Smartphone App to Manage Cirrhotic Ascites: Continues to Improve as Program Enrolls Mores.

Patricia Pringle Bloom, M.D.
Fellow in MGH Transplant Hepatology 
PGY 7
09/13/2019

I am leading a team to improve the way we manage cirrhotic ascites. Body weight is an effective proxy for ascites volume; therefore, monitoring daily weights is recommended for optimal ascites management. At present, patients with ascites rarely proactively alert providers with significant weight gains, and there are no widely available technologies specifically designed for ascites monitoring. With support from COE funding, we are performing a pilot study to assess the feasibility of an app created by Partners Connected Health to manage outpatient ascites.

In this pilot study, we are identifying cirrhotic patients with significant ascites requiring specialist management. Each patient is sent home with a Bluetooth-connected scale, which transmits weight data to the PGHD Connect Smartphone app, and then via the cloud into Epic. Weights are monitored every weekday by study staff and alerts are sent to providers if their patients' weight changes by 5lb within a week or since discharge.

Acceptance to a local and exciting technology conference

Thus far, 21 patients have enrolled in the program. Eight patients have been unable to enroll because they did not have a Smartphone and 23 because they were encephalopathic and unable to participate. Each patient is enrolled for 28 days, but several patients have wanted to terminate the program early and several have opted to extend their enrollment.Thus far, the program has transmitted weight data on 70% of days that patients are enrolled. Technology issues are occurring on approximately 10% of days. Twenty weight alerts have been fired, ~60% for weight loss and the remainder for weight gain. 65% of the alerts have been followed with some form of provider response.

We continue to enroll patients in this program, and as we do, we we continue to work with Partners Connect Health to develop new iterations of the app that enhance the program. For example, new iterations of the app are being released that resolve some of the technology glitches. In addition, we are beginning to learn more about the types of patients who do best in this program. Part-way through our study, it appears that patients with less severe disease derive more benefit from the program. It also appears that those discharged to rehab facilities have more technical issues with the program.

Recently, our efforts have been rewarded with an invitation to present our interim results at the 2019 Connected Health Conference. This will be an excellent opportunity to gather feedback on our program and app, as well as network with others working in this space.

On Becoming a Qualitative Medical Education Researcher in the Intensive Care Unit: An Interim Report

Rebecca Sternschein, MD

Fellow in Pulmonary and Critical Care Medicine at Brigham and Women’s Hospital

PGY6

July 1, 2019

I am interested in understanding and improving medical education in the medical intensive care unit (MICU) at both the graduate medical education (GME) and continuing medical education (CME) levels. To accomplish this, I have been developing a project that focuses on exploring the experiences of clinical teachers in the MICU at BWH for which I was fortunate to receive COE Medical Education Research Grant funding. My study is a qualitative examination of MICU educators’ attitudes about teaching and perceptions of the impact of teaching on professional satisfaction and physician well-being. 

I started by conducting a needs assessment survey through REDCap of faculty and fellows working in the BWH MICU. I have also held two separate focus groups (one with faculty and one with fellows) to gain an in-depth understanding of the variety of experiences as a teacher in the MICU. The focus group discussions also addressed individuals’ opinions regarding the potential rewards and challenges of teaching in this environment. One of the obstacles I encountered in this stage of the project was the difficulty of scheduling focus groups with busy pulmonary and critical care physicians. I am now in the early stages of the qualitative analysis of the focus group transcripts, and while this is a time-consuming and challenging process, it is fascinating to identify emerging themes from the transcripts. 

So far, I have analyzed the preliminary findings from the needs assessment and the data has been accepted for publication as an abstract and poster at the American Association of Chest Physicians (ACCP/CHEST) 2020 national meeting. These data demonstrate that although most physicians report minimal to no dedicated training on teaching, most identify teaching as a task that is enjoyable, meaningful and essential to their role as an ICU physician. Here I struggled with finding the best way to display the data visually, and ultimately discovered that simplicity is key. (see image) The next step for this project is to complete the qualitative analysis of the focus group transcripts.  I will also determine if any additional structured interviews are indicated to address topics or themes that require more in-depth exploration. I am looking forward to writing up the results of the research in the coming months. This project has been extremely educational for me, particularly because this is my first qualitative research experience.  The most important lesson that I have learned at this stage of the project is the immeasurable value of helpful, motivating, expert mentors.

Presenting my preliminary research at the American Academy of Neurology Annual Meeting

James Hillis, M.B.B.S. 

Resident in PHS Neurology Residency

PGY 4

May 30, 2019. 

Recently I had the opportunity to present my preliminary research at the American Academy of Neurology Annual Meeting in Philadelphia. It is the largest neurology conference with over 14,000 attendees. My poster explained the survey instrument that I have developed to investigate an evidence- and consensus-based approach for the neurologic examination. Other attendees provided constructive feedback on the survey instrument and also offered to distribute the survey at their institutions. My plan is to make the survey live over the coming months. Thank you to the Partners Healthcare Center of Expertise in Medical Education for the Research Grant that has supported this project!

If you build it, will it happen? Designing a project to implement a new clinical service

Stephanie Sun MD MS

Fellow in Rural Health Leadership at Massachusetts General Hospital

PGY-5

April 10, 2019

Point of care ultrasound puts the ultrasound in the hands of the provider at the bedside of the patient. It is huge in acute care settings like emergency medicine where getting to a timely diagnosis is critical. It’s also been shown to assist with diagnostic uncertainty, in some cases reducing the number of additional studies performed, and improves patient satisfaction. But it’s not only the patients in emergency rooms who might benefit from ultrasound at the bedside.

As a general internist who provides care on a Native American reservation in remote rural South Dakota, point of care ultrasound has the potential to help bridge logistical gaps in care. The next closest hospital to my clinic in South Dakota is 50 miles away. But if patients are requiring specialty services, they will find themselves travelling 220 miles (that’s 3 hours and 42 minutes drive) to the nearest academic center in Sioux Falls – a huge burden on our patients! If a patient is going to be making a trip that far from family and their community of support, we want to make sure that it is necessary with the best clinical certainty possible. With a point of care ultrasound in hand, my ability to screen and triage is taken to the next level.

An ultraportable handheld ultrasound about to be put into action

If point of care ultrasound is so great, why isn’t it already being used in every rural clinic in the country? Great question. The most commonly raised concerns are 1) obtaining training, 2) maintaining skills, and oh yes 3) obtaining an ultrasound. Fortunately, new technologies have led to the release of ultraportable handheld ultrasounds at much lower price points than traditional machines. But even with a machine, patient safety must come first. It would be hard to feel comfortable trying a new skill if you are practicing somewhere where there is no one around who can teach it to you or provide the feedback needed to continue to improve.

As a resident, I was fortunate enough to get to create and build an ultrasound curriculum for general internal medicine residents. Taking many lessons from our emergency medicine colleagues, we learned basic skills to pick up on depressed ejection fractions, pneumothoraxes, and free fluid in the abdomen. Now as someone who mainly practices in the outpatient setting, I wonder which other exams would be the most useful to the primary care provider.

With support from the COE in Healthcare Quality and Patient Safety, I’ll be able to acquire an ultra-portable handheld ultrasound. We’ll be training a few fellow rural physicians affiliated with both MGH and the rural South Dakota clinic in ultrasound skills, and tracking their use in South Dakota. Which exams are they using it for? How often are they using it? Feedback will be provided to them on their interpretations of images to help them continue to hone their skills.

While we work through the IRB process, I’ve held two ultrasound scan sessions where a small group of rural physicians has been learning the ins and outs of point of care ultrasound. We’ve even done some scanning on “healthy volunteers,” that is, each other. We’ll be meeting again to keep building our skills and comfort before heading to the wards to practice more scans.

Along the way I’ve reflected on all the skills we’ve gained along our journey as trainees, and how a skill can go from total unfamiliar territory to the routine. It is exciting to see how a new skill can percolate through a discipline, like point of care ultrasound is through internal medicine. By learning lessons from those who have done it before us, and adapting the tools to suit our unique needs, we’ll continue to push boundaries to provide the best clinical care to all populations.

Comparison of cost-effectiveness of admitting moderately injured patients to trauma intermediate care units vs. surgical intensive care units.

Naveen Fatima Sangji, MD

Fellow in Burn Surgery at MGH

PGY 8

April 12, 2019

As a surgical critical care fellow, I was interested in comparing the cost-effectiveness of admitting moderately injured patients to a trauma intermediate care unit vs. a surgical intensive care unit.  Preparing an application for the COE Quality and Safety grants was a great impetus to get this project off the ground and to see it through.  An immediate and tangible benefit of getting funded was that COE staff were able to liaison with the MGH Finance division to help us get access to the cost and reimbursement data we needed.  We were also able to utilize the funds to obtain software and educational materials for our research.  An intangible but more significant benefit was that the application process gave me an introduction on how to prepare a grant application as a trainee.  The experience will serve me well as I prepare to apply for both institutional and extramural grant funding for future endeavors. 

With the support of my project mentor Dr. David King, our research team which includes trauma research fellow Majed el-Hechi has made significant progress on the project.  We presented our work at the MGH SAC 2019 Research Meeting and were very pleased to receive a “Poster of Distinction” award.  We are currently preparing a manuscript to report our findings.

Many thanks to the COE leadership for funding and supporting this project.

Developing an educational video on bariatric surgery for obese patients in the primary care setting

Danny Mou, MD; Claire DeVries, MD

Residents in General Surgery at Brigham and Women's Hospital 

PGY 3

March 26, 2019 

Briefly, we hope to develop an educational video obese patients to give them a concise overview of various surgical weight loss options. We originally envisioned that this video would be shown to patients in the waiting rooms of the Jen Center PCP clinic. However, after extensive discussions with the Jen Center PCP leadership and an interview campaign with 8 PCPs, we realized that there will be operational obstacles. Obstacles include how to discreetly provide these iPad videos to only obese patients, how to manage the iPads handling/charging/maintenance, and how to minimize disruptive video noise in the waiting room.

The PCP interview campaign was helpful for us to realize that PCPs would prefer to use this video as a bridge to the bariatric surgery info session. Most PCPs prefer having the flexibility to direct their patients to this video, either in the form of a card with link and QR code, or simply a dot phrase to pull the link into the After Visit Summary printout. From this feedback, we have decided to provide the video on the Center for Metabolic and Bariatric Surgery (CMBS) website, and provide Jen Center PCPs with links to the video on business cards.

Sample screen shot of animated bariatric surgery video (source ASMBS)

As for the development of the video, in discussion with Dr. Ali Tavakkoli and Dr. Matthew Hutter at the Massachusetts General Hospital (MGH), we will use the American Society of Metabolic and Bariatric Surgery (ASMBS) animated videos (Figure 1). A number of these videos will be edited, rearranged, and addended with BWH-specific information on attending a bariatric surgery info-session.

As for next steps, we hope to publish this data so we are applying for an IRB. Primary endpoints will be a pre/post survey before and after the video for patients, PCP feedback on experience with the video, CMBS info session attendance volume, and CMBS referral volume.

From our work so far, we developed an appreciation of the challenges of identifying ways to launch an initiative with minimal impact to existing workflow. We also experienced first-hand how difficult it can be to gather stakeholder agreement over what content is important to include in the video.

Optimizing the timeliness of treatment for patients with status epilepticus – almost ready for protocol implementation

Mauricio F. Villamar, MD

Fellow in Epilepsy at BWH

PGY 5 

March 20, 2019

Shortly after starting my epilepsy fellowship at Brigham and Women’s Hospital, I was privileged to receive a grant from the Partners Center of Expertise in Medical Education. Thanks to their valuable support, we are working to implement a protocol that aims to optimize the inpatient management of status epilepticus.

Status epilepticus is a neurological emergency. Studies have found that delays in the treatment of status epilepticus are associated with increased in-hospital mortality and morbidity. This includes longer duration of convulsive seizures, increased need for continuous infusions, delayed return of consciousness, and poorer functional outcomes. More rapid seizure control has the potential of decreasing these adverse outcomes.

Despite the importance of timely management of status epilepticus, treatment delays occur commonly in clinical practice due to several factors that may vary between institutions. During my neurology residency at the University of Kentucky, we tried to address some of these delays by implementing an alert protocol for inpatient management of status epilepticus. Briefly, this is an alert system that resembles the one used for patients with acute stroke, and it involves the collaborative work of the neurology, pharmacy, and rapid response teams. Its use led to earlier administration of antiseizure medications compared to usual care. When I came to BWH, my goal was to refine the protocol and to adapt it to the specific needs of our hospital.

Being a newcomer, I think that the biggest challenge so far was to understand the practical and logistical differences between BWH and my previous hospital, and to identify BWH’s specific needs when implementing a system of this kind. The support that I have received from Dr. Jong Woo Lee, Director of the Critical Care EEG Monitoring Program at BWH, has been essential in this regard. Jack Donleavy, Neurology Operations Coordinator, is also leading the project and has provided critical logistical and administrative advice. Numerous other physicians, nurses, and pharmacists have shown their interest in the project and provided valuable feedback to optimize the protocol.

After several meetings with members of the BWH Epilepsy and Neurocritical Care Divisions, with the Neurology Quality Assurance Committee, and with Pharmacy Services, we have developed a protocol that we think fits our specific needs. It shares some similarities with the acute stroke protocol that is already being used at BWH. In the coming days we will present the status epilepticus alert protocol to the Patient Safety and Risk Management team, after which it will be ready for implementation.

Finally, we are developing methods to facilitate collection of pertinent clinical data from our electronic medical record to objectively measure the impact of the status epilepticus alert system. We have identified Research Patient Data Registry (RPDR) as a tool to obtain historical data and to assess the variables that need to be collected. We explored the Enterprise Data Warehouse (EDW) system but were unsuccessful in engaging the necessary resources. 

After working to implement protocols of this kind at two different institutions, I have learned that the most important factors determining their success are how well they adapt to the local needs, and the team’s ability to establish an interdisciplinary collaboration. I am grateful for the support I have received from the Partners Center of Expertise in Medical Education and look forward to implementing the protocol soon.

Power Struggle: The Quest to Increase the Impact of Significant Preliminary Findings

Sam Miller, MD

Resident in Internal Medicine at MGH

PGY-2

March 20, 2019 

Project Summary

Our project addresses an issue near and dear to the hearts of hospitalists, gastroenterologists, hepatologists, administrators, case managers and nurses at MGH; we are attempting to identify predictors of readmission in cirrhotic patients admitted with hepatic encephalopathy. Our study enrolls cirrhotic patients admitted with hepatic encephalopathy at MGH as they approach discharge. We examine patient demographics (age, education level, gender, etiology of cirrhosis, discharge destination), hospital complications (GI bleed, infection, drug use, kidney injury), treatments prescribed (dose of lactulose, stool frequency, rifaxamin prescription) and scores on a battery of cognitive tests (MOCA, Pscyhometric Hepatic Encephalopathy Score) at the time of discharge, to see if any of these parameters predict readmission within 30 days for hepatic encephalopathy, other liver-related complications, or alternatively, death/hospice/liver transplant.

Project Obstacles

Patient recruitment is a difficult process. This requires bi-weekly chart review of the entire hospitalist service at MGH, and communication with patients’ primary teams to determine discharge timing and confirm a diagnosis of hepatic encephalopathy. Then patients need to be approached for consent, enrolled (an hour-long process), and called for follow-up at 30 days post-discharge. Patients are often “busy” during their time in the hospital, working with PT, nutrition, case management, and consulting services, and this can often delay enrollment. Discharge timing is a constantly moving target, and staying up to date on a patient’s discharge plan requires a great deal of attention. And calling patients for follow-up is no guarantee that they will answer the phone on the first, second, or third try!

What are the next steps?

Our project has enrolled 44 patients to date, and we have found that scores on one specific cognitive test (Number Connection Test A, a component of the Psychometric Hepatic Encephalopathy Score) does predict readmission for hepatic encephalopathy, and death/hospice/transplant in a statistically significant fashion. However, the absolute number of readmissions for hepatic encephalopathy is not as high as we would like, so our next steps are to increase our enrollment in order to increase the power of our study. Fortunately, our significant findings have been collated in an abstract that has been accepted for presentation at a national conference (Digestive Disease Week in May 2019) and we are currently preparing a poster for presentation.

What have you learned about engaging in research?

First and foremost, I have learned the immense difference that a highly-functional team can make in a research project. Our prospective study design and significant administrative burden have made this immediately apparent. Without the work of our highly-motivated and flexible team members, we would not be able to enroll the number of patients we have enrolled to date. Each team member has also made significant intellectual contributions to the project; one team member has utilized their facility with statistics to ensure that our significant findings are adequately reported, while another team member independently had the idea to use a composite endpoint of death/hospice/transplant to make our findings more generalizable and clinically useful.

I have also learned the importance of flexibility when conducting a research project. For example, we had one method of collecting data on stool frequency at discharge for our patient cohort that was simply not feasible. We changed this method and have been able to report results consistently and accurately. We also had to adjust our inclusion criteria in order to capture enough patients for our cohort, and this markedly increased our yield. These small tweaks are not particularly profound, but have had significant implications for our project and have allowed us to discover clinically meaningful data that will hopefully make an impact on future patient care!

Number Connection Test A (connect the numbers in order from 1-25)

Number Connection Test B (connect alternating numbers/letters from 1-13 and A-L)

Digital Symbol Test (copy the symbols associated with each number) 

Serial Dotting Test (make a dot in the center of each circle, moving R to L) 

Line Tracing Test (complete the maze without touching the black outline.) 

Medical education research – a lesson in patience and persistence

Yun Xue, MD and Sherry Yu, MD

Residents in Dermatology Program at MGH

PGY-3

March 20, 2019

Sherry and I are two third-year residents in a combined dermatology program that spans multiple sites across Boston. Training at multiple sites has its own benefits and drawbacks – one of which is that we are constantly interfacing with rotating attendings. We learn a wide variety of practices, but our time is so short with each attending that, often, trust and autonomy is built at a much slower pace than desired. When we conceived of our research project originally, we were setting out to collect data that we had hoped would bring about more resident autonomy.

Through surveying and interviewing our fellow residents, we hoped to provide a narrative of what resident autonomy means, whether resident felt like autonomy varied between the inpatient and outpatient dermatology practice settings, and ways that resident autonomy can be expanded without compromising patient care. We were excited about the prospect of conducting research with a tangible application to our residency but did not foresee the obstacles that have prevented us from getting to the true data collection and analysis.

Our timeline was ambitious to the say the least. The process of submitting the IRB has been a lesson on coordinating meetings with our mentors, waiting for the review process to occur, and underestimating how days could turn into weeks before the next step forward in the process. We are currently still awaiting our IRB approval after submitting rounds of edits. Little distractions have also cropped up along the way that have made a bid for our time: one of us had a baby, the other became chief resident, both of us have made trips across the world and back – all major new responsibilities we had not expected when writing or accepting the grant.

Despite these unanticipated additions to our lives, we remain committed and excited about seeing this project through to the end. Our next steps are making sure the IRB goes through. The good news is that we already have our questionnaire ready because we had to submit that as part of the IRB. Once we have approval to go ahead with the project, we will plan on distributing the questionnaire and hopefully getting some preliminary data to analyze and reflect on before we embark on interviews.

It’s a difficult but also very rewarding project to see a project through from beginning to end. Often, as college and medical students, we are jumping aboard projects that have already had IRB approval and a plan going forth. It feels much more difficult, but also much more rewarding, when you are the one seeing a project through from beginning to end. Every obstacle and every success is felt a little bit more. Research is a marathon and not a sprint, and we are being taught patience and persistence every day.

Weight is more than a Number: Performing an Outpatient Weight Monitoring Pilot Study.

Patricia Pringle Bloom MD

Fellow in Gastroenterology at MGH

PGY 6

March 20, 2019

Ascites refers to fluid build-up in the abdomen, and is a common complication of liver cirrhosis. Ascites accumulation leads to both patient discomfort and frequent health care utilization. At MGH, 30% of cirrhotic patients admitted to the hospital for a complication of cirrhosis are re-admitted within 90-days. Nearly 30% of those admissions and readmissions are for ascites management. Major American and European expert groups recommend that ascites treatments be adjusted based on body weight changes, as a surrogate of ascites volume. However, in our current practice, outpatient weight data often does not reach the hepatology provider.

Our team performed an interview study of cirrhotic patients readmitted to the hospital with a cirrhosis complication. We discovered that even in this ill and sometimes under-served group, approximately 80% of patients had a Smartphone and were interested in using an application to help manage their liver disease. We also interviewed several MGH hepatology providers to better understand the root causes of ascites readmissions and to learn about their desired features for an outpatient ascites management program.

Two team members hard at work, bringing a scale to another patient!

 Equipped with an understanding of what our patients need and what our hepatology providers want, we built a team at the MGH Liver Center to pilot an existing Partners application, called PGHD Connect, which allows weight data to be transmitted from home scales directly into EPIC. Our team is assessing whether patients weigh themselves regularly at home, and if hepatology providers respond to the weight alerts generated.

The most significant obstacle thus far was obtaining IRB approval, specifically with regards to the safety of patient data as it is transmitted through the PGHD Connect application into EPIC. Even though the application is already available for clinical use, the process to obtain regulatory approval was more detailed and time-intensive than we anticipated.

Another obstacle is the overall severity of medical illness in the patient population we are treating. Rarely does a patient with cirrhosis have ascites alone – they are also often burdened by other cirrhosis complications, co-morbidities, or socioeconomic challenges. Working around those other issues has been a challenge at times to ongoing patient participation.

At present, we have enrolled 3 of our planned 20 patients for the pilot. One patient and his provider have found the monitoring system particularly useful when he lost a large amount of weight after hospital discharge. Our next steps are to focus on patient recruitment and find an application developer to help us design an application even more specific to our target population and problem.

The major lessons I have learned from engaging in this research have been two-fold: 1) When working in a large team, creating a plan for regular communication about study tasks is imperative. Just as important, perhaps, is iteratively changing that plan as needed and making sure the entire team is aware and on board with changes. 2) Every human research study must tackle the important task of maintaining the privacy of patient data. Using digital health tools adds another layer to this task and must be managed thoughtfully and proactively. When in doubt, ask someone who knows more!