Ep. 80: Leveraging Health Informatics to Serve the Underserved

Health informatics stands at the intersection of healthcare and information technology. It’s a science that uses healthcare data to uncover insights, advance innovation, inform research, and help clinicians make the best patient decisions and recommendations.

Dr. Stacey Stokes is the Medical Director of Informatics with Children's National Hospital in Washington, D.C. At the 2024 Pediatric Academics Society annual meeting in Toronto, she facilitated a series of presentations by colleagues from across the nation and experts from the Academic Pediatric Association Special Interest Groups (SIGs). They seek methods and examine best practices to leverage health informatics to move the needle on serving the underserved and addressing the social determinants of health (SDOH).

Guest:
Stacey Stokes, MD, MPH, Medical Director of Informatics, Children’s National Hospital

Carol Vassar, producer

Views expressed by guests do not necessarily reflect the views of the host or management.

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Transcript

Carol Vassar, podcast host/producer:

Welcome to Well Beyond Medicine: The Nemours Children's Health Podcast. Each week we'll explore anything and everything related to the 80% of child health impacts that occur outside the doctor's office. I'm your host, Carol Vassar. And now that you're here, let's go.

Music:

Let's go. Well Beyond Medicine.

Carol Vassar, podcast host/producer:

Health Informatics stands at the intersection of healthcare and information technology. It's a science using healthcare data to uncover insights, advance innovation, inform research, and help clinicians make the best decisions and recommendations for their patients. Dr. Stacey Stokes is the medical director of informatics with the Children's National Hospital in Washington, DC.

At the 2024 Pediatric Academic Societies meeting in Toronto, recently concluded, she facilitated a series of presentations by colleagues from across the nation, experts from the Academic Pediatric Association (APA), and their special interest groups or SIGs, as she'll refer to them.

They are seeking methods and examining best practices to leverage health informatics to move the needle on serving the underserved and addressing the social determinants of health, especially now that SDOH screening has become nearly universal. Here's Dr. Stacey Stokes.

Dr. Stacey Stokes, Children's National Hospital:

Now that everyone is talking about social determinants of health and everyone is screening, how do we push the envelope and say, how do we close our loops with our patients? How do we use the EHR to help us, not hurt us, in collecting this information in an equitable way, in a trauma-informed way, and keeping privacy in mind to make sure that our patients are not only being screened but connected to resources that are really going to improve their outcomes, which is the very end of all of the steps that we're trying to get to in this process.

Carol Vassar, podcast host/producer:

Those are great questions that you've posed. What were the results? How did you answer those questions? Or did you?

Dr. Stacey Stokes, Children's National Hospital:

There were a lot of new questions that came up out of these conversations. We had some small group breakout sessions where we talked about how do we screen equitably and keeping patient privacy and autonomy in mind. And there were a lot of great discussions around where to put the information, who should have access to the information, and what types of questions you should be asking.

Because if you're asking a question that you can't provide any resources for or do anything about, should you really be asking those questions simply because there's a regulatory requirement now through CMS or JCO that says you have to ask those questions? And so there were a lot of discussions about some really great work being at institution and division levels at certain institutions on ways that they've navigated those decisions.

And then also talking about closing the loop with either your EMR, providing that connection to connect your patient to resources outside the hospital in the community, or bringing the community partners into your institution and housing space within that area to make it easier for your patients to access the resources that are needed.

There was a lot of discussion about, yes, we're closing the loop and making sure that we're hearing back from referring institutions to the outside institution and back and forth, but we're not actually checking in on the outcome. So, did our patients' quality of life or social needs get met in the resources that we are providing them? Or is this all just a lot of work that we're doing that's not actually benefiting our patients?

And that's really the next step that people are starting to think about in leveraging our EHR to gather that information and have a housing point for that information. And we talked about some really great ideas about how you could do that.

Carol Vassar, podcast host/producer:

I want to get back to that in a moment. I want to pull on one string that you mentioned. How do we screen equitably?

Dr. Stacey Stokes, Children's National Hospital:

Great question. Some would argue that means we screen everyone no matter what it says in their demographic information in the patient's chart. Every single patient gets screened at a cadence no matter what and gets asked questions. Some people said maybe screening should not be the equitable part. Maybe we offer resources to everyone no matter what.

Maybe we opt out of the ability to have patients have to answer these questions and have them housed in the EHR and have concerns about who's going to see those answers, and we just offer them the information that's available. The other thing that we talked about is thinking equitably about screening. You have to think about how you're asking these questions.

So we want to do it in a respectful way for families. And a lot of people have moved to electronic-based screening, so patients either filling something out through their patient portal or having an iPad at the office space. But you have to think about who has health literacy concerns, who has literacy concerns, who has language limitations in the way that we're able to ask these questions.

While we think in one way we are addressing making something more available and more private for families, we may also be limiting who's actually able to complete these screeners while fully understanding what the questions are.

Carol Vassar, podcast host/producer:

Let's get back to the idea of programs that are doing this well. Who is doing this well already?

Dr. Stacey Stokes, Children's National Hospital:

Yes. So I'm going to actually give a plug to my co-presenters. So I had the pleasure of presenting with an incredible group of physicians. I was joined from the Health Informatics APA SIG by Mark Mai.  And, unfortunately, Nymisha Chilukuri, who was our third co-chair, was unable to make it. And then from the Serving the Underserved APA SIG, Dr. Shweta Antani and Padma Swamy.

And then from the newly created SDOH SIG, Dr. Yannett Lacks, Dr. Gabby Cordova-Ramos, Dr. Aditi Vasan, and Dr. Zoe Bouchelle, who were able to speak to some implementation that they did at their institutions that combined some paper resourcing, some EHR use, being able to flag for providers when a patient screened positive for a particular question in the screener to drive providers or social workers to then investigate and meet with the family and provide resources where needed.

And then we also talked about in our small groups some programs out of New York and out of Philadelphia as well, where families have been able to have referrals, and then we have oftentimes third-party vendors that help connect and make those referrals and then close the loop with the providers or the social workers back at the institution. It's still a moving target on how to do that well, but people are starting to adapt and create quality improvement projects to improve that process.

Carol Vassar, podcast host/producer:

It sounds like there's a lot of great work going on in this area. When we were talking about equity, you raised some of the challenges, the language, the literacy. What other challenges are you facing in terms of making this connection between what's in the EHR and what's needed to satisfy some of the social determinants of health, such as being unhoused, having food insecurity, et cetera?

Dr. Stacey Stokes, Children's National Hospital:

I think what came out of this session for me was that the IT solution is not going to 100% fix the problem, and boots on the ground are not 100% going to fix the problem. It's going to be a hybrid solution that really is going to solve the problem. And some of that work that Dr. Lacks and Dr. Wieschel talked about was really utilizing both of those, depending on the tier of severity of the social need that needs to be met. And so does everyone get some level of information about resources that are available?

But if you check yes for things like being unhoused, having a certain amount of food insecurity, or something related to your immigration status that really requires the escalation to a social worker or a family navigator, then a flag is raised within the EHR to trigger that group of the clinical care team to get involved in that patient's care and try to address some of those needs.

Carol Vassar, podcast host/producer:

Do we have everyone at the table? Are they all convened in one place, either electronically, virtually, or in person to resolve this issue, and to move this forward? It sounds like there's a lot of great work, but it takes a lot of people, it takes a lot of people in the nonprofit world, in the social services world, etc. Are we at the table with everyone?

Dr. Stacey Stokes, Children's National Hospital:

Yeah, I think the short answer is no, but we're working on it. I think the more expanded answer is there is a lot of work being done in silos as people navigate how to do this best while being pushed by regulatory requirements that are coming at us very quickly to document things like social needs or social determinants of health.

And I think at least at my institution, we have a social determinants of health special interest group where we really try to do that exact thing, bring all the stakeholders into one meeting, meet regularly and say, how are the social workers coming at this? How are the informaticists coming at this problem?

What are the subspecialty clinics doing versus what primary care is doing, even just at our own institution? And how can we actually get everyone talking to each other and on the same page so that our endocrinology clinic isn't screening patients and offering services there, and then two weeks later, they go to their primary care visit and have to answer the same questions over again and maybe have access to different kinds of resources?

So how do we make that universal within our own institution and do that well while also talking to other institutions? We're asking broadly on Listservs and at these conferences, what are you doing? How are you doing this well? Because it's a very complicated question that involves so many stakeholders and really ends up impacting 80% of what impacts a child's health.

Carol Vassar, podcast host/producer:

As we look at the electronic health record behind the scenes, there is clinical decision support working together with the data coming in from the EHR clinical decision support helps with decisions basically that pediatricians or others may be making. Can that help with social determinants of health?

Dr. Stacey Stokes, Children's National Hospital:

It absolutely can in some ways. So you can have flags for when a patient completes an electronic screener. If they were to click yes to something having a social need, it can do lots of things in the EHR. The clinical decision support can drive a social work consult to automatically be placed in the EHR. It can create a targeted passive alert to that provider on their patient list for the day in a column that says there's SDOH needs here that need to be addressed and have that flag.

And then there's things that everyone thinks about truly as clinical decision support. We talked about this at another APA QI conference workshop this weekend that are those true BPAs that we think about, best practice alerts, that are pop-ups in your face and really stop you from your workflow to have you think about something. And we really reserve those for when you really can't let that patient walk out the door without having something addressed.

And so I actually haven't heard a lot of programs doing those pop-up alerts that really try to get people to address these needs. They're more subtle, passive alerts or connecting to the care team member based on a screening result so that they're able to then interact with the family and address the needs directly.

Carol Vassar, podcast host/producer:

Are there any specific populations that you would think who are currently disproportionately affected by the social determinants of health that would ultimately benefit and maybe raise health equity levels across the board?

Dr. Stacey Stokes, Children's National Hospital:

I think it depends on what level of data you're looking at and what populations you're looking at in terms of where you live. So, in the community where I work, 90% of the patients I see are Medicaid patients and are also either Black or African American. And then there's a much larger Hispanic population as well. And it's in these communities that we do see a lot of increased social needs that are identified in our patient populations.

And I think some people could extrapolate that to a more national level, but I think it also makes a huge difference if you're in a rural population and that demographic may look very different but have some of the same social needs that need to be addressed in extremely different ways because the resources available and the barriers themselves may actually be very different.

Carol Vassar, podcast host/producer:

That's a good thing to point out is that community, the solutions are going to oftentimes look very different, as you said, depending on the circumstances, the resources, et cetera. I want to look at informatics writ large. Talk about the overlap between informatics and advocacy of any kind.

Dr. Stacey Stokes, Children's National Hospital:

There's a huge overlap. So much of what we end up doing in informatics is related to advocacy for our patients and families or related to what I consider advocacy for our providers and our care team. Because so much has just become standard requirements for us to do in the EHR that it eats up so much of our time. We're not spending time with families. We're spending time in front of computers.

And how can we make that dynamic switch where we're spending less time in the EHR and more time actually talking to our families? There's advocacy on both sides of that spectrum. And anyone who's ever done a quality improvement project knows that the top-hitting thing that everyone wants to fix their problem is an EHR solution. And oftentimes, it's not the solution they come to us with. We sit with people and say, what are you actually trying to improve?

What are you trying to advocate for for your patients or families? And then work with them on finding a solution that's going to actually work for the patients and families, but not increase the burden on our patient care team as they're navigating through the EHR.

Carol Vassar, podcast host/producer:

It's important to remember that the EHR is a tool and that medicine is an art and a science. Well, let me ask you something. I read that you actually lived and studied in Europe and you noticed well-structured, well-funded support for children and families there led to better quality of life and outcomes. Did this experience influence the work you're doing today?

Dr. Stacey Stokes, Children's National Hospital:

That's a great question. Having been a utilizer of the universal health care system in Europe was really eye-opening for me. We don't often get to experience the healthcare system in our early phases of our career, nevermind in the United States, but anywhere else, and being able to see the differences in my own experience, as well as how medicine is practiced abroad.

And one, being able to check all of those stereotypes that people talk about with universal health care and how they're actually not realities and in fact there are some things that work so much better there. And two, being able to compare what I'm able to offer my patients and families as I practice medicine here versus how I experienced it over there.

There's a lot of value-based care that happens over there because it's a universal health system and they're counting every Q-tip, every alcohol swab. In fact, they don't use alcohol swabs where I received care. They have a vial of alcohol, and you have your cotton swabs that you think about back in the 1930s. I likely received equitable care there and got the right care that I needed without having to worry about value-based care.

Here, we have to think about that actively because our system is not set up to practice that, but abroad, it's just how they practice medicine because they have to. So that was very eye-opening to me, and I often think about that as I'm treating my own patients here in the United States.

Carol Vassar, podcast host/producer:

Looking forward, where would you like the work that you have been doing in informatics and working on reducing the social determinants of health to go? What's your vision?

Dr. Stacey Stokes, Children's National Hospital:

I think my vision encompasses finding solutions in the EHR that help both our patients and families and our providers by working in dynamic and new ways, using things that are coming out of the woodwork at a rapid pace, like artificial intelligence and machine learning so that we're working smarter, not harder.

And we're able to get back to that face-to-face experience with our patients that I think so many of us as providers are missing and also being able to show our patients we're improving their outcomes by the work that we're doing in this system. We're giving them more access to their own information. We're allowing them to drive the conversation about the resources and the health care they want to receive.

Carol Vassar, podcast host/producer:

Artificial intelligence, does that play a role in all of this? Obviously informatics, the information goes into AI, it's processed, it's looked at. Talk about that.

Dr. Stacey Stokes, Children's National Hospital:

There are so many things happening in AI right now. Even at this conference, I've heard and seen so many topics relate back to artificial intelligence and how it is starting to shape how we practice and how our EHR is used. And I think every institution is not thinking about we should consider AI. They're thinking about how are we going to use AI.

There won't be an institution in this country in the next five to 10 years that is not somehow using it in a way that hopefully is, again, driving us back to talking to our families more and taking the burden off of the use that we spend in the EHR, but also using it to be able to flag things face up for us that we may not catch in our encounter with a family. So ambient listening is top of mind for a lot of people and crafting documentation based off of ambient listening.

Using machine learning to capture things in the chart that a family may have filled out a form on but you didn't have time to review. That information can be face up to you as you're just reviewing the chart and going through your visit with them. There's so much happening in that space, it's almost hard to keep up. But I think it's going to be a true driver in how our standard of care and our standard of practice for our patients changes over the next five to 10 years.

Carol Vassar, podcast host/producer:

Anything I haven't asked you that you'd like to share about the work you're doing, about your experience here at PAS?

Dr. Stacey Stokes, Children's National Hospital:

The only thing I'll add in terms of the advocacy space and really bridging the work that we do into working smarter, not harder, in the informatics world is I think there are a lot of siloed areas that end up falling under one big umbrella. Part of what I do is really try to remember what falls underneath that umbrella so that we're not just focused on the hot topic of the day, which I think really is social determinants of health, and it has a right to be that hot topic, but things like gender equity and access to mental healthcare.

Those types of things are evolving quickly as well in the informatics space and are things that our families are living day to day that we often don't have time to address in the time that we're able to spend with them. And EHR solutions, artificial intelligence, machine learning, they're all going to hopefully help us tackle these problems and provide more patient-centered and trauma-informed care to our patients.

Carol Vassar, podcast host/producer:

Dr. Stacy Stokes, Medical Director of Informatics and Assistant Professor in Pediatrics at Children's National Hospital, Washington, DC, thank you for joining us.

Dr. Stacey Stokes, Children's National Hospital:

Thanks for having me.

Music:

Well Beyond Medicine.

Carol Vassar, podcast host/producer:

Thanks to Dr. Stokes for joining us in Toronto, and thanks to you for listening. What's happening in your world when it comes to addressing the social determinants of health? Leave us a voicemail on our website, NemoursWellBeyond.org. You may also visit there to get all our previous podcast episodes, subscribe to the podcast, and leave a review. Remember, that's NemoursWellBeyond.org.

Our production team for this episode includes Joe Gillespie, Cheryl Munn, Che Parker, Susan Masucci, Lauren Teta, and Steve Savino. Join us next time as we celebrate the Well Beyond Medicine Podcast first anniversary or what we're calling our podaversary. I'm Carol Vassar. Until then, remember, we can change children's health for good well beyond medicine.

Music:

Let's go. Well beyond medicine.