<v Jordan Cooper>We are here today with doctors, Afar Chowdhury, Senior vice President and Chief Digital and Information Officer at Seattle Children's. As afar, thank you so much for joining us today.</v>

<v Chaudry, Zafar>Thank you for having me. It's a pleasure to be here.</v>

<v Jordan Cooper>Yeah. So for our listeners, Dr Chaudry is a former CIO of Cambridge University Hospitals, NHS Foundation Trust and former CIO at Europe's largest Women's Hospital and also its largest Children's Hospital, both in Liverpool, England. The far then serves as research director for Global Healthcare. Gartner became CEO of Cambridge University Hospitals in the UK is now at Seattle Children's, a 400 bad pediatric hospital with 46 states across four states.</v>

<v Jordan Cooper>So so far I understand that as part of your current role, you're responsible for defining standards and protocols for data exchange, communications, software and interconnection of healthcare network information systems. Many of our listeners may be familiar with the standard set forth by CMS, the standards for Medicare and Medicaid services, the health IT Policy Committee, the Office of the National Coordinator. But some may be less familiar with the standards that are developed internally for an individual health system. Would you elaborate upon the standards your team have been developing and why?</v>

<v Chaudry, Zafar>Well, I think the standards we use are defined overall nationally by healthcare as a community and also driven sometimes in collaboration with vendor partnerships. So there are some big vendors in the electronic medical record space and the data interchange space. And so traditionally those standards have been built on HL 7 recently while over the last.</v>

<v Chaudry, Zafar>Two years or so, we've moved to the fire based a standards on data interchange and exchange and some vendors we work with are able to exchange data within their own systems across not only the nation but also the world. So it really depends on what type of information you want to exchange with who, who your partner is and how amenable and open the vendor partner is in terms of that interchange. But it's.</v>

<v Chaudry, Zafar>It it's possible it's doable. The question is what information do you need to exchange and how?</v>

<v Jordan Cooper>I see. And what information? Uh, have you found any unusual use cases at Seattle Children's?</v>

<v Chaudry, Zafar>I mean, we do get more international patients that seems to be opening back up post pandemic and yes we our primary electronic medical record system is Epic and we can see information if the patient comes from an epic site no matter where they are in the world. So we've seen some of that. We do some work for the military and able to see some information for the patients that are sent from the military services as well.</v>

<v Chaudry, Zafar>But it really depends on why the patient is coming to us and for what type of care. Of course, there are other challenges is if you're seeing a physician, how long do you actually get with the physician and how much time does that physician have to look at that data during the visit or previsit?</v>

<v Jordan Cooper>And so.</v>

<v Jordan Cooper>When uh provider is looking to coordinate care for a child who comes to Seattle to receive this specialized care, how do you overcome the challenges of not only getting them the information as you just spoke to, but actually having the physician review and account for the information that is available to him or her?</v>

<v Chaudry, Zafar>So that's the the physician workflow process is defined by the clinical community that we have. So they have processes and workflows in place based on specialty as to what information needs to be seen and how that is seen. In many cases, if you're referred to children's, there is a triage step that happens and we're using nurses, nurse practitioners, physician assistants to help us triage.</v>

<v Chaudry, Zafar>And collect that information in preparation for the actual physician visit.</v>

<v Chaudry, Zafar>And a lot of that information now is electronically available, whether it comes through the EMR, whether it comes through a health information exchange.</v>

<v Chaudry, Zafar>Unfortunately, some information still comes through the the dreaded fax machine as well, but that seems to be on the decline. There's a lot more electronic data interchange and for us that shifted about two years ago when we moved from a dysfunctional EMR to a single standard. EMR is when we started to see more interchange of data than ever before prior to that.</v>

<v Chaudry, Zafar>We didn't have a lot, a lot of electronic data in our patients. We were still using paper and lots of facts services, but we don't do that as much now because most organizations will provide the data electronically and it really doesn't matter what system they're on. The challenge is usually do arise though from smaller practices that refer to us. So if you're a small pediatric practice, you probably are running an antiquated.</v>

<v Chaudry, Zafar>Paper slash electronic electronic medical record system and they tend to fax over information, but if you're coming from a standard practice that's run by a big health system, it's either interchange through Epic or Cerner directly to us.</v>

<v Jordan Cooper>I see.</v>

<v Jordan Cooper>Now you have previously spoken so on the topic of OK we've covered.</v>

<v Jordan Cooper>How do you gain access to information and then how once you have access to information, how do you actually utilize it? So you've previously spoken about application rationalization, whereas Children's Hospital has gone from 840? Do I believe 788 digital applications and you had to determine in a rationalization of each application which are valid, which should be archived, which should be decommissioned? Could you speak more about?</v>

<v Jordan Cooper>Uh. Determining how you maintain your digital portfolio?</v>

<v Chaudry, Zafar>So I think application and application sprawl is a challenge for any healthcare organization. We certainly gone through that cycle multiple times. I think rationalization of applications for us is an ongoing piece of work which never seems to end because as we add new applications, we have to deprecate old ones. We've tried to identify subject matter expert slash owners for each one of the applications that we have.</v>

<v Jordan Cooper>Mm-hmm.</v>

<v Chaudry, Zafar>Whether they're clinical or not, and then we consult with them to see whether the application is valid, whether that application still needs to remain on and if that application is to be turned off, what happens to that data shows that data be archived or can that data be deleted in Pediatrics? What we find is you tend to have to keep the data for a really long time up to 30 years and therefore, any system you deprecate the data has to be archived, but it's a consistent Q&A.</v>

<v Jordan Cooper>Hmm.</v>

<v Chaudry, Zafar>Of the validity of each application. Now by putting in a single integrated EMR, we were able to deprecate some applications, but at the same time as needs and wants and demands change for for the clinician, new applications have to be installed or applications are revised or changed from 1 vendor to another in the clinical space. So we might have an EMR at the core, but there are about 40 other systems bolted into that that require refresh upgrade.</v>

<v Chaudry, Zafar>Potential change. And then there's the whole interoperability between all of the systems which we have a platform that we use, which happens to be intersystems, so we also have to maintain, run and reconfigure that system as well as part of the application rationalization process.</v>

<v Jordan Cooper>I see. So you use uh intersystems to promote interoperability between different systems?</v>

<v Jordan Cooper>You are constantly evaluating which applications are necessary and and you said you've moved to a single integrated EHR which is epic. And previously I mentioned that you have been in the United Kingdom. What do you think? Are there any lessons learned from your time, any knighted Kingdom where there's a single payer?</v>

<v Jordan Cooper>National Health Service system.</v>

<v Jordan Cooper>Uh, and that you leverage it also leverages intersystems is, are there any lessons that you learn from your time in the UK that you think could benefit American healthcare delivery systems?</v>

<v Chaudry, Zafar>Well, I think in the UK the government made interoperability a lot simpler because as part of the process of being a vendor on the approved list by the government, you had to comply with standards of information interchange. You didn't have a choice if you didn't agree to the national standards, which were.</v>

<v Chaudry, Zafar>Not difficult to meet. You couldn't be a preferred supplier to the government, therefore couldn't provide systems to the independent hospitals across the country. So and the UK's health model is based on a national spine of information so similar to having one major health information exchange for the entire country, and they call it the national spine. And all clinical systems are required.</v>

<v Chaudry, Zafar>To send data to the national spine and then that national spine can be accessed from any health care facility using a smart card and that will have all the patients information.</v>

<v Chaudry, Zafar>Doesn't matter where you live, and that was a requirement that the government placed on every vendor doing business in the country. Of course we don't have.</v>

<v Chaudry, Zafar>I'll have reached the ability where the federal government has said if you want to play in the healthcare space, you must meet these certain standards. I think CMS has been trying to do some of that.</v>

<v Chaudry, Zafar>I may have put some of that into action, but then some of it has been delayed, so it's taking a lot longer to get to that. You know, how do we interchange the information? I think the lessons learned is.</v>

<v Chaudry, Zafar>They still needs to be some legislation that says people must do the right thing.</v>

<v Chaudry, Zafar>We're using the standards which most vendors can support. Sometimes choose not to.</v>

<v Jordan Cooper>Hmm.</v>

<v Chaudry, Zafar>Comes proprietary, right? But the end of the day, if I open my system up to you and you open your system up to me, then I can't necessarily charge you for all of those interfaces that I would.</v>

<v Chaudry, Zafar>In general, charge you for.</v>

<v Jordan Cooper>I see so, but you've mentioned.</v>

<v Jordan Cooper>Umm. Well, you mentioned that moving Seattle Children's to 1 instance of EPIC has been helpful, but that you've still required the use of inter systems to.</v>

<v Jordan Cooper>Uh promote, enter the the successful interchange of information, especially when integrating different information from individual pediatric clinics. Can you speak more about?</v>

<v Jordan Cooper>Uh, that particular need.</v>

<v Jordan Cooper>What value the integration engine provides to healthcare delivery systems or hospitals that have moved to one individual instance of any ajar?</v>

<v Chaudry, Zafar>So an integrated EHR EMR isn't going to solve all of your clinical needs. There are still some ancillary systems that that require interconnectivity, that the beauty of working with an interface engine specialist such as intersystems is they will support any standard.</v>

<v Chaudry, Zafar>And don't block standards, but support them all and therefore you can use that tool to connect from.</v>

<v Chaudry, Zafar>Smaller vendor systems to larger vendor systems, and that's what we've done. So Epic or Cerner or any of those don't necessarily solve all the use cases that you need clinically. Sometimes you have to buy other systems like a document management system, workflow systems, etcetera. And they then have to be even radiology systems. And therefore they have to be bolted in to the EMR and most health care organizations will use an interface engine system.</v>

<v Chaudry, Zafar>That that will support all the standards. So we've been using the intersystems.</v>

<v Chaudry, Zafar>I'm sort of healthcare platform for a really long time.</v>

<v Chaudry, Zafar>Once the information is flowing through Intersystems health share, you can actually take a feed of the data from that system and then use that.</v>

<v Chaudry, Zafar>To to provide information in the in the form of analytics. If you choose to do that, and so you can actually do that and we do that, we feel all of our data into a data warehouse as well and all of our reporting that gives us our clinical outcomes data, our performance data, etcetera comes through dashboards which we display on Microsoft Power BI. So there's value to the data that you're interchanging between systems.</v>

<v Jordan Cooper>Umm.</v>

<v Jordan Cooper>Hmm.</v>

<v Chaudry, Zafar>I'm in the sense that you can improve clinical outcomes. Look at how you're treating patients and most health care organizations have some form of that, some more advanced than others.</v>

<v Jordan Cooper>So in United King, back to the United Kingdom, you said that all vendors working with NHS are required to adhere to certain data interoperability interchange standards, I believe is what you referred to. What would be the need for having an integration engine if every?</v>

<v Jordan Cooper>Uh, if every service already here is to the same standards?</v>

<v Jordan Cooper>Umm.</v>

<v Chaudry, Zafar>Well, if you did, if you if you were able to get people to sign up to to a standards based model, then yes, you wouldn't need the interface engine because each vendor would be signing up to the same pledge in effect. And so the NHS use of interface engines does exist but isn't to the magnitude that let's say we do it children's.</v>

<v Jordan Cooper>Hmm.</v>

<v Chaudry, Zafar>So there is some reduction in cost from doing that?</v>

<v Chaudry, Zafar>Uh, but at the same time, you have to then get everybody to agree to a particular standard, and it's easier to do in a publicly funded health system such as the NHS because they can mandate that as a way of doing business. Of course, in the US, we do not run a system where we force people to do anything.</v>

<v Chaudry, Zafar>And that's why that's going to be very difficult to implement here. It's gonna be more of a does it become a federal guideline which then people try to follow versus how do you enforce that?</v>

<v Jordan Cooper>Mm-hmm.</v>

<v Chaudry, Zafar>Because in an open, competitive environments such as the US, you can't force people not to do business, right? You have to encourage them to do the right thing, but at the same time you can't block them from doing business, which is different in publicly funded health systems. They can tell you that you can't do business in a particular country if you don't follow a particular standard.</v>

<v Jordan Cooper>So.</v>

<v Jordan Cooper>We've covered a big ground speaking about the NHS, different interoperability standards.</v>

<v Jordan Cooper>I'd like to ask you, so far as we move towards the end of this podcast episode, if what sort of projects are is Seattle Children's working on that you find to be exciting that are leveraging some of these standards that may be exchange exchanging data with with other other entities. What sort of interesting projects are you excited about that you'd like to share with our listeners?</v>

<v Chaudry, Zafar>So our most.</v>

<v Chaudry, Zafar>Our biggest focus at children's right now, using the data that we sit on and it's a lot of data, is around equity diversity and inclusion. We're putting a huge focus that children's and we have done over the last 12 months in taking all the data that we have around the patient's around the demographics of the patient, they're outcomes, their ethnicity to figure out whether we are being equitable and diverse in how we treat patients equally.</v>

<v Chaudry, Zafar>And the data has allowed us to do that. So we're able to see how we treat white patients worse versus Asian patients versus African American patients by race, by sex, by age. And we're able to modify our clinical procedures and workflows to bring a level of equality that wouldn't have happened if we didn't have the data that showed us areas where they may be discrepancy. So the real value for us with the integrated EMR.</v>

<v Chaudry, Zafar>And interchanging data between the systems that we have and receiving data from other partners systems is we can now tell you how long it takes to give patient X of a particular race of a particular sex pain medication what the outcomes are post operatively, what the outcomes are when they go home and whether the outcomes are the same. So if you were to take a 6 year old child.</v>

<v Chaudry, Zafar>Of multiple races female who just had a tonsillectomy. Do they get the same petition pain medication? Do they get the same doses? Do is our outcomes the same? Do they recover within the same time frames and it's allowed us to adjust the way in which we practice medicine for the better and better outcome for the clinical patient. So that's the most exciting thing we've been working on in the last 12 months. I believe using the data that we have.</v>

<v Jordan Cooper>With that particular use case, you just.</v>

<v Jordan Cooper>Elaborated upon and in that particular example of the the patient who's getting a tonsillectomy. If you did find a difference in the outcomes or the time of getting the pain medication, could you just give a quick example of how you how you have in the past modified a clinical workflow?</v>

<v Chaudry, Zafar>So give me the example of tonsillectomy. What we learned with tonsillectomy was if you have a tonsillectomy, it children's.</v>

<v Chaudry, Zafar>All the patients that had tonsillectomies were getting opioids.</v>

<v Jordan Cooper>Umm.</v>

<v Chaudry, Zafar>For pain control, which isn't, which isn't unusual, but of course you don't really want to give opioids to kids.</v>

<v Jordan Cooper>Mm-hmm.</v>

<v Chaudry, Zafar>So what we did is we looked at the data and said how how many medical, how many pills do we give for pain? How long does the child have pain after surgery and can we change the cocktail of pain medication and move it away from opioids?</v>

<v Chaudry, Zafar>So we changed the the different types of medication we give postoperatively and we've reached a point that we do not give opioids at all now for post tonsillectomy patients, which is a lot safer for the patient, right, because of the levels of addiction to pain medication. So we've made that change, but that's been a collaboration between the surgical teams and the post operative teams and close monitoring of the patient. So talking to the patient on a daily basis.</v>

<v Chaudry, Zafar>Feeding that information into our data pools and then saying actually we've found a new way of treating pain with zero opioid usage. And so that's how you change it by collaboration between teams looking at the data, working with the patients and that's huge. If you have opioid free post tonsillectomy pain medication, there's zero risk then of any form of addiction to to an opioid. In that case scenario.</v>

<v Jordan Cooper>So, Zafar, I'd like to thank you for for joining us today. I think we've had an interesting conversation that in in one way metaphorically has mirrored actually kind of the rollout of EHR across the United States. You'll notice that the American Recovery and Reinvestment Act 1008, there was an incentive to get every single American life covered by an EHR in a way that we measured an incentivized that use with something called meaningful use. I think over the course of this discussion we've spoken about.</v>

<v Jordan Cooper>How hospitals and providers can access various different forms of data and the standards required in order to enable the access of that data. But then on top of that, our conversation moved to how can providers meaningfully leverage that data in order to improve clinical outcomes, reduce disparities of care and generally improve the value and quality of care that is provided? I think that's a very interesting narrative, and I appreciate your willingness to share that with me and our listeners on Healthy Data podcast today.</v>

<v Chaudry, Zafar>Thank you for having me. Thank you for the conversation. It's been a pleasure.</v>