Teaching Machines to Talk: Edward P. Ambinder Interview, Part Two

Tony Hagen

"We really do have the capability of having what everybody wants: a value-based system where the computer works for you and you don’t work for the computer."

This is the second segment of a two-part interview originally published by OncLive.

Difficult as it may be to coordainate communication between physicians and patients, primaries and specialists, and departments within health system, the challenge of getting newer and more complex machines to communicate with one another efficiently and safely becomes increasingly important by the day. Edward P. Ambinder, MD, clinical professor of medicine at the Icahn School of Medicine at Mount Sinai, serves as chair of the ASCO Health Information Technology Work Group. He has a special interest in improving the interoperability of computer technology to facilitate the sharing and security of patient records for the purposes of furthering patient-centric, coordinated, and value-based care. He recently answered questions about the advances that are making this possible.

Do you believe it’s possible to protect patient information to the same degree as financial information is currently protected?

You use the same standards. In other words, if I go to the financial planning site Mint, I have to give them my usernames and passwords, which they use to go to financial organizations to get financial information from checking and brokerage accounts with particular banks or Wall Street firms. And then they take that data and they will store it, and they will consolidate all of the different financial information. Then they will give me a picture of how everything fits together. There are tools on the Internet that can deal with anything related to the Health Insurance Portability and Accountability Act (HIPAA), anything related to identification of a person, provider, or proper authorization. I have no doubts that, with current internet standards and tools, the movement of encrypted medical data can be done in a safe and secure way.

Do you see similar conveniences emerging in the management of patient data?

What Apple has done with mobile computing and apps for healthcare is amazing. They have the iPhone, which has frameworks, such as a Healthkit that stores medical device data, vital signs, and other health measurements. The data are controlled by the patient. The patient can give that data to anybody they want. They can give it to a doctor, a hospital, or a health system. It’s encrypted, and it’s kept in firmware on the medical device, so it doesn’t go to the “cloud.”

ResearchKit is an open-source framework that is primarily intended to make it cheaper and easier for researchers to rapidly recruit large numbers of patients, educate them about a study, obtain their consent, help collect the data, and connect them to providers involved in the study or in special circumstances with other participants in the study. CareKit is an open source framework for health apps. It has core modules that include a way to display care plans, a symptom and measurement tracker for monitoring symptoms and tracking objective measurements, health tips, a means of visualizing trends, and ways to engage care teams and family members as partners in the health journey.

Apple is putting into their latest operating system (iOS10), the ability to capture a C-CDA medical document, which any EHR can make available to us, or a CCD, which the primary care doctors create based on their evaluations of the patient. That document can be placed on an iPod or an iPhone. It’s on the hardware—in the firmware—and, again, it’s totally controlled by the patient and nobody can get to it, not even Apple. The patient can share these interoperable documents with most modern provider and hospital EHRs.

Once this information is loaded into your iPhone, what then?

They’re creating a system where you can be anywhere in the world where there’s a 911-type system, and if you’re in trouble and you have your medical summary on your phone, you can press the button, on your watch or iPhone, invoke the SOS app, and connect directly to the 911-type of that location. The phone knows where you are. It immediately opens up the audio channel and the video channel, so that the person who is at the 911 site can receive audio and video. Since your medical record is on the phone, it can be sent to the emergency medical people who are responding.

The Apple watch and iPhone could automatically monitor your vital signs, and up to two people who were chosen before the emergency can be contacted if you’re in trouble. They will be alerted and put in constant audio and visual contact with the person at the 911 number. The EMT who is getting your medical information could have received a CCD or a CDA document, or both, or an abridged medical history that is entered by the device’s owner for those who do not have access to these standardized technical documents. They also have actionable information about you when you’re in trouble. Knowing Apple, I would not be surprised to see the SOS app being able to detect if a person falls and undergoes a period of unconsciousness, which would trigger a 911 call but also permit the owner of the device to cancel the call within 15 seconds if it was an error.

So, to me, this is the way I want to practice medicine. I want my engaged patients to be protected. I want my patients to really be able to access any of their medical information. We’ll no longer be in a world where we have silos of information that nobody can use. Once you break the silos, it’s amazing how much more efficient, how much safer, and how much more effective, enjoyable, up to date, and customizable our EHRs could be. And that’s where things are going over the next several years.

We really do have the capability of having what everybody wants: a value-based system that’s efficient, where the computer works for you and you don’t work for the computer. Today, the doctors are frustrated because the EHRs don’t have these functionalities. They’re not designed to help the doctor get information especially for the cancer patient, and it becomes a nightmare where when doctors are putting in one to two extra hours every night to deal with inputting and documenting the this data. They take that time away from seeing the patient. It’s a system that can’t survive. In my mind, I really think that’s the way we’re going. I see how the internet works for everybody else. The beauty of it is, it works. You don’t have to think about it, you just do it, and that’s what we want to be able to do with healthcare data. With the existing tools, you can have HIPAA-compliant secure data. And if you really want to make the data as secure as possible, you do what Apple is doing with patients’ records.