Grand Rounds April 7, 2023: A Nudge Towards Cardiovascular Health: Incorporating Insights From Behavioral Science to Improve Cardiovascular Care Delivery (Srinath Adusumalli, MD, MSHP, MBMI, FACC)

Speaker

Srinath Adusumalli, MD, MSHP, MBMI, FACC
Adjunct Assistant Professor of Medicine, Perelman School of Medicine
Adjunct Professor of Healthcare Management, The Wharton School
Affiliated Faculty, Center for Health Incentives and Behavioral Economics
Staff Cardiologist, Hospital of the University of Pennsylvania and Philadelphia VAMC University of Pennsylvania
Senior Medical Director, Enterprise

Keywords

Pragmatic trials, cardiovascular medicine, cardiovascular care delivery, behavioral science, electronic health records, implementation science

Key Points

  • A nudge is a subtle change in design that is intended to impact human behavior. They are intended to remind, guide, or motivate a decision, and they should be transparent. Dr. Srinath Adusumalli described a nudge as something that helps make the right choice an easier choice.
  • Nudges and other behavioral interventions are prevalent in industries like business and entertainment, but there is an opportunity for nudges in medicine and health care delivery.
  • Launched in 2016, the Penn Medicine Nudge Unit is the world’s first behavioral design team embedded within a health system. It works to improve health care value and outcomes, advance the science of designing interventions to change behavior and evaluate and disseminate the impact of interventions. The team then worked to incorporate an implementation science lens for designing interventions for scale to the health system.
  • The health behavior is supported by a technology backbone, including the Penn Medicine EHR and other systems that bring insight and nudge within workflows. The context and stakeholder input have been key in developing and implementing nudges.
  • Useful nudge principles are limitations of information provisions, inertia or status quo bias, choice overload, loss aversion or framing, social ranking and the limits of willpower.
  • Implementing the nudge tool within the Penn Medicine revealed several positive impacts, including referral rates increasing significantly via the implementation of a default pathway.
  • The PRESCRIBE trial revealed the value of active choice as well as peer decision-making to prompt decision-making.
  • Key considerations for developing and implementing a nudge include the right information and guidelines, the right individual to receive the nudge, the right intervention format, the best channel for the nudge and the best time in a provider’s workflow to receive the nudge.
  • Key learnings from the studies highlighted included the need for more transparency as to the reason for a nudge, limiting the number of choices in CDS intervention, passive CDS is often ineffective and it is critical to provide the path for the individual to immediately act.
  • New frontiers in nudging include integrating nudges and behavioral science with applied machine learning, phenotyping patient and clinician behavior to more precisely target single or combination nudges, the simplification and automation of downstream actions, and the alignment of incentive and behaviors across health care actors, including systems and payers.

Discussion Themes

In the last few years, there has been great reception to the value of behavioral science and implementation science in the field of cardiology. There is opportunity for more evidence to be developed and to implement lessons that have been learned.

Behavioral science tools, such as these EHR-integrated nudges, must be modified to fit within different settings and EHR systems, but they often provide a strong foundation for other contexts. Customizing existing tools to different systems can save significant time and resources in developing behavioral health tools.

Tags

#pctGR, @Collaboratory1

April 8, 2022: COVID-19 Surveillance in PCORnet: Year 2 Update (Jason Block, MD, MPH; Thomas W. Carton, PhD, MS)

Speakers

Jason Block, MD, MPH
Associate Professor
Harvard Pilgrim Health Care Institute
Harvard Medical School

Thomas W. Carton, PhD, MS
Chief Data Officer
Louisiana Public Health Institute

 

 

Keywords

PCORnet; COVID-19; Electronic health record (EHR); Surveillance data

 

Key Points

  • PCORnet is a national network of 66 million people with EHR-derived data available for research.
  • After significant database modifications to effectively include COVID-19 related data, the CDC PCORnet COVID-19 project began in April 2020 with the first query. 43 participating institutions update data monthly.
  • There have been 40 queries of the PCORnet COVID-19 data completed to date looking at descriptive trends of COVID-19 by care setting and demographics, vaccinations, chronic disease, and treatments.
  • PCORnet COVID-19 data tracks percent hospitalized and relative risk of testing positive for COVID-19 by race over time.
  • Data also shows treatment disparities with monoclonal antibodies over time by race and ethnicity. White patients or non-Hispanic patients who tested positive for COVID-19 were more likely to be treated with monoclonal antibodies than any other race or ethnicity.
  • PCORnet COVID-19 data have also been used to investigate myocarditis and pericarditis after both COVID-19 vaccination and COVID-19 infection. Males ages 12 to 29 have increased risk of cardiac complications after COVID-19 infection compared with COVID-19 vaccination.
  • PCORnet is evolving to improve the capture of information, advance analytics, and provide better collaboration between federal public health and PCORnet investigators.

Discussion Themes

    • Complete surveillance data is difficult to obtain when not all testing or vaccination is being reported.
    • State vaccination data does not always get added the EHR until the patient has another primary care encounter.
    • The ability to continue doing this kind of work relies on a national public health infrastructure.

Read more about PCORnet.

Tags

#pctGR, @Collaboratory1

December 17, 2021: Cyberthreat, Cybersecurity and Cyber Compliance in Clinical Research and Healthcare: One Size Fits None (Eric Perakslis, PhD)

Speaker

Eric Perakslis, PhD
Chief Science & Digital Officer
Duke Clinical Research Institute
Professor
Department of Population Health Sciences
Chief Research Technology Strategist
Duke University School of Medicine

Topic

Cyberthreat, Cybersecurity and Cyber Compliance in Clinical Research and Healthcare: One Size Fits None

Keywords

Cybersecurity; Attack Surface; Cyber-Compliance; FISMA; InfoSec

Key Points

  • Over 40 million medical records are compromised each year.
  • Electronic Health Information is targeted due to its high value with respect to improper medical payments. Medicare estimates over $25 billion in improper payments each year.
  • The focus for cybersecurity should be on the most vulnerable groups. Women, BIPOC, and elderly populations experience cyberattack and identity theft more often than other populations.
  • Security objectives should focus on confidentiality, integrity, and availability.
  • The Cyber Risk Equation: Risk = Threat*Vulnerability*Impact*Likelihood
  • When starting a study, design with cybersecurity in mind, minimize attack surface, know your weakest link, add InfoSec expertise to the design team, and lean-in to innovation.

Discussion Themes

Researchers should take some responsibility for learning how to secure patient information. Training programs to make researchers more aware of cybersecurity concerns would increase researcher comfort in working with electronic health data.

A research network consisting on multiple sites may have differing needs and capacity to secure data. Treating each research site individually could allow greater representation in research, but those sites may be more vulnerable to cyberattack.

 

Read more about cybersecurity by Dr. Perakslis in A cybersecurity primer for translational research.

 

Tags

#pctGR, @Collaboratory1, @eperakslis

October 5, 2021: New Article Identifies Challenges and Prerequisites for Using Electronic Health Record Systems for Pragmatic Research

JAMIA Cover

In a new NIH Collaboratory study, 20 NIH Collaboratory Trials responded to a survey about challenges encountered when using the electronic health record (EHR) for pragmatic clinical research. The goal of the study was to elucidate challenges and develop solutions—or prerequisites for pragmatic research—to enable healthcare system leaders, policy makers, and EHR designers to improve the national capacity for generating real-world evidence.

The article was published in the Journal of American Medical Informatics Association (JAMIA).

The challenges identified by the projects fell into 6 broad themes, including inadequate collection of patient-centered data, lack of functionality for structured data collection, lack of standardization, lack of resources to support customization, difficulties aggregating data from multiple sites, and difficult and inefficient access to EHR data.

Researchers from the NIH Collaboratory’s EHR Core and colleagues from the Patient-Centered Outcomes and the Health Care Systems Interactions Core Working Groups discussed the issues and iterated possible solutions. The authors developed the following prerequisites for the conduct of pragmatic research:

  • Integrate collection of patient-centered data into EHR systems
  • Facilitate structured research data collection by leveraging standard EHR functions, usable interfaces, and standard workflows
  • Support creation of high-quality research data by using standards
  • Ensure adequate IT staff to support embedded research
  • Create aggregate, multidata type resources for multisite trials
  • Create reusable and automated queries

The authors argue for the ability to tailor EHR systems to enable the collection of patient-centered outcomes and the extraction of high-quality, standardized data. Although the primary uses of the data are for clinical care and billing, high-quality data from the EHR also have the potential to improve clinical care and population health by providing reliable evidence and to support pragmatic research and learning within and across healthcare systems.

Read the full article.

This work was supported within the National Institutes of Health (NIH) Health Care Systems Research Collaboratory by the NIH Common Fund through cooperative agreement U24AT009676 from the Office of Strategic Coordination within the Office of the NIH Director. This work was also supported by the NIH through the NIH HEAL Initiative under award number U24AT010961.

 

August 11, 2021: EHR Core Facing Familiar Challenges, Intensified by Pandemic

Leaders of the NIH Collaboratory’s Electronic Health Records (EHR) Core Working Group spoke in a recent interview about the impacts of the COVID-19 pandemic on pragmatic trials. They also talked about upcoming projects and a recent survey of the NIH Collaboratory Trials.

 

“The pandemic amplified themes that we’ve heard all along, which is how to get resources, how to get support for the data that we need for these trials or to configure EHRs as we need for these trials,” said Dr. Rachel Richesson, a professor of learning health sciences at the University of Michigan and a cochair of the EHR Core. “The pandemic just shifted priorities tremendously and made it quite challenging. As a result, we’ve had discussions about…really making the value case for pragmatic research and embedded research,” Richesson said.

View the full video.

Dr. Keith Marsolo, also a cochair of the Core, added, “The pandemic obviously was a big challenge for health systems in general as they transitioned to telehealth, dealt with shutdowns, things of that nature.” Marsolo is an associate professor in population health sciences at Duke University.

“Things are starting to move forward a little bit more. In one [NIH Collaboratory Trial], they were able to leverage some infrastructure that was purchased to help provide telehealth services for their region. So they’ve been able to bootstrap their trial off of that infrastructure,” Marsolo said.

Richesson also described an upcoming paper reporting the results of a recent survey of the NIH Collaboratory Trials. The survey focused on the challenges of using EHR data in pragmatic trials embedded in healthcare systems.

“No surprise on the challenges we encountered: It’s still challenging to get data from organizations for research, the data are still heterogeneous,…and there are challenges on the research team to ensure that that information is equivalent and how these data can be pulled together to support the research question,” Richesson said. “There’s a particular emphasis with the newer studies on patient-reported outcomes and how to get those collected as part of routine care,” she said.

View the full video.

 

Screen shot of video interview with Dr. Rachel Richesson and Dr. Keith Marsolo
Dr. Rachel Richesson and Dr. Keith Marsolo

Podcast July 8, 2020: Reflection on Advances at the Intersection of Digital Health, Electronic Health Records, and Pragmatic Clinical Trials (Wendy Weber, ND, PhD, MPH; Lesley Curtis, PhD; Patrick Heagerty, PhD; Keith Marsolo, PhD)

This episode of the NIH Collaboratory Grand Rounds Podcast, led by Wendy Weber, ND, PhD, MPH, reflects on the Grand Rounds EHR workshop series, “Advances at the Intersection of Digital Health, Electronic Health Records, and Pragmatic Clinical Trials.” The podcast features panelists Lesley Curtis, PhD, Keith Marsolo, PhD and Patrick Heagerty, PhD, who all moderated webinars included in this Grand Rounds series.

Click on the recording below to listen to the podcast.

Want to hear more? Access the full Grand Rounds presentations for this series here.

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Read the transcript.

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July 6, 2020: NIH Collaboratory EHR Workshop Podcast With Dr. Joshua Denny Now Available

The latest episode of the NIH Collaboratory Grand Rounds Podcast is now available on the Living Textbook. Part of a special Grand Rounds series on electronic health records (EHRs), “Real World Evidence: Contemporary Experience and Future Directions” follows an in-depth conversation between NIH Collaboratory PI Dr. Lesley Curtis and Dr. Joshua C. Denny, chief executive officer of the All of Us Research Program.

This discussion provides a deeper look into Denny’s May 8 Grand Rounds presentation with co-panelist Dr. Jacqueline Corrigan-Curay, JD, on advancing EHRs and the development of a health condition database by the NIH’s All of Us Program for multi-study use.

In this episode, you will learn more about:

  • Denny’s early experience with EHRs and the All of Us Research Program
  • The building of algorithms through an electronic medical records and genomics network
  • How the All of Us study is responding to the impact of the COVID-19 pandemic

Podcast May 8, 2020: Advances at the Intersection of Digital Health, Electronic Health Records, and Pragmatic Clinical Trials: Real World Evidence: Contemporary Experience and Future Directions (Joshua C. Denny, MD, MS)

This episode of the NIH Collaboratory Grand Rounds podcast follows the conversation on Electronic Health Records (EHRs) between Dr. Lesley Curtis and Dr. Joshua C. Denny, Chief Executive Officer of the All of Us Research Program. The discussion covers questions on Dr. Denny’s early experience with EHRs, his journey on working with All of US and EHRs, and how the program is addressing the impact of the COVID-19 pandemic. This discussion follows Dr. Jacqueline Corrigan-Curay and Dr. Denny’s keynote presentation of a Grand Rounds Series titled Advances at the Intersection of Digital Health, Electronic Health Records, and Pragmatic Clinical Trials.

Click on the recording below to listen to the podcast.

Want to hear more? View the full Grand Rounds presentation.

For alerts about new episodes, subscribe free on Apple Podcasts or SoundCloud.

Read the transcript.

Rate this podcast

June 24, 2020: EHR Workshop Grand Rounds Series Continues With Keys to Success in the Evolving EHRs Environment

The NIH Collaboratory is using its ePCT Grand Rounds platform for a special webinar series on electronic health records (EHRs). The series, Advances at the Intersection of Digital Health, Electronic Health Records and Pragmatic Clinical Trials, is highlighting advances in digital health, new approaches and evolving standards for EHRs, and implications for researchers conducting pragmatic trials.

In this week’s EHR workshop session, a panel of investigators from the NIH Collaboratory Trials—including Drs. Teresa Zayas-Cabán, George (Holt) Oliver, Christopher Longhurst, and Rachel Richesson—will discuss “Keys to Success in the Evolving EHR Environment.” Dr. Keith Marsolo of Duke University will facilitate the discussion. The Grand Rounds session will be held on Friday, June 26, at 1:00 pm eastern. Join the online meeting.

Other upcoming sessions in the EHR workshop series include:

  • Recording June 30, Available July 7, 2020: Podcast: Summary Expert Panel Discussion (Patrick J. Heagerty, PhD; Keith Marsolo, PhD; Wendy Weber, ND, PhD, MPH; Moderator: Lesley H. Curtis, PhD)

May 27, 2020: EHR Workshop Grand Rounds Series Continues With Experiences From the Collaboratory PCTs

The NIH Collaboratory is using its ePCT Grand Rounds platform for a special webinar series on electronic health records (EHRs). The series, Advances at the Intersection of Digital Health, Electronic Health Records and Pragmatic Clinical Trials, is highlighting advances in digital health, new approaches and evolving standards for EHRs, and implications for researchers conducting pragmatic trials.

In this week’s EHR workshop session, a panel of investigators from the NIH Collaboratory Trials—including Drs. Jerry Jarvik, Lynn DeBar, Doug Zatzick, and Vince Mor—will discuss “Experiences From the Collaboratory PCTs.” Dr. Wendy Weber of the National Center for Complementary and Integrative Health will facilitate the discussion. The Grand Rounds session will be held on Friday, May 8, at 1:00 pm eastern. Join the online meeting.

Other upcoming sessions in the EHR workshop series include:

  • June 26, 2020: Keys to Success in the Evolving EHRs Environment (Teresa Zayas-Cabán, PhD; George [Holt] Oliver, MD, PhD; Christopher A. Longhurst, MD, MS; Rachel Richesson, PhD, MPH; Moderator: Keith Marsolo, PhD)
  • Recording June 30, Available July 7, 2020: Podcast: Summary Expert Panel Discussion (Patrick J. Heagerty, PhD; Keith Marsolo, PhD; Wendy Weber, ND, PhD, MPH; Moderator: Lesley H. Curtis, PhD)