Duke ITAC - July 28, 2016 Minutes

Duke ITAC - July 28, 2016 Minutes

ITAC

Meeting Minutes

July 28, 2016

I.  Announcements

Recent Phishing Attack:  Richard Biever reported that there was a recent phishing attack that contained ransomware - software designed to block access to a computer through encryption until a sum of money is paid.  The attack targeted faculty and staff in Duke University and Duke Medical Center.  Security teams from Duke University and Duke University Health System worked together along with the Enterprise Internet Services (EIS) team to quickly identify and contain the impact.  

In response to the event, we’ve adjusted the protection in the email phishing and spam protection system to account for these types of attacks.

There were several questions and comments; however, it was recommended that the topic be explored in more detail at a future meeting due to time constraints.

II.  Agenda Items

4:05 – 4:20 – Duke IT Internship Program, Scooter Freeney, OIT Human Resources Director (10 minute presentation, 5 minute discussion)

What it is:  The Duke IT Internship program is run by the Office of Information Technology.  In this role, OIT facilitates recruitment, placement and assessment/evaluation of internships.  Scooter will provide an overview of the program and current service offerings.

Why it’s relevant:  At Duke University, IT services and support are provided by various groups of IT professionals with a single goal in mind: to provide the highest quality and sustainable information technology services in support of Duke’s academic and research missions.  The Duke IT Internship program focuses on acquiring fresh ideas and talent that enhance our ability to support this goal.

Overview:  The IT internship program run by OIT is in its 3rd year.  The original goal of the program was to offer opportunities to underrepresented groups in the IT industry.  The program has grown from just 4 interns in its first year to 14 in the current year.  We have students from local universities including ECPI University and N.C. Central University as well as two students from local high schools.  The original goal of the program to offer opportunities to underrepresented groups is still being met.  Out of the 14 interns, we currently have 7 females and 4 minority group participants in the program. 

The program continues to provide opportunities to students to get introduced to Duke and higher education.  The students who have taken part in the internship have told us that they never would have thought about a career in higher education if it had not been for the internship program. 

Expansion:  We are extending the placement of interns beyond OIT.  We are currently working to place an intern at DHTS.  There also has been interest from other IT departments on campus.  OIT will help place students in these expanded areas to set up a program tailored to fit their needs as well as the interns’ needs.  This past year the Diversify IT group offered a training session to interns to help them improve their interviewing skills.

Question:  Are we seeing a disparity between our supply and demand for interns?  Answer:  Our supply is not meeting the demand.  The students have been very impressive which is driving the demand.  We need more students.  Let Scooter know if you would like to refer someone or have recommendations for sourcing.

Question:  Are these paid internships?  Answer:  Yes.  We follow Duke’s guidelines and pay scale for student workers.

Comment:  OIT worked with Arts and Sciences to help them set up an internship program that would meet the needs of their department as well as the needs of the interns.  We want to provide learning opportunities.  These are bright students that we’d like to transition from student intern to employee upon graduating.

Question:  Do interns have to be students?  Answer:  They have to be in some kind of educational program.

Question:  Where were the high school students from?  Answer:  Durham Public Schools – they have 6 programs designed around IT.  Comment:  Hillside High School and North Carolina School of Science and Mathematics might be good schools to reach out to.

4:20 – 4:40 – Innovative Clinical Research – Telehealth at DCRI, Dr. Kevin Schulman (10 minute presentation, 10 minute discussion)

What it is:  The mission of Duke Clinical Research Institute is to develop and share knowledge that improves the care of patients around the world through innovative clinical research.  Dr. Schulman will discuss potential opportunities and assets being used by DCRI through the merger of technology and medicine.

Why it’s relevant:  As part of the Duke University School of Medicine, the Duke Clinical Research Institute is known for conducting groundbreaking multinational clinical trials, managing major national patient registries, and performing landmark outcomes research.  As the need for access to Duke’s world class medical care increases, so does the need for technology to support it.

Background:  For over a decade, Dr. Schulman has been the Director of The Master of Management in Clinical Informatics program at Duke.  The full-time degree program has 25 to 30 students per year and runs every other weekend so that professionals can participate.  The goal of the program is to teach people how to use technology to have an impact on healthcare.  Dr. Schulman designed and currently teaches a class called Health IT Strategy where students look at ways technology can be used to improve quality and reduce cost. 

Connectivity Evolution:  Dr. Schulman presented the evolution of connectivity of healthcare records and obstacles that we are still facing today.  There is one big question that we have struggled with for decades.  How do we achieve connectivity of healthcare information when there are multiple data islands that reside in labs, pharmacies, dentist offices, hospitals, and physician offices to name a few? 

Over the years we have seen attempts to answer that question.  The Clinton Health Reform of 1993 proposed carrying around a health ID card that would contain patient information on a microfiche strip.  In 2004, Dr. David Brailer mapped out the Regional Health Information Organization (RHIO) Strategy which promoted the adoption and use of interoperable electronic health records so that information could be shared across regions, networks, organizations and providers.  A few years later, physicians began using the Health Information Exchange (HIE) to electronically share medical information with other providers to better coordinate the care of Medicaid patients.  HIE is the electronic transmission of healthcare-related data among facilities, health information organizations (HIO) and government agencies according to national standards. 

About a decade ago, Duke rolled out HealthView Portal which provided a unified health site where patients could view their personal health profile, clinical content and account information.  Although the portal had benefits other technologies didn’t like remarkable online images and tracking of implanted medical devices in case of product recall, it had its drawbacks including sustainability issues.  In 2013, Duke transitioned to a new electronic medical record (EMR) technology called Maestro Care (Epic) with the goal of having one patient, one record for one health system.   Nonetheless, there remain challenges to effective connectivity of electronic patient information.  Some of the issues that we are still facing include:

  • Non-standardized implementation of EMRs across providers, even when the EMRs are from the same vendor, makes sharing data across provider systems a challenge.
  • Patient access to health data is limited and difficult to comprehend.
  • EMRs are expensive – the financial benefit of an EMR is realized under capitated models (payment per person rather than payment per service) by keeping patients out of the hospital.

Moving Forward:  Recently, Duke students have developed a new data architecture whereby the patient’s personal health record is located on their mobile device.  The objectives of the new approach to connectivity are to (1) empower patients to easily store, access, understand and utilize their health records from their mobile device and (2) provide interactive and customized health information and education to patients, enabling them to take ownership of their healthcare. 

The patient’s record on their mobile device could have several types of views including a provider view, a patient view and a clinically based view such as a diabetes view.  Since providers would still need access to data sets for public health reports and research, the backend could use data federation whereby data is collected from the database in the cloud or device without ever copying or transferring the original data itself.

Key features include:

  • Patients can have immediate access to their records.
  • Patients can control who can see their record, and how much information they will see.
  • A patient’s EHR can grow through the addition of health and service modules.
  • Patients can easily become informed about their diseases and treatments.
  • Patients can easily communicate and collaborate with their care team directly from the application and set goals to improve their health.

The next steps will include developing a mobile application prototype and conducting a pilot test in Nigeria.  There are significant legal issues surrounding patient data in the cloud.  However, we are working on the ability to do this while still maintaining the right protection around patient data. 

Comment:  It might be worth looking at library systems that share information among institutions to see if the architecture could be replicated in healthcare.  Response:  It is harder to share information in healthcare because the data structure isn’t standardized like it is for libraries. 

Comment:  Healthcare tests aren’t standardized so other institutions may not trust the data even if connectivity is achieved.

4:40 – 5:05 – Telehealth at Duke, Dr. Alex Cho & Donna Phinney (15 minute presentation, 10 minute discussion)

What it is:  Formally, telehealth is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.  As a measure of how rapidly the use telemedicine expanding, more than 15 million Americans received some kind of medical care remotely last year, according to the American Telemedicine Association.  Dr. Cho and Donna Phinney will discuss how the union of medicine and technology is being used to fulfill the mission and vision of Duke’s Global Health Institute.

Why it’s relevant:  Telehealth enhances communication across distances, facilitates teamwork and increases access to care, particularly in areas where access to health care is difficult to come by. 

Program Overview:  The Duke Telehealth Office (DTO) has been assisting Duke University Health System (DUHS) and the Private Diagnostic Clinic (PDC) in evaluating, developing, piloting and launching new telehealth services for over 2 years now.  It reports to an Oversight Board composed of DUHS, PDC and Duke Health Technical Services leaders.  The 4 core telehealth success objectives include:  (1) enhancing the patient experience, (2) financial benefit to patient, health system and/or physicians, (3) clinical quality and patient safety, and (4) strategic growth and retention. 

There are many steps the DTO takes to integrate the development and delivery of distance-based medicine.  The delivery of telehealth is very complex and is more about process than technology. 

Established Types of Telehealth Services:

Video Clinic Visits (Outpatient Consults at Community Practices):  Fixed-to-fixed telehealth model where a Duke provider uses a tele-presence workstation in a defined location to perform scheduled outpatient visits with patients referred from the community.   Example:  PDC ßà Practice/Facility

Video Visits (with Patient in Home):  Fixed-to-mobile telehealth model where a Duke provider uses a tele-presence workstation in a defined location to connect and provide clinical services directly to a patient in the home or other variable location, via secure Cisco Jabber video/MyChart.  Example:  Duke ALS Clinic ßà Home/Mobile

Telestroke (Duke Telestroke Network):  Provides hospitals with video-based emergency stroke consults and coverage, plus expedited transfer if needed and on-site provider & staff training.  Example:  Duke ßà Wilson Medical Center

Inpatient Video Consults (Routine Specialty Consults):  Fixed-to-fixed telehealth model where a Duke provider uses a tele-presence workstation in a defined location to provide live, video-supported remote inpatient consultations in lieu of traditional in-person consults.  Example:  Duke neurointensivist ßà Duke Raleigh Hospital

eCommunications (Dermatology, et al.):  Used when a PCP sends an “eCommunication” request to a Duke specialist, for remote specialty support for a specific clinical issue.  Can reduce unnecessary referrals and the time before specialty input can be applied to individual patients’ cases, improving access / capacity.  There is no reimbursement available.  Example:  PCP ßàSpecialist via Epic

Services in Development/Investigation:

Case Review (PowerShare)In Development:  A community physician or affiliated hospital wants to obtain a supportive opinion on a clinical case, involving review of a DICOM/other imaging/wav/pdf files by a Duke specialist.

E-Visits (MyChart Secure Messaging)Business Case Justification:  MyChart secure messaging encounters for established patients & providers.

Tele-Urgent Care/Acute Care (Partnership) – Still Investigating:  Investigating partnership options to support Urgent Care Centers and the Emergency Department so that patients can see an online Emergency Physician.  Example:  Tele-Urgent Care Provider ßà Urgent Careßà ER

Question:  Where can Student Health Services find out more information about video visits?  They would like to have something in place by August, but at the least by January.

Answer:  We currently don’t have the ability to know if the doctor is ready to see someone nor have the ability to park a patient in a queue in Cisco Jabber Video.  Around October 1st, however, we will be piloting Cisco Extended Care.  It will allow a link to be placed in MyChart so that the patient can click on it to initiate a teleconference session and be parked until a provider is ready.  Student Health Services is using Epic already so that is an option.  We might be able to implement something for Student Health Services by January.  Dr. Cho and Billy will meet with Tim Bounds to discuss this further.

5:05- 5:30 – The 6th Vital Sign App, Janet Bettger & Jacob Kelly (15 minute presentation, 10 minute discussion)

 What it is:  The 6th Vital Sign is a global research study that uses Apple’s ResearchKit to measure a vital sign.  Vital signs, like blood pressure or temperature are measurements used by doctors and nurses to show how a person’s body is working.  Recently, how well someone can do day-to-day activities has been recommended as the sixth vital sign to be checked.  Walking speed  is one way to see how well someone can perform these activities and has been shown to predict changes in health, predict falls, needing to go to the hospital and how long someone might live.  Janet and Jacob will discuss how the 6th Vital Sign App is being used to help determine the health of patients. 

Why it’s relevant:  Vital signs are how health care providers assess the health of patients.  They help doctors and nurses understand patients quickly and can be used to check for health risks.  Mobility, in particular is associated with every body system.  When walking speed becomes slower than what is normal for a person, it informs doctors and nurses that something could be going wrong with one of these systems. 

About the Study:  Jacob reported that walking speed is a more accurate predictor of life expectancy than just age or gender alone.  Walking speed also predicts cognitive function and mental and physical well-being.  More than any other vital sign (blood pressure, breathing rate, heart rate, pain, body temperature) walking speed can predict future falls, hospitalization and functional decline among older people.  The 6th Vital Sign Study goals are to:

  • Learn about walking speed and health as measured on a smartphone.
  • Create a 2MWT (2 Minute Walking Test) comparison chart by age and gender for all adults (like height and weight charts) and for targeted clinical sub-groups (e.g., stroke, cardiac, pulmonary, musculoskeletal, mental health, etc.).
  • Predict outcomes using a mobile-phone based assessment of walking endurance.
  • Establish gait speed as a vital sign measured in routine clinical practice (minimum: primary care for general health; hospital admission and discharge as markers of health status; post-injury and hospitalization specialty care to monitor recovery).
  • Communicate and widely disseminate norms, health risks, and geographic variation related to walking speed.  Expand this study to other countries (IRB approval, translate to other languages, etc.) and go global!

About the App:  The 6th Vital Sign App was created using Apple’s ResearchKit.  It was developed over a 10 month period with a soft launch of April 10th of this year.  The app is intended for use by iPhone 5+ owners older than 18 years of age and is intended to be used in a community setting.  Multiple accounts can be set up on the app to engage hard to reach participants that may be older, ill, sensory impaired, non-iPhone or smartphone users.  Only about 10% of hospitalized patients at Duke have an iPhone so having it intended for use in a community setting (family, friend or neighbor) was important.  Users can participate as a guest or they can set up accounts to participate more than once.  Participants can stop in the middle of the test and continue later and can complete the test anytime from anywhere.

How it Works:  The participant downloads the app from iTunes.  The participant will see a summary page, detailed information about the study, 3-4 demographic questions, a consent form, account creation page, walking instructions, 12 more demographic questions following a 2 minute walk and test results that can be saved and shared via email.  The walk test results include total distance, total number of steps, average speed, and population average.

Participants to Date:  In the first 50 days since launch, there were 1,111 views in iTunes, 771 downloads with 398 consenting to participate.   Participant demographic data:

  • 27 states represented
  • 65% within a 100 mile radius of Duke
  • 54 median age
  • 25% that were 65 years or older
  • 58% female
  • 89% white
  • 7% with <=12 years of education
  • 76% living with a chronic health condition
  • 75.4% agreed to be contacted for future research studies

Future Study Opportunities:  The app could be used in a clinic setting to get data immediately. There may be opportunities to push data into a Vital Sign flow sheet.

It took a large team to develop the study and app.  The cost to develop the app was $130k (excluding investigator time).  The cost is higher than a typical app ($30k - $50k) because this is a research study which has to go through the Institutional Review Board (IRB) process.

Question:  How concerned are you about the quality of the data?  Answer:  The type of smartphone and the location of the phone (hand/front pocket/back pocket) can have an effect on the quality of the data; however, a large population set should minimize the effects of these on the quality of the data.  They will be doing further testing around data quality.