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RSNA 2017: The Year of Image Augmentation

Managing clinical variation continues to be a significant challenge facing most hospitals and health systems today as unwarranted clinical variation often results in higher costs without improvements to patient experience or outcomes.

Like many other hospitals and health systems, Flagler Hospital, a 335-bed community hospital in St. Augustine, Florida, had a board-level mandate to address its unwarranted clinical variation with the goal of improving outcomes and lowering costs, says Michael Sanders, M.D., Flagler Hospital’s chief medical information officer (CMIO).

he says, noting that traditional methods of addressing clinical variation management have been inefficient, as developing care pathways, which involves identifying best practices for high-cost procedures, often takes up to six months or even years to develop and implement.

“In medicine, what we typically do is we’ll have an idea of what we want to study, design a protocol, and then run the trial and collect the data that we think is important and then we try to disprove or prove our hypothesis,”

Working with Palo Alto, Calif.-based machine intelligence software company Ayasdi, Flagler Hospital initiated a pilot project to use Ayasdi’s clinical variation management application to develop care pathways for both acute and non-acute conditions and then measure adherence to those pathways.

The application uses unsupervised machine learning and supervised prediction to optimally align the sequence and timing of care with the goal of optimizing for patient outcomes, cost, readmissions, mortality rate, provider adherence, and other variables.

The initial work saved nearly $850,000 in unnecessary costs—the costs were trimmed by eliminating labs, X-rays and other processes that did not add value or resulted in a reduction in the lengths of stay or readmissions.

The hospital has expanded its plans for using Ayasdi to develop new care pathways, from the original plan of tackling 12 conditions over three years, to now tackling one condition per month.

Future plans are to tackle heart failure, total hip replacement, chronic obstructive pulmonary disease (COPD), coronary artery bypass grafting (CABG), hysterectomy and diabetes, among other conditions.

The effort to create the first pathway began with the IT staff writing structured query language (SQL) code to extract the necessary data from the hospital’s Allscripts EHR, enterprise data warehouse, surgical, financial and corporate performance systems.This data was brought into the clinical variation management application using the FHIR (Fast Healthcare Interoperability Resources) standard.

After being fed data of past pneumonia treatments, the software automatically created cohorts of patients who had similar outcomes accompanied by the treatments they received at particular times and in what sequence.

The optimal events, sequence, and timing of care were presented to the physician team using an intuitive interface that allowed them to understand exactly why each step, and the timing of the action, was recommended.

We went into the EMR to make sure the data was in fact valid, and after they realized that, then they began to look at the outcomes, the length of stay, the drop in readmissions and how the costs dropped, and they were on board right away.”

While Flagler Hospital is a small community hospital with fewer resources than academic medical centers or larger health systems—for example, the hospital doesn’t have a dedicated data scientist but rather uses its in-house informatics staff for this project—the hospital is progressive in its use of advanced analytics, according to Sanders.

The Rising Danger of Cyber Crime in Healthcare

Legacy imaging systems are connected to picture archiving and communication systems (PACS), which are being linked to electronic medical record (EMR) systems and best of breed IT systems, as hospitals increasingly move to enterprise imaging.

Spurred by patient demands for increased access to their data, as well as “Meaningful Use” mandates from the federal government, providers have created a plethora of patient portals.  “This is where the real vulnerability is,” said Krishna Kurapati at the Healthcare Information and Management Systems Society (HIMSS) 2017 meeting in February.

  Ransomware attacks against all industries, not just healthcare, quadrupled from 1,000 per day in 2015 to 4,000 per day in 2016, according to the U.S. Department of Justice.

The malware is usually delivered through “spear phishing,” in which an unsuspecting person in the network opens an e-mail from what appears to be — but isn’t — a known person.

“If you can’t tell what’s going on with your system, you won’t be able to tell if they are being attacked,” he said.  Healthcare providers should sack these legacy applications as soon as possible, according to Clifton.

Enterprise Vulnerabilities As noted by the FDA in its postmarket cybersecurity guidance, Postmarket Management of Cybersecurity in Medical Devices, “networked medical devices, like other networked computer systems, incorporate software that may be vulnerable to cybersecurity threats.” This vulnerability, according to a statement issued early this year by the FDA, “increases as medical devices are increasingly connected to the internet, hospital networks and to other medical devices.” Attacks against a patient portal might come if a patient accesses medical records while on a public network.

This kind of attack can bring down not just the patient portal, but the EMR and all other connected IT systems.  In his HIMSS presentation, Joe Carson, senior director of sales engineering at TrapX Security, described the risk as shared among providers and manufacturers: “Healthcare organizations (have to) do their part to prevent attacks from being successful, to mitigate attacks and put controls in place;

and device manufacturers have to ensure that they are patching and applying everything they can to mitigate attacks against devices.” Barrett recommends that providers look for and implement ways to reduce the risk of a successful cyber attack.

And when you do get hacked, it’s how quickly you can recover from the attack.”  Mitigating the damage means more than just minimizing the monetary cost, he said: “You want to minimize the damage to the practice’s or hospital’s reputation.” Barrett advocates an audit to identify gaps and vulnerabilities;

After successfully infecting a system, typically by enticing an employee to click on an e-mail carrying malware, cyber criminals encrypt patient data then demand payment for its decryption.

At HIMSS 2017, the cybersecurity company — through sponsored speakers — advised backing up computers and servers regularly so that replacement data is available;

Cloud Dangers  Driven by the need to collaborate, as well as increase efficiency and lower costs, processing operations and data are moving into the cloud — or, more exactly, to data centers that are accessed over the internet.

The problem, according to Thomchick, senior director of cloud security at Symantec, is that “your data is going all over the place.” Not surprisingly, a big concern is data compromise.

This is why the ideal solution may be a hybrid, according to Clifton — an on-premise archive of patient data with a backup copy in the cloud, ready to be used in the event of a denial of service attack or serving as a backup in case of a ransomware attack.

and fifth, plan how to recover from an attack.  When it comes to ransomware, the U.S. Department of Justice recommends training employees to recognize danger so as not to click on e-mails that may be carrying malware.

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