During the HIMSS AI for Healthcare Forum in Boston, Dr. Eve Cunningham, MD, MBA, GVP, Chief of Virtual Care and Digital Health at Providence Health presented a few AI use cases including an impactful example which empowers PCPs for better care decisions.

Today primary care doctors are pressured to address patient health concerns in an average of 18 minutes with an average of 220,000 data points in the patient’s electronic medical record. With over one in 3 patients referred to a specialist each year, PCPs are tasked with diagnosing the health issue to and making decisions about the need for a specialist.

Barriers to Specialist Care Decision

With vast amounts of patient data that is not clinically organized around context within the patient’s chart, PCPs must spend time pulling together and reviewing relevant information to support the patient’s health problem. Then the PCP must determine if a specialist is needed, and if so which type of specialist.

Given the shortage of primary care doctors and specialists, optimization of the referral process is critical to access to care. However, the referral process today is both inefficient and ineffective causing problems:

• Patient did not need to go to a specialist. (Note: About 20% of patients referred to specialists do not need to see a specialist at all)
• Patient is sent to wrong specialist and/or at inappropriate level of urgency.
• Patient arrives to specialist without any prereferral work-up such as lab, imaging and first-line therapy for a condition.
• Patient has delayed care until there is a specialist appointment

Accelerating Primary Care Referrals

The September issue of NEJM Catalyst’s article on “A Physician-Created Platform to Speed Clinical Decision-Making and Referral Workflow” describes the problem and process that Providence Health has undertaken to conceptualize and build their MedPearl Platform.

“As primary care clinicians struggle to access the expanding base of specialized knowledge and experiences, they attempt to refer patients to specialists, often without the advantage of usable tools at the point of care.”

Developing this needed platform entailed using a “Human- Centered Design approach with a Jobs to Be Done framework, working closely with our clinicians and UX designers”, explains Dr. Cunningham. “We began by asking clinicians how this platform needed to work and look, and got input from 270 clinicians in the design process, which was essential for gaining buy-in”.

MedPearl Platform Built by & for Clinical Care Decisions

Based on clinician’s requirements, Providence built MedPearl as an application within their Epic electronic medical record (EMR) to integrate a digital assistant with clinical knowledge to support  primary and urgent care clinicians. MedPearl has “concise, human-authored algorithmic primary and subspecialty care next best actions on over 700 conditions”.

Clinicians utilize MedPearl’s AI algorithms to pull up and review essential clinical information alongside contextualized patient data to see next best actions with what has/hasn’t been done for the patient, empowering clinicians to optimize the “work up” while reducing redundant diagnostics.

Since it can take weeks to months for the patient to get in to see the specialist, the MedPearl platform enables PCPs and urgent care providers to take care of the diagnostics in the interim to optimize the care referral decision. With MedPearl, clinicians can see the testing stream, make sure tests do not need a referral, find the most appropriate specialists and triage the urgency of the specialist appointment based on patient history and diagnostics. Think about what this means for rural health where accessing a specialist is even more challenging.

Providence has designed MedPearl with icons to reduce the clinicians cognitive reading load and provides links to guidelines and QR codes to scan for evidence -based applications.

Clinician Experience with MedPearl

Providence Health has deployed MedPearl across their health system which is available in Epic’s Marketplace.

Dr Cunningham as MedPearl founder comments “Our clinicians tell us that with MedPearl they are spending less time in the EMR, fewer outside work hours and are more productive. To date, we have 7,000 clinician users, making 30,000 searches per month on the MedPearl platform”.

During the initial pilot with 216 participants conducting 14,000 searches, clinicians reported the clinical content helped with clinical decision support: they did not need to refer the patient 20% of time, improved care plan and work-up 72% of the time and changed referral specialty and/or level of urgency 20% of the time.  

With MedPearl, clinicians are also realizing better resource efficiency. “We had a challenge with some of our more newly onboarding clinicians overwhelming our Medical Directors with clinical questions and curbside phone calls. The call volume   decreased significantly when these clinicians were advised to reference MedPearl first for answers”, shares Dr. Cunningham.

Clinicians often walk through the MedPearl tool with their patients. They review educational content together, discuss the algorithms and use the decision support tools. 

Feedback from Clinicans Using MedPearl

After using the MedPearl tool, clinicians commented about the ease of use, quick access to the most essential patient data and benefits of leveraging this patient data for the physician, practice and patient.

   “MedPearl provides concise and focused clinical evidence -based summaries, making it easier to quickly access the most relevant information. Its streamlined format saves time and effort, ensuring health professionals can find information without being overwhelmed by unnecessary details”. Medical Director Urgent Care 

   “The cognitive offloading and reassurance that knowing the Prov approved standard of care has been helpful for me, and I love being able to share it with newer clinicians”. Urgent Care Physician

   “The Headache algorithm – perfect example of how to reduce variation in our urgent care practice.” Urgent Care Physician

   “With the demand for neurology consultation greatly exceeding the supply of neurologists for the foreseeable future, MedPearl improves access when it has never been more vital.” Chief of Neurology

   “MedPearl is a point of care tool we need to augment our clinical acumen and to help drive uniformity of patient care path the best -practice level. This allows primary care physicians to provide more care value, improving diagnostic testing, treatment, and referrals and in opening more specialist access.”  Medical Group Director

   “Recommendations re: referrals and specific imaging with and without contrast very helpful. Truly has improved physician satisfaction and flow for the day”.  Family Medicine Physician 

   “Contextualization is pretty cool. Makes Pearl useful in multiple ways.. Quick way to see all relevant data about a work up for a particular topic.” Internal Medicine Specialist

   “Love the patient experience, engagement and shared decision-making components of this tool.”  Practice Senior Director of Operations

   “I love the headache algorithm. During a recent appointment, I had a patient point to each symptom that applied to her.”  Physician

Future Direction of MedPearl for Health Systems

Dr. Cunningham describes Providence Health’s approach with “feedback and iteration as a core principle by which we drive our MedPearl features roadmap and design. We also push our end users to think beyond the workflow of today, and envision workflow of tomorrow.”

The MedPearl team continues to collaborate with users to gain insight into future enhancements. Specifically, they are focused on these platform innovations:

1. "Expanding contextualization beyond labs, imaging and procedures to further enrich the context aware data aggregation experience"

2. "Adding documentation support features to expedite documentation workflow"

3. "Further refine home page to create a more dynamic experience to delight end users"

4. “Since we believe all workflows will converge on ambient technology, we are preparing ourselves to integrate into ambient workflows. We don’t plan to be the ambient provider, rather we envision ourselves as a clinical intelligence plug-in to further enrich that experience.”

Dr. Cunningham confirms plans to begin “deploying MedPearl to other health systems using EPIC and then Oracle EMRs. We see ourselves as ‘headless’ clinical decision support system that is EMR agnostic and application agnostic. We want to permeate and spread the goodness of MedPearl in a seamless fashion, and meet clinicians and patients where they are“, Dr. Cunningham concludes. 

In October 2022, Providence Saint John's Health Center invested in Project Ronin, an AI driven cancer intelligence platform to empower cancer patients and their clinical teams to manage treatment symptoms, care communications and clinical decision support. Their goal is to reduce ED visits and deliver better patient care and outcomes.

According to the American Cancer Society’s 2023 Cancer Statistics report, cancer remains the second highest cause of death after heart disease. This is an estimated 2 million newly diagnosed cancer cases resulting in about 610,000 deaths.

Dr. Martin, MD, CMO of Providence Saint John’s believes that providing a new “space where cancer people can engage with their physicians has some very real, tangible benefits.”  The digital tool is designed to support “patients with less-critical symptoms, which has the potential to reduce emergency department visits and improve clinical efficiency, which means a more efficient utilization of resources. Of course, we always advocate patients to come to the emergency department if they believe they are experiencing a medical emergency.”

Cancer Care Collaboration 

Successful treatment of cancer is multifaceted, requires a multi-disciplinary care team, entails managing different data sets with continuous capture and monitoring of data, and has data complexity given the non-linear nature of the disease (i.e. diagnosis, treatment, remission, recurrence, treatment, survivorship/death).

Patients struggle to manage their cancer, both mentally and physically. Patient treatment symptoms can be severe. Questions come up between treatments but care teams are extremely busy. Patients need to remain connected to care teams to stay engaged, better manage, and communicate side effects.

Providers try to navigate their inefficient clinical workflows, address the administrative burden due to documentation requirements, and deal with workforce shortages. Today, providers spend 20-40 minutes finding patient info to prepare for patient visits, sometimes missing key data.  Providers are overwhelmed to make needed decisions for cancer patients at the point of care.

AI Cancer Platform Delivers Care & Decision Support

The Ronin Cancer Platform enables patients to “take control of their care in a way that wasn't possible before and feel better connected to their care teams,” explains Dr. Neil Martin, MD, CMO of Providence Southern California Clinical Institutes and Executive Director of Saint John's Cancer Institute.  Clinicians utilize this cancer intelligence platform’s predictive analytics and clinical dashboard to define treatment pathways and support more informed care decisions.

How does this work? The Ronin cancer platform takes structured and unstructured data from different EHR silos, and then cleans, calibrates, contextualizes this information to present care insights. With predictive analytics, providers can identify at-risk patients and see a complete real-time view of the care journey for immediate actions.  

AI Data- Driven Cancer Platform: Patient Experience

Patient Patricia (patient persona), 74 years old, is newly diagnosed with breast cancer. While meeting with her new care team, Patricia learns about new resources including the free Ronin Symptom Monitoring App, to educate and support her as she navigates her cancer path. During her next appointment, Patricia notices the poster in her doctor’s office prompting her to download this patient app.

   Patient Symptom Monitoring App Poster:

We want to support you through your treatment. In between your visits, please let us know how you're feeling by using the Ronin Symptom Monitoring Application. This will help us catch any side effects that you may experience. Studies show that symptom monitoring can ...

• Help people live longer and improve their quality of life

• Help people stay on treatment longer

• Lower visits to the emergency room and reduce hospital stay

Patricia downloads and begins using the Symptom Monitoring app which captures her Patient Reported Outcomes (PROs), enables her to track and manage side effects for treatment tolerance, displays her symptom history and provides her with personalized education based on what she is reporting. Within the app, Patricia selects from a list of symptoms and then sees a message that her symptoms “are concerning”, that her care team is monitoring this and will reach out to her within 24 hours.

AI Data-Driven Cancer Platform: Provider Experience

Patricia’s care team receives a “symptom alert” through the EHR based on the information that she has entered. Her symptom information has required a response (e.g. new symptom, moderate or severe symptom). The Nurse Navigator reaches out electronically or telephonically to check in on Patricia to understand more about her symptoms.

When her Oncologist Dr. Davis initially set up Patricia’s personalized care pathway on the platform, he indicated her specific disease type, which triggered patient reported outcomes surveys and at-risk surveys which captures data and intelligently prioritizes for the care team to take quick action to course correct and preempt adverse events.

While preparing for an upcoming office visit with Patricia, Dr. Davis uses the Ronin Platform to view a longitudinal timeline of her cancer journey, filled with real-time data (e.g. labs, images, pathology, treatment, surgery notes, past encounters) to make informed, proactive and personalized treatment decisions.  Following the visit, Dr. Davis (or the clinical staff) pushes educational content to help Patricia to navigate her new symptoms or cancer stages.  

AI Driven Care Experience Value Proposition

At Providence Saint John's Health Center, both patients and providers are finding value using the AI Ronin Platform, including clinical efficiencies, better care and outcomes and higher satisfaction. Here are some comments from the patient and provider users:

 Patient Experience:

 “Ronin provided confidence someone was monitoring me.” 

 “Ronin made me feel like my care team was with me, even at home.”

 “I prefer not having to call the hospital. (With app) I am able to record side-effects right away as they are happening”. 

 “It’s (app) so easy to open up and write how I’m feeling…It’s a great reminder to me that even though I may think I’m fine, I need to pay attention to my symptoms.”

Provider/Staff Experience:

  “We were able to catch an immune- related toxicity early for a patient of mine. Without Ronin, I would not have caught it”.  Medical Oncologist

  “We want to make sure the patients are having the best quality of life. With Ronin, we can check in on them more frequently.”  Nurse Navigator

  “From the treatment team’s standpoint, it’s made it easy to follow patients. It’s a great way to stay hands-on.”  Nurse Navigator

  “I had a patient straight up tell me ‘If it wasn’t for the app, I would be calling you guys every day'.” Medical Oncologist

   “Visually, the Timeline tab makes it much easier to get up to speed on a patient. Especially compared to reading my colleague’s last notes.”  Medical Oncologist

 Success Metrics

In addition to gathering qualitative comments about the patient and provider/staff experience, Providence Saint John’s tracks quantitative success metrics for the AI driven Cancer Program. Some key metrics include:

● Reduced unnecessary ED admissions by >20% (early findings)

● Improved efficiencies with 35% decreased patient call volume and 32% patient-initiated messages.

● Strong patient satisfaction & experience

• 84% see positive impact on care experience
• 90% say app is easy to use
• 88% are satisfied with solution

Future for Providence with Ronin Cancer Platform

Moving beyond the patient mobile app and care communication from phase one, Providence Saint John's is planning to provide clinical decision support with oncology and risk dashboards and the capability to view comparative patient analytics in phase two.

"We are proud to implement evidence-based care solutions for patients in our community," said Brad Bott, Executive Director of the Southern California Clinical Institutes. "Our partnership with Ronin will help improve cancer care delivery while empowering our staff to practice more efficiently. It's a win-win."

Digital Medicine is a nationally recognized, clinically proven program revolutionizing how we treat chronic conditions combining digital tools and engagement with a dedicated care team.

Ochsner O Bar Supports Patient's Digital Health needsIn 2015, Ochsner Health launched its first Digital Medicine Program for Hypertension. Since publishing success outcome measures in The American Journal of Medicine, Ochsner’s Chief Clinical Transformation Officer Dr. Richard Milani, and his team have built on the framework to support patients with chronic conditions (e.g., Diabetes, COPD) and Maternal care. Over 30,000 patients have participated in an Ochsner Digital Medicine Program.

With the cost of chronic care, including indirect costs (productivity loss) reaching $3.7 trillion a year, Ochsner is focused on better managing chronic care through three key levers: medication management, behavioral change, and frequent data collection from home.

Milani believes that a successful Digital Medicine Program must:

• use the latest guidelines for medication management, important because ideal medications are always changing, and a certain medication may be more effective for one patient (profile) than another.
• be designed with behavioral science to impact lifestyle change, which includes everything from delivering the right type and timing for nudges to aligning patient needs with right level of high touch care support.
• leverage data captured and presented within a reasonable time so that clinicians can respond before the patient’s health becomes a problem.

Dedicated Team, Centralized Monitoring

Ochsner’s Digital Medicine programs are supported by a dedicated team of over 60 professionals, including clinicians, coaches, pharmacists, physical therapists, behavioral scientists, IT developers, technology engineers, user experience, content specialists, data scientists and advanced analytics.

Team members help patients throughout their program journey, with onboarding, educating and ongoing care support.  An important benefit of having one Digital Medicine team is that the program can be personalized to the patient’s specific needs (e.g., required monitoring devices) and supported by the same clinician and coach.

EMR Foundation  

“The technology foundation of our Digital Medicine Programs is the EMR Epic,” explains Milani.  “Our patients are given clinically validated devices approved for the program, with device data flowing into the EMR.”

Ochsner has evaluated and selected a set of devices for this program for each condition, which patients are required to use to connect into the Program. Ochsner distributes the devices and is the point of contact for any technical issues.

Patients access their Digital Medicine Program through the Epic portal My Chart (via website and patient mobile app), where they can view trends on device measures, access educational information, complete assessments, and exchange messages with the Digital Medicine Care team.

“For our clinicians, we have designed dashboards which help triage and prioritize patients based on incoming patient health data including Social Determinants of Health,” says Milani “We have set up alerts for our program care team based on selected physiological and inputted measures.  Other providers of the patient’s care can access information in Epic, including a Monthly Report.

Patient Digital Medicine Program Experience

Ochsner Digital Medicine Patient After a referral from his physician, patient Peter (not his real name) is invited through Epic to participate in Ochsner’s Hypertension Program. Participating in the program means that Peter can reduce time off from work and save time driving time for some appointments.

Peter has the option of having the device(s) and program setup information mailed to him, or if nearby, Peter can stop by Ochsner’s O Bar – a physical location that allows patients to test drive more than 100 Ochsner-approved health apps and purchase devices. There’s a technology specialist behind the counter to answer questions and give app demonstrations. (Think genius bar to support patient health technology).  

Once Peter sets up his blood pressure monitor, his measures are sent to his care team. If any measures are out of range, his care team will reach out to discuss any possible changes needed. Peter’s coach sets up personalized messages regarding lifestyle changes needed and reminders to keep him on track with taking his medication and taking his readings. Peter can communicate with his coach via SMS texting, My Chart messages or via phone.  

“We are seeing that patients prefer to communicate asynchronously with their clinicians and coaches, so we are giving them the tools to do so,” says Milani.

Digital Medicine Program Success

“We evaluate success based on a few key measures,” says Milani. “We look at outcomes and are seeing a consistent 2-3 times improvement in control rates with our program. We also look at Net Promoter Scores (NPS) and we are getting very high patient satisfaction scores of 87-90.”

Ochsner recently conducted a pilot program (beginning in June 2020 and ongoing) to investigate how digital medicine with remote patient management can improve outcomes for Medicaid patients battling chronic diseases like Hypertension and Type 2 Diabetes. The results were statistically and clinically significant. Enrollment in Ochsner Digital Medicine brought nearly half of all out-of-control Hypertension patients under control at only 90 days, which was 23% more likely than usual care. Control rates continued to improve as patients remained in the program during its first 18 months. More impressively, 59% of people with poorly-controlled diabetes achieved control over their condition as part of the digital program – a rate twice as high as usual care.

Most patients achieved control of their hypertension and diabetes within 90 days of beginning the program, even those who had poor control prior to enrollment.

In addition to improving health outcomes, participation in the digital medicine program resulted in high patient satisfaction, with a net promoter score greater than 91 for Medicaid participants. This is consistent with the high patient satisfaction with digital chronic disease management programs at Ochsner among non-Medicaid patients.

“We're offering patients compassionate human care combined with the power of technology, and we’ll continue to expand these programs to help more patient populations”, Milani concludes.

Success in their words

Patients:

“My care team has been really helpful. They’ve explained things to me… offered me suggestions. I really like the fact of daily accountability. I’ve lost about 103 pounds. I feel better. I have energy that I didn’t have a year ago.”

“I know I’m sleeping better–my hair, my skin, my vision–just different things that you start to notice that we take for granted that are all tied into our blood pressure and blood sugar. I’m a living testimony that it (the program) works! I know for a fact Ochsner Digital Medicine has saved my life.”

“I feel like this is more normal. Someone’s got my back and… I will be able to use [the program] for the rest of my life.”

“The Ochsner Digital Medicine Care Team helped me by guiding me in every way possible – giving me tips on my diet and adjusting my medication on the fly. They are a good support team.”

Staff:

“I love the Ochsner Digital Medicine program. As a physician, I love having the Digital Medicine team helping me because it’s like having other coaches on the team.”  Dr. Victoria Smith

Ochsner’s Digital Medicine Program is available to employees across their health system. 

“The Ochsner Digital Medicine program is one of the most important components of healthcare for our (employees). If I can offer better benefits and possibly reduce healthcare costs, why wouldn’t I? We have had employees sign up for the hypertension and Type 2 diabetes programs and have seen many positive results in a short period of time. The program lets your employees know how much they mean to you by investing in them”, Chief of Administration, Chris Kaufmann

Ochsner Mobile O BarOver five years ago, Ochsner Health launched their O Bar (Apple genius-like concept) to support patients getting started with digital health tools. Today, Ochsner has nine physical O Bars located in the bottom floor of their health centers and one mobile O Bar.

Although any Ochsner patient can visit the O Bar to begin using a curated set of digital health apps and devices, patients who are invited to join a digital medicine program can go to the O Bar to get set up with selected digital tools to manage and monitor their health journey.  Digital medicine program participants have the option to have their digital tools sent via the mail, without going to the O Bar and can call their program tech support for any assistance. Pre-Covid, about 5-10% of patients chose to receive their digital health tools by mail. During the pandemic, it is mostly all mail.

Ochsner Hypertension Digital Medicine ProgramTo date, Ochsner Health is offering digital management initiatives for hypertension, diabetes, pregnancy and the latest COPD program. Patients do not need to have access to WIFI to participate, just a smartphone or tablet. Less than 5% of patients participating in the digital medicine program use the tablet and instead have their apps downloaded to their smart phone. 

“Our digital medicine programs are realizing 2-3x better outcomes rates than the standard of care”, explains Dr. Richard Milani, Chief clinical transformation officer and innovationOchsner Medical Director, Ochsner Health. “In order to understand how these programs were designed, it is important to take a step back and think about how we need to help patients manage their chronic condition(s). First, we need more frequent data to know at any point in time if their chronic disease is under control. Second we must make sure individuals are prescribed guideline-directed pharmacotherapy.  With the number of new medications coming onto the market and medical research about the profile of patients experiencing the best outcomes, we must be sure patients are having the best chance to achieve an optimal outcome. Finally, we need engage our patients on the “right behaviors” (e.g. nutrition, fitness, stress reduction).”

"We set up our digital medicine programs to be supported by a dedicated team who interacts with and manages the patient’s condition(s)”, shares Dr. Milani. “Their doctor invites the patient to join the program, but it is a digital medicine team who responds to the incoming data and alerts from the digital health tools.” Ochsner’s digital medicine team consists of a pharmacist/APP to help the patient with the “right guideline-directed medicine” and a health coach to provide guidance on lifestyle decisions using behavioral health science techniques. Patients that are on two of Ochsner’s digital medicine programs engage with the same pharmacist/APP and health coach, creating a holistic approach to patient care.

Patients access all of digital health tools in the digital medicine program area with their patient portal. A patient logs in to access patient education information (videos), communicate with her team by scheduling a phone call or sending asynchronous messages and view monthly reports which shows how she is doing, and progress made over time. The patient can also contact the digital medicine team for technical support for their digital tools, which is rare because these connected devices are easy to use for even less tech savvy patients.

Ochsner Connected Mom Pregnancy Digital Medicine ProgramIn addition to appropriate connected devices given to patients to capture and transmit key measures (e.g. diabetes/wireless glucometer, hypertension/ wireless blood pressure cuff, COPD/wireless inhaler and pregnancy/ wireless blood pressure cuff & wireless scale), patients receive texts to capture changes in condition (e.g. COPD severity level), track self- efficacy measures or to be notified of a health concern (e.g. warning about the poor air quality level). Patients have the option of connecting in and sending more information such as weight measures from their own digital scale or steps from their fitness tracker to share with the digital medicine team.

Program Success Measures & Expansion Plans

Ochsner has enrolled more than 15,000 patients across their digital medicine programs.

Over the past 5 years, Ochsner has received positive feedback from their digital management team (e.g. Pharmacist, Health Coach) and from patients in the program.

 “The role of a clinical pharmacist isn’t always to add more medicine. We work with each person to incorporate lifestyle changes and medications that are right for them. This includes stopping or decreasing medicine doses when lifestyle changes lead to improved health.”  -- Carrie, Clinical Pharmacist

“I work with individuals to make small, achievable goals that will not only improve their health, but ultimately improve the way they feel mentally and physically. This allows the patient to feel confident in themselves to make healthier choices in any situation.” – Christina, Professional Health Coach

“I like that it is private. I don’t have to take a blood pressure reading at a Walgreens or CVS. It’s encouraging to know that the lifestyle choices I’m making as well as my compliance to my drug regiment is having a positive effect.” – Alan, Digital Medicine Hypertension Program 

“For anyone who has doubts about joining the program, I would say step out and take the journey.” – Lance, Digital Medicine Diabetes Program

“You get a lot out of Ochsner Digital Medicine. You get a family who is by your side every step of the way.”  - Gaylan, Digital Medicine Hypertension Program

In addition to patient and staff feedback, Ochsner uses a set of quantitative measures to evaluate success. Dr. Milani is proud to share the Net Promoter Score of patients in the digital medicine program of 87.5, which indicates a high level of recommending the program to others.

Dr. Milani explains, “the key success measure is the reengineering of chronic disease care into a new model of care delivery. Our metrics of success are control measures for the disease (i.e. better blood pressure control, better diabetes control, etc.).”

Ochsner has plans to grow their digital medicine programs in 2021.  “We are expanding the population we currently serve and will be adding more disease categories (like lipid management and others). We look at the prevalence of disease burden and the opportunities for better control when deciding on new digital medicine programs,” Dr Milani concludes.