Changing the Status Quo of Healthcare Using GIS
Bryan Sivak (Photo at righ), CTO of the Department of Health and Human Services (HHS), kicked off the Esri Health GIS Conference held in Colorado Springs, CO in early November. He set a tone of optimism, suggesting that his role, and that of many of his peers in government, is to do things differently. He shared a quote from Charles Kettering, an inventor, which ricocheted around the conference for the next few days:
If you've always done it that way, it's probably wrong.
Sivak detailed how HHS is changing the way things are done by investing in people via grants, bringing in contributors with different expertise, and getting groups to work together.
Many of the presentations were about disparities. Why do some parishes in Louisiana have so many more children on ADHD medications? Ryan Bilbo of the Louisiana Department of Health and Hospitals shared lots of ideas as to why, but the most important outcome of his team’s work wasthe creation of a work group to explore the matter. A team from the New Mexico Department of Health (four speakers in a 20-minute presentation!) are looking at the status quo for chronic diseases via maps and learning of the geographic challenges of this large and largely rural state. Pennsylvania, also a large and largely rural state, has a population with challenges in accessing healthcare services, including geographic challenges. To account for the uneven population distribution Jeremy Zuckero and colleague Thomas McCleaf of the Pennsylvania Department of Health developed a cancer burden index, a new statistic to explore how to provide better access to breast and cervical cancer screenings. The upshot: when the state invited bids to provide these services, preference was given to bidders serving in-need geographies.
The status quo at Esri changed this year also as Bill Davenhall turned over leadership of Esri’s Health and Human Services Team to Dr. Este Geraghty. Geraghty introduced herself and shared some of the ideas on her mind in the new role.
One Health - The idea that a full understanding of health involves looking at the intersection of human, animal and environmental health.
Barriers to GIS Adoption - To break down the barriers to GIS use in health and human services, she noted, practitioners need to identify the value of using GIS as a tool to encourage interoperability of different groups and datasets. They can also note significant return on investment achieved by reducing waste. The Health Insurance Portability and Accountability Act (HIPPA) was designed to help workers retain insurance when changing jobs and set standards for electronic health records, but it has implications on data use. Esri, Geraghty offered, can help GIS users comply with the act by suggesting guidelines and best practices.
Esri Commitment - The company is committed to keeping users up to date on technology, open data options and best practices. Those in the industry can expect to see new webinars, custom solutions and outreach.
A version of the “iceberg” slide which highlights how visible symptoms and possible treatments are only the tip of the iceberg in healthcare. Multiple influences lay below the surface and are harder or impossible to see can change. Source: Latrobe University
With all of the focus on medical care, it was telling that I saw the “iceberg slide” or its equivalent (above) no fewer than three times in two days. The graphic shows just 20% of an iceberg above the water; that’s healthcare’s role in keeping a person healthy. Under the surface are the bulk of the factors that determine health, including lifestyle, environment and genetics. The message is that the health community needs to highlight its relatively small role in overall health and advocate for other types of wellness campaigns.
The Affordable Care Act (ACA) has shaken up the status quo on a number of fronts. One new reimbursement rule popped up in many presentations. As of now, if a patient is readmitted for the same issue within 30 days, there is reduced Medicare/Medicaid reimbursement to the provider. That has incentivized hospitals to find ways to discharge patients with the knowledge, medications or resources so they can stay out of the hospital. At Children’s National Medical Center in Washington, D.C., mapping is one of the tools used to explore how best to limit readmissions. A study to explore possible interventions is focusing on sickle cell disease and bronchiolitis. One finding of interest in initial sickle cell disease data: patients closest to the hospital are least likely to readmit. That, explained Jefferson McMillan, seemed counter intuitive. If patients were nearby, you might think they’d be more likely to return and readmit. It turns out they didn’t readmit because subsequent care was handled in a clinic. Those are the sorts of unexpected findings that capturing and exploring data can reveal.
One term that continued to pop up was interoperability. I learned pretty quickly that its use here did not refer to the interoperability standards from the OGC, though those did pop up from time to time. In this context, interoperability refers to having groups work together, but also being able to share and successfully use one another’s datasets.
I particularly liked Vernon Brown, vice-chairman of Stewards of Change Institute’s example of interoperability. He spoke about changes in foster care. He runs a non-profit, Aspiranet, in California with a focus on creating stable families. He noted that one predictor of incarceration later in life in California was a student’s inability to read by third grade. It’s not clear if that’s true. Still, Aspiranet borrowed a state curriculum used to boost reading at that age to share with its foster parents.
Randy Johnson, Hennepin County (MN) Commissioner, made the case for interoperability by focusing on the county’s own health solution. By identifying and wrapping the “most costly” users in county services, they were able to significantly reduce emergency room visits and related costs. And by coordinating care, a number the county’s homeless found permanent homes, increasing their quality of life and enhancing their health.
Larry Green of the National Committee on Vital and Health Statistics and the University of Colorado School of Medicine introduced us to several early physicians who used GIS principles. Neither was named John Snow. Check out William Pickles of the UK, who mapped, quite uniquely, cases of flu, measles, dysentery, varicella (chicken pox) and herpes in the UK in the winter of 1932. And, do a bit of homework on Curtis Hames, from Georgia who was in the first cohort of McArthur Genius award winners. He was an early pioneer in heat disease epidemiology. Green’s main point, however, was about a Community of Solution. It’s a simple idea: to solve health problems, all of those involved need to work together. The idea dates back to the Folsom Report (1966), which re-emerged in 2012 because so many of its ideas are part of the ACA! Green also noted something I was not aware of: there is legislation that identifies health extensions, akin to agricultural extensions at the Land Grant Colleges. As the legislation gets funded, these programs could be valuable partners in building and using health GIS.
Data, Data, Data
The state of data, the status quo, is not high enough for those attending the conference. Even renowned Duke Center for Health Informatics, which showed some of the most impressive cutting-edge uses of GIS, was hampered by poor data. In short, putting dots on a map is easy; getting good data to locate those dots is still challenging.
Loma Linda, also a leader in geomedicine, ran into challenges attaching “good addresses” to its patient records. The hospital has a prototype of an addition to its EPIC health records implementation: a “wellness map” button. It takes data from the record and creates a map of services related to the patient’s medical needs on the fly. A diabetic, for example, might find healthy food resources, fitness providers and support groups all within a short drive. The tool, said Mark Zirkelbach, CIO, Loma Linda University Medical Center, could be used by physicians to prescribe better post-operative exercise programs. If a patient lives in a neighborhood without the requisite hills to climb, the doctor may suggest a gym with an adjustable grade treadmill. Loma Linda considers place to be the seventh vital sign, adding it to the familiar list of temperature, heart rate, blood pressure, respiration rate, pain and distress.
Collecting good data is one challenge, getting it in the hands of those who can use it is another. HealthLandscape offers tools to explore health and related data. While it builds custom solutions for clients (one for identifying schools that would be best to host health clinics is in the works), there are generic tools at the website. Community Commons gathers data and works to tell stories around it, since that’s a key way to make large reports and datasets relevant. The group offers great tools and data for those who want to make maps, too. Loma Linda is using Esri story map templates to create resource maps for school staffers and physicians that highlight parks, healthy eating and the like around elementary and middle schools.
I left the Health GIS Conference with a positive outlook for its practitioners and their ability to effect change. It’s clear from the formal presentations and informal chats that they see much that can be changed to better serve healthcare organizations and clients. The conference reaffirmed two key pathways to that change: working with other stakeholders both locally and beyond, and gathering and using the best spatial and non-spatial data possible.
Disclosure: Esri covered travel and lodging for this event.