Care Redesign

Using Big Data to Make Wiser Medical Decisions

Article · December 23, 2015

As the chief information officer of a large academic medical center, I oversee four petabytes of data. Is that “big data”? I have little difficulty storing, securing, and accessing it, so I’m not sure it qualifies as big. To me, the bigness of data is not its absolute size, but the task of transforming it into wisdom.

At Beth Israel Deaconess Medical Center (BIDMC), we use big data to create real-world applications that lead to wise clinical decisions for patients. That’s something any forward-thinking provider must aim for in today’s data-driven health care environment. I’d like to discuss three BIDMC big-data applications that required both technical expertise and leadership — and that have helped our patients, including my family and me.

Patient-Generated Health Data

For most of my life, my blood pressure (BP) has been 110/50 — a boring number that is considered medically reasonable. During an annual physical exam this past summer, it was 170/100. My medical workup suggested no medical cause for this elevated BP, such as heart- or kidney-related problems. My clinician was perplexed: Was this sudden increase caused by a stressful commute (the Massachusetts Turnpike is awful), too much tea (caffeine and theobromine), or work-related anxiety? To find out, we needed data.

I have a Withings BP cuff linked to my iPhone 6 via Bluetooth Low Energy. My iPhone is connected to my clinician’s electronic health record via a new app called BIDMC@Home. Using the cuff, I took my BP before and after commuting, drinking tea, and attending anxiety-provoking meetings — nearly 100 measurements in a week. The raw data were just numbers, although they helped reveal interesting information — that none of my life activities (commuting, tea drinking, work) influence my blood pressure. The problem, logged as a discrete data point in my electronic health record (EHR), turned out to be my parents. My mother has essential hypertension, as did my father. So did their parents. It took 53 years for my genome to catch up with me and manifest as hypertension. What wisdom did we glean from this knowledge?

Well, I have glaucoma (elevated eye pressure, also inherited from my family) and an occasional fast heartbeat, called atrial tachycardia. Both can be treated effectively with beta-blocker medication, as can essential hypertension. Drawing on clinical guidelines, my EHR took all three conditions into account and suggested beta-blockers as the ideal medication for me. Today, with 25 mg of the beta-blocker metoprolol taken at bedtime, all of my conditions are completely controlled without any side effects. In short, the BP data I had gathered telemetrically at home, coupled with information in my EHR, helped my clinician and me make a wise choice about my treatment.

How did we make BIDMC@Home happen at an organizational level? Our IT leaders started by showing how patient-generated health data could tie in with pay-for-performance reimbursement. Their IT strategic-planning exercise, with a 24-month outlook, involved 30 stakeholders on the front lines of patient care. This group saw that new mobile apps for patients (which measure and manage health outcomes) could yield clinical and financial benefits. The idea was presented to BIDMC’s senior-management operating council and then to the Board’s IT oversight committee. With support at all levels, the project was funded, new support staff were hired, and the rollout ensued. Our IT leaders also served on Obama Administration committees that wrote requirements for patient-generated health data into 2018 federal health care IT regulations, thereby ensuring the concept’s longevity.

Precision Medicine

In December 2011, my wife was diagnosed with stage IIIA breast cancer with a specific type of tumor. (For medically minded readers, it was estrogen-positive, progesterone-positive, and HER2-negative.) She was 49 at the time, is Korean, and has no other significant medical problems.

Using I2B2, an open-source tool available at all Harvard hospitals, I was able to ask this big-data question: Of the last 10,000 Asian women near age 50 who were treated for the same tumor, what medications were used, was surgery or radiation necessary, and what were the outcomes? The answer: a combination of taxol, adriamycin, and cytoxan was most effective, but the amount of taxol had to be carefully limited to avoid nerve damage. My wife was treated successfully and is now cancer free.

To launch I2B2, the leaders of that effort assembled a coalition of senior IT people, throughout Harvard’s hospitals, who became early adopters. They developed the policies and technologies needed to query large databases across institutions, thereby attracting national and international audiences. With each new adopter, momentum built, implementation risks diminished, and institutions decided they didn’t want to be left behind. I2B2 is now used by more than 60 academic medical centers globally. And the Obama Administration’s Precision Medicine initiative aims to bring this kind of decision support, using data from large numbers of successfully treated people, to every new patient.

Wise Analysis

For my wife’s case and my own, the data analytics were done retrospectively, not in real time. A computer did not constantly mine data and then alert clinicians to a new finding. Someone had to ask the right questions — in short, to glean information from the numbers and then use knowledge to make wise, analytical choices.

At BIDMC, we now use a tool called “screening sheets” to support continuous data analysis. Experts decide what data elements and what questions are important for common diseases — and that information is built into the screening-sheets tool. As patients receive new medications, lab results, and diagnoses, the electronic health record alerts clinicians when to take action. For example, a patient with newly diagnosed diabetes is automatically enrolled in a protocol that includes eye exams, foot exams, and pneumonia vaccines.  Any gaps in care for the patient are coupled with information about best practices, and the clinician is proactively informed about both so that he or she can make a wise clinical choice.

We will soon incorporate big data from the genome into our screening sheets. As the second human sequenced in the personal genome project, I know the disease risks identified in my DNA. My clinicians, aided by computer-based clinical decision support, can analyze my new lab results and symptoms according to the likelihood that, given my genetic profile, I will experience a particular disease in my lifetime.

To make screening sheets a success, our IT leaders articulated a vision that was consistent with clinicians’ need to improve quality, safety, and efficiency for better population health. Although the clinicians could not pinpoint the specifications they desired, they enthusiastically embraced the resulting functionality — a “list manager” of patients identified by the screening sheets. The list manager might, for example, generate this message: “Of 4,000 patients seen, 372 (9.3%) have a diagnosis of diabetes; 50 of the 372 have not had their recommended pneumonia vaccine this year. Your care manager should contact these 50 patients (listed here) to schedule vaccination.” It’s easy to act on that type of message.

At BIDMC, we don’t overwhelm clinicians with big data but instead reduce their burden by staying one step ahead of what they need to make wise clinical decisions. Our IT leaders “skate where the puck will be” and score important goals for the entire organization and the patients it serves.

New call for submissions ­to NEJM Catalyst

Now inviting longform articles

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Summary of Comprehensive Approach to Physician Behavior and Practice Change

Engaging Stakeholders to Produce Sustainable Change in Surgical Practice

How an initiative designed to improve patient outcomes and satisfaction while containing costs led to sustainable change in surgical practice and physician behavior.

Myths and Realities of Opioid Use Disorder Treatment.

Primary Care and the Opioid-Overdose Crisis — Buprenorphine Myths and Realities

There is a realistic, scalable solution for reaching the millions of Americans with opioid use disorder: mobilizing the primary care physician (PCP) workforce to offer office-based addiction treatment with buprenorphine, as other countries have done.

Coffey02_pullquote family-centered care in medical and surgical procedures

What If Family-Centered Care Were Extended to Medical and Surgical Procedures?

Though the concerns are valid, early experiences suggest that family member engagement may be an effective tool for improving the value of care.

Evidence Needed for Health Systems Change to Address Social Determinants of Health and Obesity and Diet-Related Diseases in Turn

Better Clinical Care for Obesity and Diet-Related Diseases Requires a Focus on Social Determinants of Health

To more effectively treat the problems of obesity and diet-related conditions, health systems need to restructure the traditional medical model of care delivery to address the social determinants of health.

People Living with Dementia Around the World - Value-Based Chronic Illness and Dementia Care

Value-Based Care Must Strengthen Focus on Chronic Illnesses

To effectively control costs and improve value, new models must address our increasingly older patients and chronic care patients, especially those with Alzheimer’s and related dementias.

The Barriers to Excellent Care Vary Widely Across Geographic Regions - both Rural Health Care and Urban Health Care

Survey Snapshot: Rural Health Innovations Born from Challenges

According to NEJM Catalyst Insights Council members, every health system has to develop its own definition of what is meant by “rural” health.

Same-Day Breast Biopsy Workflow at Baylor College of Medicine

How Care Redesign and Process Improvement Can Reduce Patient Fear

Seeing how clinicians take care of their own when they are in frightening situations was the epiphany that led to a same-day breast biopsy program.

Rural Health Care Is Rated Comparable or Worse Across Quadruple Aim Aspects

Care Redesign Survey: Lessons Learned from and for Rural Health

Although care delivery models in rural and urban/suburban areas are distinct, by virtue of geographic density and resource availability, each locale affords lessons for the other.

Comprehensive Intervention Review at Lurie Childrens Hospital - improving patient flow and length of stay

Reducing Length of Stay in the ED

A comprehensive redesign of triage and ED care.

Pumonary Nurse Post-Discharge Follow-Up Note for Patients with COPD

TOPS: Telephonic Outreach in the Pulmonary Service at VA Boston Healthcare System

A nurse-directed intervention targeting veterans who had been hospitalized for COPD resulted in improved access to ambulatory care and a reduced rate of readmissions.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Social Needs

88 Articles

Better Clinical Care for Obesity and…

To more effectively treat the problems of obesity and diet-related conditions, health systems need to…

A Successful Pilot to Improve Access…

Actionable data and modest financial incentives can help motivate clinicians to adjust their behavior around…

Coordinated Care

129 Articles

The Evolution of Primary Care: Embracing…

Primary care must leverage disruptive innovations to ensure that patients receive first-access, comprehensive, coordinated, continuous…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now