Helping Drive Health Care’s Fast-Moving Technology Train
In the first week of October 2012, a team of engineers and scientists from GE Global Research and GE Healthcare huddled with a team of nurse scientists from UCSF School of Nursing. In a conference room on the UCSF campus, they began exploring a collaboration to create and refine technology-based clinical interventions that would be fully informed by the real-world needs of patients and providers.
Such collaborations are less common than one might think. Since the early 1990s, some researchers have observed the way health care institutions jump aboard the technology train and have voiced concerns. They worry that the seductive nature of technology and the speed of technological change sometimes outpace the ability and willingness of health care institutions and scientists to appropriately shape the tools or assess and mitigate the risks of adoption.
It’s not that those raising the questions fail to understand the miracles technology has promised and often delivered. New medical technologies like artificial organs and more precise diagnostic tools have saved countless lives and significantly improved the quality of countless others. Advances in informatics, particularly electronic health records, connect provider to provider, patient to provider and both to essential health research and information. Mobile technology means providers can efficiently extend their ability to help patients far beyond traditional health care settings. A deepening understanding of online learning promises to expand and diversify the health care workforce at a time when both are desperately needed.
But, says Dean David Vlahov of UCSF School of Nursing, “Our role in technology adoption has to be that of supportive skeptics. We have to evaluate and mold technology-related tools and interventions so that we optimize the benefits and avoid unintended consequences.”
And unintended consequences do happen – from alarm fatigue due to overly sensitive patient monitors to confusing electronic health record implementations and a proliferation of mobile phone applications that have not undergone the rigors of clinical validation and, at best, go unused by patients.
“We have to process, interpret and respond so the right technology and interventions are getting to the right users,” says nurse scientist and pediatric nurse practitioner Christina Baggott, who facilitates a group at the School examining the changing roles that nurse scientists can play in the process.
“With technology becoming a part of everything we do in health care, my vision here is to create an expert consulting group of technology-savvy nurse scientists who research, evaluate and even develop health care technology and who use the online world to expand access to education,” says Vlahov.
Creating the Framework
Realizing that vision requires both patience and dedication. Though faculty at the School have been involved with technology-related projects for some time, it wasn’t until a schoolwide rally in the fall of 2011 that a dedicated technology group became a reality. That group is striving to create synergies within and outside the School by marrying faculty skill sets and interests with relevant research and educational initiatives.
“Expanding on and amplifying our technology expertise seemed like a natural next step forward for a leading school of nursing, because there is a gap in nurse researchers and educators assuming the role they should in helping understand the nurse-technology interface,” says Vlahov. “At UCSF, we are so close to Silicon Valley that we have a unique opportunity to help technologists build tools that incorporate nursing’s perspective in ways that truly improve patient care and nursing education.”
That effort is being helped along by the hiring of Kylie Grenier to be the School’s first director of information technology. A Silicon Valley veteran, Grenier’s primary role is to serve as a consultant to help faculty evaluate future technology trends and work effectively with the IT community to create lasting solutions.
“I’m passionate about the effort here to acknowledge that technology underlies everything we do, and that we must find a way to use these new tools effectively to move us forward as educators and scientists,” says Grenier.
For example, she is playing an active role in facilitating the type of academic-industry partnerships that the GE Healthcare meeting represents. That meeting emerged from the work of faculty member and cardiac care expert Barbara Drew on a project in which she is studying alarm fatigue in ICUs. Research and anecdotal reports have shown that patient monitors are so sensitive and generate so many false alarms that some frustrated nurses are shutting the alarms off so they can better do their jobs.
“Barbara’s project is a great example,” says Vlahov. “GE can bring the perspective of how they addressed alarm fatigue in aviation, and together we can come up with a solution that tailors their aviation solution to clinical settings.”
He notes that Drew is not alone, that many faculty members have established research programs that can and do add value to such partnerships. Another example: For years, Glenna Dowling, chair of the Department of Physiological Nursing, has partnered with Red Hill Studios to create video games that help patients with Parkinson’s disease better manage some of the disease’s physical challenges. Vlahov’s plan is to expand work like this by easing the lines of communication among School of Nursing researchers, colleagues from other disciplines throughout UCSF, collaborators at other health sciences institutions and private industry.
Bridging the Nurse-Technologist Communication Gap
But, says Grenier, effective collaboration demands that all participants have a clear understanding of how their counterparts think. The technologists, she says, tend to come to these discussions from the perspective of meeting customers’ needs, but not with the in-depth understanding nurses have of patients or of the health care delivery system.
On the other hand, nurses need to understand that technologists typically don’t want to be presented with the solution and then asked to build it. Rather, they want to understand the problem nurses want to solve and then use their creativity to help figure out the best solution.
“When you have that kind of blank slate, some truly interesting ideas emerge,” says Grenier. But using that blank slate effectively also involves making sure the technologists and the nurse scientists are speaking the same language. So Grenier spends part of her time trying to integrate the language and culture of the two groups.
Collaboration is also part of the thinking behind other efforts at the School of Nursing. These include creation of a Sensor Lab, which houses an array of physiologic sensors that faculty can test and then comment on to each other and to developers, and a growing bevy of educational projects.
Most of these projects stem from a belief that nurses and nurse scientists do have a unique role to play in helping to develop and use technology. “We are very familiar with what limits people’s ability to get and stay healthy, and so we have a strong sense of where technology can play a role,” says acute care nurse practitioner and faculty member Jill Howie-Esquivel.
While that understanding can inform innovations in numerous areas of health care delivery, there are two areas where nursing insight is primary: (1) patient monitoring and (2) coaching for patient self-care and disease prevention.
“The bulk of what we do as nurses is monitor people, try to figure out if they’re moving toward recovery or going in the other direction,” says Drew. “For example, there are a lot of people surviving with chronic illnesses, and we need to do a better job of monitoring them to keep them out of the hospital and reduce readmits. Technology enables us to discover less invasive ways to do that.”
Drew’s busy research program reflects that vision. She is in the midst of a five-year study in which her team remotely monitors heart transplant patients to determine whether measures found on self-administered, home-based electrocardiograms (ECGs) can give clinicians the diagnostic information they need to address early signs of organ rejection – without the frequent and invasive biopsies that transplant patients need today to achieve the same goal.
Drew also has begun the aforementioned study with GE Healthcare on alarm fatigue in the ICU. “Our project will create a very rich database that will help determine how much of an issue this really is and to inform future software development,” says Drew. “If as we suspect we have too many false alarms at baseline, we will have the information we need to create smarter, more actionable alarms that are more sensitive to real emergencies.”
Other monitoring-related studies also have shown promise to improve patient care. Howie-Esquivel, an expert in heart failure, knows that movement in the hospital is an important factor in helping heart failure patients reduce their length of stay and improve their prospects once they get home. Yet there is only a minimal understanding, based on highly inconsistent self-reported data from patients, of how and how much patients move during hospitalization and in the days following hospital discharge. Howie-Esquivel came up with the idea of placing a monitor, called an accelerometer, on a group of heart failure patients.
“Our pilot was the first to use accelerometers in hospitals, and we found with remarkable consistency that in a 24-hour period heart failure patients move less than an hour total each day while they are hospitalized,” says Howie-Esquivel. “I’m hoping to use the pilot data for an NIH-funded study that can lead to a hospital-based intervention to increase and improve that movement while they are hospitalized and at home.”
Baggott is completing a pilot study that uses a mobile phone application to understand pediatric cancer patients’ experience of their day-to-day symptoms. In the past, many providers have asked young people to keep written diaries, but only about 11 percent were able to sustain the process. Baggott’s app prompts patients to enter their symptoms once a day through an easy-to-use checklist; this approach achieved 95 percent adherence in the pilot. If she can fully validate these results, “It will be the first step toward creating a mobile app-based intervention to help young people better manage their symptoms,” says Baggott, who has already begun work on the coaching intervention.
Such studies are creating palpable excitement among researchers. Though Drew has witnessed firsthand the downsides of less than fully informed technology implementations, she also has been around long enough to understand that when done right, technology offers enormous potential for advances in patient care.
“When monitors began, they were all analog and there was no storage, no way to go back and review the patient’s experience,” she says. “Today we can store waveforms up to 96 hours, and if a patient describes symptoms, we can go back to the monitor and review. But software programs in current monitors were designed decades ago; now we have to do the hard work of improving the algorithms…and nurses are the ideal people to help with these solutions.”
Coaching for Self-Care and Disease Prevention
Another central piece of nursing care is helping patients effectively care for themselves – an especially important concept for those with chronic conditions. Unfortunately, once the patient is beyond the watchful eye of a clinician, self-care efforts often slip. Today’s hope is that technology can consistently extend the nurse’s voice and expertise far outside the walls of a hospital or clinic, so that patients can access their nurse/coach at home, on the road and whenever they’re needed.
“Health care is this very personal, tactile thing – this human touch,” says Grenier. “The School of Nursing is trying to use technology to extend that touch to create this circle of care, where the tools help round the connections between patient and caregiver and back again.”
“The coaching is essential,” says Vlahov. “The question is, Can we create nursing apps that enable us to continue to coach patients from setting to setting?” To help answer that, numerous projects are in place at UCSF School of Nursing.
- Through her Mobile Health (mHealth) Research Lab at the Institute for Health & Aging, Yoshimi Fukuoka currently oversees three clinical trials that test mobile phone-delivered interventions that encourage physical activity in two patient populations: sedentary women and obese pregnant women; and a weight loss intervention in patients with prediabetes.
- Christine Kennedy’s latest project tests whether the visual capacity of mobile phones can be leveraged to more effectively reach a low health literacy population at risk for physical inactivity.
- Both Glenna Dowling and Heather Leutwyler are testing video game interventions to promote physical activity in patients: Dowling’s work is with Parkinson’s patients, and Leutwyler’s involves individuals with schizophrenia.
- Jill Howie-Esquivel and her colleague Doranne Donesky, an expert in chronic obstructive pulmonary disease (COPD), are testing the efficacy of multipoint, interactive videoconferencing technology as a way to extend a yoga class to homebound patients with both heart failure and COPD.
- As noted above, Christina Baggott is experimenting with a mobile application for helping young oncology patients better manage their symptom burden.
- Occupational nursing expert OiSaeng Hong is applying an interactive multimedia Internet technology to deliver a tailored health intervention to avert hearing loss among firefighters.
- Janine Cataldo is piloting an intervention for lung cancer patients that can help them navigate the health care system and work more effectively with their providers – another aspect of patient coaching. Patients can walk through a virtual clinic visit in which they practice and get feedback on asking for the information they need to make the right health care decisions and improve their self-care.
Of course, patients aren’t the only ones who can take advantage of technology advances.
“We believe technology has matured enough to significantly expand access to a top-notch nursing education,” says Vlahov. He notes that many nurses – for example, those who live in rural areas, or RNs who want to become advanced practice nurses but can’t drop everything to come to a brick-and-mortar campus like UCSF – should now be able to get much of that education online. Georgetown University, says Vlahov, already has a family nurse practitioner program that is online in 44 states.
“We want to explore similar programs,” he says. “How can we make this happen using methods that include asynchronous lectures and tools like Adobe Connect and Moodle to conduct discussion groups where teachers and students can interact from all over the country?”
UCSF School of Nursing already has created a number of distance learning programs, including perinatal programs in collaboration with UC Irvine and the University of Hawaii. For her class, faculty member Annette Carley is using simulated online pediatric emergencies to help advanced practice nursing students practice their responses.
Vlahov also points to a new project: a master’s program in Health Administration and Interprofessional Leadership that would employ a hybrid online/face-to-face curriculum. The proposal, which is the brainchild of faculty member Mary Louise Fleming, would create the first-ever online master of science degree program at UCSF.
Again here, Grenier is playing the role of facilitator by helping connect Fleming with the systems developers needed to make the online portion of the curriculum a reality. The School and UC Academic Senate have already approved the proposal, and Vlahov expects to launch the program in 2013.
Finally, UCSF School of Nursing faculty have a prominent role in Coursera, a company offering massive open online courses (MOOCs), which can be available to many thousands of people at one time. UCSF School of Nursing faculty members Jerusalem Makonnen and Katie Clark are two of the first three UCSF faculty members to have their courses showcased. Makonnen’s course is titled “Contraception: Choices, Culture and Consequences”; Clark’s is titled “Nutrition for Health Promotion and Disease Prevention.” According to ucsf.edu, in the 24 hours after UCSF announced its first three free online courses, more than 2,500 students signed up.
Maintaining a Balance
Despite the excitement, most faculty involved in these projects voiced notes of caution that echo Vlahov’s belief that they need to be supportive skeptics.
“One of the dangers is that the technology can trump content and an awareness of individual patient needs,” says Dowling. “That’s why it’s always important to pair the technology with a clinician who can tailor an intervention to specific deficits, constantly adapt the intervention as patient needs change, and help enforce accountability for self-care.”
Fukuoka warns that especially for a generation of patients who did not grow up with these technology tools, “It’s important to remember that part of this is teaching patients how to effectively use the technology.” This applies to many clinicians as well.
Then there’s the need to rigorously validate interventions even as the technology races ahead with little regard for the pace of health research. “A whole group of people at the NIH is looking at alternative ways to speed research and approvals along,” says Baggott. She notes that at UCSF, people are exploring ways to test mobile interventions on a “backbone app” that could be modified quickly as the technology changes.
All of this challenges nurse scientists to keep their eye on the horizon. Drew, for example, has developed an interest in interactive technology where the technology gets “smarter” through interaction with patients or providers. “This is all theoretical right now,” Drew says, “but imagine if we could have a monitor that understands each patient’s normal waveforms so nurses could tweak the algorithms to that patient’s individual needs and make the alarms smarter.”
“You always need to look at what’s coming next,” says Fukuoka. “Predict and prepare. This isn’t always easy, because people can think you’re crazy when you get too far ahead of the curve, but it’s important to keep doing it; that’s how we move science forward.”