary leader, Scott Weingarten, who directs Clinical Transformation at Cedars-Sinai. We offer a set of tools to help value-based innovators make a difference. We're going to be doing a lot over the next 5 years. Digital Health is just one small part of that. The Value Collaboratory will be the centre for ideas within Cedars. For example, if innovators seek internal funding for a project, then they can work with the collaboratory to refine their idea, evaluate its health economic potential, and create a formal case for its support."

2. Tell me more about the team, what types of people work in CS-CORE
"There are 12 of us in CS-CORE, and we have a combination of health system and statistical expertise. We have social scientists, behavioural scientists, mobile health experts and more. It's a multi-disciplinary team. For example, Dr Almario is a gastroenterologist, who has always been interested in health services research, and was awarded a career development award from the American College of Gastroenterology, which is very rare, in Digital Health to pursue research. Garth Fuller with a background in health policy and management has been working with us for the last 5 years and has a strong interest in medication adherence, and conducts research to understand how we can show that 'Beyond the Pill' strategies in the pharma industry are working. Bibiana Martinez with her background in Public Health is hands on, and works with our patients. Bibiana helps filter the real world barriers faced in Digital Health research and bring them back to our team. We have an all-hands-on-deck research crew."

3. What has surprised you during your research in Digital Health?
"We've had some unexpected findings. For example, we had a patient who reported less pain, and our original expectation was that the data from her wearable would report that she had been walking more, as the pain was subsiding. However, that wasn't the case, as her pain decreased, she was walking less. It turns out the patient was an author, and being free of pain meant she could sit for hours on end and finish writing her book. Completing the book was the outcome that mattered to the patient. What should we do when a patient's steps fall from 1,500 a day to almost 0? Do we give them a call, simply because we perceive it as unhealthy? How often does your doctor ask you what your goal is for your visit? I show these charts of pain vs steps when I teach my health analytics class at UCLA, to challenge how my students think."

4. How else have your assumptions about how patients use Digital Health tools been challenged?
"In healthcare, we often make a lot of assumptions about the needs and wants of patients. We have been fitting Virtual Reality goggles with hospital patients, so that we can transport them from their hospital bed to far away places such as Iceland. One patient asked if we could transport him somewhere more tropical, as the hospital is cold, and having a VR experience in Iceland made him feel even colder. 

We had an instance where a patient wasn't able to charge her Fitbit. We tried to explain over the phone, but it actually required a house visit in order for this patient to understand how to charge the device. We thought we could put sensors around the ankle joint of patients to measure steps, and some patients felt like they were under house arrest when wearing our sensor on their ankle."

5. What are some of the most exciting projects you're working on today?
"Well, we create our own technologies and sensors. We find out soon if our first sensor is approved by the FDA. Also, with the vision of our hospital Enteprise Information Services (EIS) team, our hospital's EHR is now connected to Apple's HealthKit, it's a great achievement, we now have 750 people pouring in real-time sensor data into our EPIC Electronic Health Record. We've also developed My GI Health, a patient provider portal which by gathering information on symptoms in advance of a visit to the doctor, helps us learn more about a patient's GI symptoms. The computer doesn't forget to ask questions, but sometimes the doctor forgets to ask questions. Although much of our research is in GI, we are working across healthcare. We are now building a version of My GI Health for rheumatology, for example. We are also interested in testing whether the first visit to a specialist doctor should be virtual or in person? What would patients & doctors actually want? We are putting a study design together now that will compare both types of visits."

6. What are some of the challenges you face in your research?
"The research we do is often challenging for the IRB because it’s so different.  We work closely with our IRB to explain the nature of our work. As more academic groups conduct Digital Health research, it will be important that medical centers develop regulatory expertise around this type of work.

There is also an urgency to test quickly, fail quickly and succeed quickly. What we need is a high level discussion to understand what risk means in the context of Digital Health research. Can we generate evidence faster?"

7. What are you doing to help ensure that no patient gets left behind in Digital Health?
"We are soon going to start a community-based study in partnership with African American churches in Los Angeles. We will work with these 'mega churches,' which have up to 10,000 congregants, and will distribute healthy living experiences delivered by Virtual Reality goggles using Google Cardboard.  We will also use an app for obesity and diabetes management. We observe that many families from minority backgrounds are mobile first, and we see that the next digital divide is opening up over mobile. Healthcare isn't built for mobile. We are also researching the mobile usability of hospital websites across America."

8. What message would you like to share with others also on the same journey as you?
"Listen to the patients, get used to Digital Health being dirty and difficult, it may be harder than you think. We can say that with some authority now, that it can sound easy, but in reality it's been very hard. Our team has developed devices and applied them directly to patients; what happens next is often unexpected and challenges our assumptions. Digital Health is really hard to do. We have to focus on the how of Digital Health. We understand why it's valuable, but not as much about how we will be doing it. Value is another big theme - we need to improve outcomes and reduce costs of care. It takes time to do it right. We also try to never forget the end user, both the physician and the patient. 

This work is 90% perspiration, and 10% inspiration. You need to have a sense of humor to do this because, you’re going to get a lot of unexpected bumps and failures. It’s a team sport to figure it out. Defining the problem in terms of the health outcomes and costs is the key, and generating a solution that has value to patient and providers is paramount.. 

Finally, the 'cool test' is so seductive. Don’t been fooled by the 'cool test' in Digital Health. What may be cool to us may not be cool to the patient. Don’t be seduced by the 'cool test' in healthcare."

I really enjoyed my time with Dr Spiegel and his team, not only because of the types of research they are doing, but also because of their vision, values and valor. Their unexpected findings after putting new devices on patients has subsequently made me think at length about health outcomes. I was reminded about the human factors in healthcare, and that both patients and doctors don't always do what we expect them to do. I'm glad CS-CORE are not just thinking from the perspective of medicine, but through the lens of public health too, and how to ensure that no patient is left behind. I'm not the only one who is admires their work. David Shaywitz, has recently written a post about the research conducted by CS-CORE, and mentions, "they are the early adopters, the folks actually in the arena, figuring out how to use the new technology to improve the lives of patients." 

Dr Spiegel did admit they've been under the radar so far, focusing on putting “one foot in front of the other” in research mode while working with a wide variety of partners from industry and academia. The team is also looking for collaborators who want to road test their digital health solutions in a “real world” laboratory of a large health system. Their team is equipped to conduct stem-to-stern evaluations with an eye to rigorous research and peer-reviewed publications. I see that Dr Spiegel is one of the speakers at the Connected Health Symposium later this week, as part of a panel discussion on Measuring Digital Health Impact & Outcomes. I won't be there but I hope to be part of the live Twitter discussion. 

Since my visit, I note that Cedars-Sinai and Techstars have partnered to launch a Digital Health focused accelerator. What does this accelerator aim to do? The website states, "We are looking for companies transforming health and healthcare.  Companies that are creating hardware, software, devices and/or services that empower the patient or healthcare professional to better track, manage, and improve health and healthcare delivery are eligible to apply." Techstars is one of the world's most highly rated startup accelerator programs, the other being Y Combinator. It's fascinating to see the marriage of two very different worlds, and who knows what unexpected findings will result from this partnership. In the 21st century, when we think of radically different models of care, startups and emerging technologies, large traditional hospital systems are not the first place we think of looking for them. Maybe the lesson here for large healthcare institutions is to "disrupt or be disrupted?"

In the world of Digital Health, the trend of moving healthcare out of the hospital into the home, virtual visits and telemedicine may be causing concern to hospital executives. If all of these converging technologies (often coming from startups) really are effective and become widely adopted, then surely we will need smaller hospitals, or perhaps in certain scenarios, we may one day not need to have that many hospitals at all? Perhaps the hospitals that survive and thrive in the 21st century will be the ones that boldly explore the unknown in Digital Health, rather than the ones that hide and hope that the world of Digital Health will just be a passing fad? 

“It is the tension between creativity and skepticism that has produced the stunning and unexpected findings of science.” - Carl Sagan

[Disclosure: I have no commercial ties to any of the individuals or organizations mentioned in this post]

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