Kensaku Kawamoto, MD, PhD, MHS, FACMI, Associate Chief Medical Information Officer for University of Utah Health and Vice Chair of Clinical Informatics for the University of Utah Department of Biomedical Informatics. At the University, Dr. Kawamoto chairs the Clinical Decision Support committee and is a leader of the University’s Interoperable Apps and Services (IAPPS) initiative, which is a multi-stakeholder effort to enable standards-based, interoperable applications and software services to improve health and health care. To learn more, download Dr. Kawamoto's ROCC Star Profile.
What is the University of Utah IAPPS initiative?
The University of Utah’s Interoperable Apps and Services (IAPPS) initiative is a multi-stakeholder effort to improve patient care and the provider experience through innovative, interoperable extensions of native functionality provided in the electronic health record (EHR), which for us is Epic®. Through IAPPS, we are developing various provider-facing clinical applications and decision support capabilities that are seamlessly integrated with the rest of the EHR, as well as patient-facing smartphone applications that are synched with the EHR. We are leveraging emerging health IT standards such as FHIR, SMART, and CDS Hooks with the goal of enabling these apps and services to be shared across healthcare organizations and EHR platforms. We are developing apps and services spanning the continuum of care, including prevention, chronic disease management, acute care, and transitions of care. Several of these initiatives are being pursued with the support of research grants, such as a project funded by the National Cancer Institute for identifying and managing individuals with elevated risks of breast and colorectal cancer using standards-based, interoperable, and ultimately widely scalable approaches. We have also recently launched an initiative called Re-Imagine EHR that builds on IAPPS and encompasses the various dimensions of interoperable EHR optimization including research, operations, and clinical services.
Could you share an initial success story of the initiative’s work across research, operations, and clinical services? [Perhaps the neonatal bilirubin app?]
As one of the first IAPPS apps, we started with a simple bilirubin visualization tool developed by our colleagues at Intermountain Healthcare, which uses the Cerner® EHR platform. Because this tool was developed using the SMART on FHIR interoperability platform, we were able to build on this tool to create a full-featured app for managing neonatal bilirubin. The app is integrated with the Epic EHR system and is in operational clinical use every day by our providers. We worked closely with our clinical champions, in particular, Drs. Carole Stipelman and Julie Shakib, and we incorporated a variety of research findings, including recommendations from the American Academy of Pediatrics and a recently published predictive model for rebound hyperbilirubinemia from Chang et al.
The app is accessible as a tab in the EHR. Once the user clicks on the tab, the app automatically loads in relevant patient information including the patient’s gestational age, the patient’s laboratory results, the mother’s laboratory results, phototherapy orders, and phototherapy administration timings in nursing documentation. Based on all this data, the app provides patient-specific care recommendations according to the evidence sources described above. Besides anticipated improvements in care quality and patient safety – which we are in the process of evaluating – we estimate that the app is saving hundreds of hours of physician time every year. Our leadership has approved sharing this app with our colleagues for free, and we are actively working towards this dissemination through “app stores” that have been sent up by EHR vendors including Epic and Cerner. This app has also won several awards in the U.S. Department of Health and Human Services’ Provider User-Experience Challenge.
When developing the apps to improve patient care and the provider experience, what are the major challenges associated with interoperability across academic medical centers?
We are at an exciting phase of interoperability across academic medical centers, in that major EHR vendors are embracing key interoperability standards such as FHIR, SMART, and CDS Hooks. That being said, as with anything that is relatively new, there are certainly growing pains. The University of Utah Department of Biomedical Informatics recently hosted a two-day meeting on how to move forward on interoperable apps and services with colleagues from across the nation, in partnership with the Healthcare Services Platform Consortium. We dedicated an entire session focused on major challenges associated with interoperability. One important challenge is the need for additional, standard application programming interfaces (APIs) – that is, ways to pull data out of the EHR and to push data back in. For example, for the bilirubin app, we had to create custom APIs to pull a variety of data points out of the EHR, including for the baby’s gestational age, the mother’s laboratory data, and phototherapy orders. Even when standard APIs have been defined, other important challenges include the lack of specificity in those standards, which lead to different interpretations and implementations of those APIs by different EHR vendors, as well as the need for local terms such as for laboratory tests to be accurately mapped to standard terms. Finally, a critical challenge is that addressing these issues requires multiple stakeholders – including academic medical centers – to work closely together. As we all know, this type of inter-institutional collaboration requires significant effort and commitment, particularly among stakeholders who are already over-committed on so many fronts.
What do you think is needed to advance the field?
I think it is critical that healthcare systems – and in particular academic medical centers – organize and speak with a unified voice on what is important to us, and what we wish to happen. Much of what is needed to advance the field depends on EHR vendors, and they make the very reasonable point that given all their different competing priorities, it is important for their customers – us – to provide clear direction on what is most important. And I would argue that being able to harness the deep talent and innovation among academic medical centers to collectively optimize the EHR is a critical priority, important for everything from providing high-value care to ensuring patient safety and addressing provider burnout. I hope the AAMC can help us organize our efforts, so that we can speak with a unified voice in this area on behalf of our patients and our providers.
Related to this issue of coordination and cooperation, I think we should dream big but start small. In particular, I think we should start with a few initial collaborative projects where the stakeholders have agreed to share any associated intellectual property (IP) for free. To that end, I would suggest starting an AAMC initiative to share a free SMART on FHIR app among its members, such as the bilirubin app I described earlier. Another potential area where we could start would be sharing a free CDS Hooks service, such as decision support services that we and other colleagues have developed to deliver point-of-care advice based on the CDC guideline for the use of opioids for chronic pain management. These opioid management tools were developed with the support of the CDC and the Office of the National Coordinator for Health IT, and they can also be shared for free. If we can work together to make these types of initial capabilities widely available across academic medical centers and EHR platforms, I think we will have established a clear roadmap for how we can continue to work together to deliver value to our patients and to enhance the provider experience.