Designing for Health: Interview with Dr. Srinath Adusumalli

Nudging, behavioral science, and implementation science paired with intentional design have the potential to improve the quality, safety, equity, and experience of healthcare while improving care team well-being, achieving the Quintuple Aim.

In this episode of the In Network podcast feature Designing for Health, Dr. Srinath Adusumalli chats with Nordic’s Chief Medical Officer Dr. Craig Joseph and Head of Thought Leadership Dr. Jerome Pagani about the nudges and sludges that fill our healthcare ecosystem, the ways non-traditional methods of care delivery can help fill gaps, and the keys to designing better user experiences at scale.

Listen here:


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Show notes:

[00:00] Intros

[01:20] Dr. Adusumalli’s background

[03:48] The Nudge Unit at Penn Medicine

[05:30] Retail health and what it offers consumers that they can’t find in a traditional healthcare model

[07:40] Dr. Adusumalli’s study involving statin-prescribing nudges for both clinicians and patients

[14:21] How retail health can help fill care caps

[16:17] Care navigation and how combining people and technology can improve outcomes

[24:08] How to apply lessons learned on the intentionality of design to the broader health ecosystem

[27:53] Three things outside of healthcare that are so well designed they bring Dr. Adusumalli joy

[29:42] Outros



Dr. Craig Joseph: So, Sri, it seems that you've always wanted, since you were a very young child, to be a clinical informatician working at the nudge unit at Penn, since you were very, very young. Is that accurate or did I misread that?

Dr. Srinath Adusumalli: That's 100% right. Well, you know, Craig, I've always wanted to be in the field of medicine, really, ever since I was young and also as a practicing cardiologist, really has been a dream of mine, has been a privilege and honor to be able to do so. But also, as I've gone through both earlier stages of education as well as started to practice, I started to develop a passion for the use of health information technology and intentional ways to help improve the quality, safety, and value of care. And that's where my interest sort of at the interface of both health IT as well as behavioral science have come in.

Dr. Craig Joseph: So I think that I read that really you started off interested in quality and did a lot of work in quality, and as a background you just happened to be interested in technology, and you were that kid who was programming computers at a young age and wondered if you could perhaps put those two things together.

Dr. Srinath Adusumalli: That's right. As a young kid, always was, you know, a tinkerer with technology, started out with the Gateway 2000 computer and a variety of other technology tools really from the age of four. And so that's always been a background interest of mine for years. And only till relatively recently that I discovered the ability to merge that interest, which has been more of a hobby, with technology, with the field of medicine. And that's really occurred through the channel of health informatics. And you're right that originally my formal education outside of clinical medicine has been in the space of quality improvement and inpatient safety, did a fellowship in that area, and a master's in health services research, which included some formal education there. But I started to notice along the way that a lot of our activities in the quality and safety space were dependent on health IT and health IT systems. And oftentimes, it was either that the health IT system would be the enabler to beneficial change from a quality perspective or the barrier. But yet, we didn't have enough individuals at that interface who could translate between the worlds, the clinical and the technology world. And that's really where I found my passion in trying to deeply understand both worlds and serve as a bridge between the two.

Dr. Craig Joseph: That's great. And I can't believe that you would say on the air that sometimes IT was a barrier. I'm shocked at that.

Dr. Srinath Adusumalli: More often, a facilitator.

Dr. Craig Joseph: And this is me being slightly sarcastic. Can you talk a little bit about the nudge unit at Penn? I think it's one of the first of its kind and rather unique.

Dr. Srinath Adusumalli: It is, yeah. And so, the nudge unit at Penn Medicine was formed in 2016. The founding director was Dr. Ritesh Patel, one of my mentors. And it emerged as really rooted in a tradition of behavioral science within the University of Pennsylvania and was a collaboration between the Center for Health Incentives and Behavioral Economics at Penn, as well as the Center for Health Care Innovation. Both very strong groups in their own right. And really, as Dr. Patel founded it and many others, and I started to sort of get engaged with the work, started to notice that it was at the interface of health system and health system operations as well as behavioral science. And the mission, like other nudge units in other settings around the world, which by the way, have been well-established, for example, in areas like government, the mission was to rigorously apply the principles of behavioral science to healthcare delivery, and then to evaluate those with rigorous study designs up to and including randomization, randomized clinical trials as well. And oftentimes, in a number of those projects, ended up being framed around or utilizing the electronic health record as a form of health IT. And I think that there have been a number of projects, all of which have built on each other and built on the findings of each other to be able to find out and study, you know, what is actually effective in changing the behavior of patients and clinicians towards the goal of improving healthcare outcomes.

Dr. Jerome Pagani: That's great, Sri. And just to pick up on that thread of improving healthcare outcomes, let's talk a little bit about retail health. What is retail health and what does it offer health consumers that they aren't just finding in a traditional healthcare model today?

Dr. Srinath Adusumalli: So I think retail health has the capability to augment that journey and contribute to the journey of a healthcare consumer and really in ways of making healthcare more accessible and convenient and simple for the healthcare consumer by being able to place health services in areas where they live, work, and play. And that also includes, for example, services like virtual primary care that can help consumers get their foot in the door, so to speak, into healthcare and to be able to start advancing their journey along with services like preventative health, which we know are often underutilized preventative screening services in healthcare today. So, it really helps to bring healthcare to where the consumer is at and meet consumers where they're at, so to speak.

Dr. Jerome Pagani: And that sounds like it begins to solve one of those key problems in healthcare, which is the idea of engagement beyond those sort of episodic sick care, you know, there's an interaction between the healthcare system and the patient when they're very sick, and then they get better, and then there's sort of a lack of engagement in between.

Dr. Srinath Adusumalli: That's right. And we know that, you know, relationships are a foundation of healthcare delivery relationships between patients and their clinicians and the trust within those relationships. And one thing that telehealth hopes to build on is building out those relationships and building trust between patients and clinicians in ways that are easy and convenient for patients to be able to advance healthcare outcomes. And not only convenient for patients, by the way, also, we know that there's lots out there about workforce burden on healthcare workers. And we know there's an epidemic of clinician burnout. And oftentimes, you know, there might be ways through retail health to help those clinicians and providers practice in ways that are also able to reduce the burden of burnout for them.

Dr. Craig Joseph: Sri, let's talk about a recent article that I read in JAMA Cardiology that had a lead author. That was you. Congratulations on that article, by the way. It was, I think, well received, I certainly liked it. In that article, you were studying if it was possible to increase the uptake of cholesterol-lowering medications. So, to do that, I think if I understood your article, there were a couple of things that you looked at. One is, while those cholesterol-lowering medications need to be prescribed, that's one issue. And the next issue is that they need to be picked up at the pharmacy, and they also need to be taken by the patient. And so, can you talk a little bit about that study and what you learned?

Dr. Srinath Adusumalli: Yeah. Yep. Thanks so much, Craig. That study, which, as you noted, was published in JAMA Cardiology back in November, was conducted with the primary aim of studying effects of nudges embedded within workflow to clinicians, patients, or both to increase guideline-directed statin prescribing, as you noted. Statins are cholesterol-lowering medications that there is, at this point, decades of evidence in our field that show both the reductions in mortality and morbidity for cardiovascular disease, which also, as we know, is the leading cause of mortality and morbidity generally in the U.S. and globally. So, you know, we think of lots of potential for impact here in terms of improving healthcare outcomes by nudging clinicians and patients to prescribe and then take statins. This study is part of a portfolio of work that we've done within the nudge unit on statin prescribing. It's a great sort of example of nudging and action and nudge units in action in the sense that the goal of these nudges were to improve outcomes without restricting choices. And what we were trying to study was the way we were presenting choices to clinicians within the electronic health record, as well as to patients, and the way that we sort of frame those choices as well. So, this study really was rooted in a portfolio of work that we've done starting a couple of years ago, where Dr. Patel had completed a study utilizing a dashboard with a list of patients who are eligible for statin prescribing, where a clinician could indicate that they'd like to prescribe statins. And part of the nudge was helping to facilitate the statin prescription. But all of that was done outside of workflow. And subsequently, we did a study inside of workflow directed towards cardiologists, had a couple of key learnings there, and then incorporated those now into this randomized controlled trial. And so, what this study was about was we wanted to expose clinicians within the EHR to an alert that both presented information on eligible patients for statin prescribing, that a patient was eligible, and this is the type of statin they should be on, and this is why. And we wanted to present it at an appropriate time and workflow where a clinician was ready to sign orders. So, each of those steps, we thought pretty carefully about, about how to architect that nudge to be most convenient and accessible to the clinician and present the correct information. So that was one aspect of it. Along with that, also within the EHR again, so within workflow, we sent a message to clinicians via an InBasket with peer comparisons on statin prescribing rates. So, we're trying to pair multiple concepts from behavior science together. So that was a clinician-focused intervention. Patient-focused intervention was actually a simple text message nudge that was delivered prior to a visit to a patient to be able to ask them to discuss statin prescribing with their clinician and then also gave them a shared decision aid. And then we had another arm of this randomized study, which actually combined those both, clinician and patient nudges. And ultimately, the bottom line is what we found is that the combination of clinician and patient nudges was most effective in raising rates of statin prescribing. So, I think it's a good example of workflow electronic health record-based interventions that can help increase guideline-directed care, but then also grounded in evidence-based principles of behavior science and how you can combine those interventions together. Moving forward that these were designed and tested in one EHR platform, but they could be in the future, you know, scaled even beyond the health system they were designed.

Dr. Craig Joseph: I love it. And it's everything that, you know, we talk about all in one study. I think what was great is that you did combine, you know, you kind of stacked learning upon learning and then also combined multiple ways of showing folks the right way, but also giving them, of course, the choice for the patient in front of them to not go with these guidelines, if appropriate. And really, to me, the key learning from your study was details matter. So it's the wording of the alert. You mentioned the workflow impact that you were considering exactly what was the right time to send this message, this reminder to the clinician? You gave them the appropriate information that they needed, some of it that they needed. So, hey, this is what the risk score for your patient is. This is the indication. Some that they maybe didn't want to see, which is, and by the way, the percentage of your colleague s with similar patients to these, here's where their percentages are in terms of following the guidelines. It all kind of comes together. And so, what was the final outcome? Did you cure hypercholesterolemia in the Philadelphia area? Is it all done now? Are you out of work now, Sri? Is that what's happening?

Dr. Craig Joseph: That would be an aspirational goal. Still certainly plenty of work to do. And ultimately, our nudge increased statin prescribing by 7.2 percentage points relative to usual care, the combined patient and clinician nudge. And you know this was keep in mind in a population of patients who weren't already prescribed statins, so perhaps those who might even be harder to reach. But that being said, the group already has additional work underway to think about, okay, how do we continue to build upon these learnings? Because, you know, behavior change is about motivating individuals. It's about reminding individuals to change behavior. And it's also about making things easy and simple and giving them the ability to do so. It's sort of the nexus of those and essentially summarized by our chief innovation officer at Penn Medicine Roy Rosin likes to use the term, you know, make the right thing to do, the easy thing to do. And I think that that's really what we continue to strive towards, whether that's purely within the EHR and using health information technology. But then also, you know, how do we go beyond that with workflow, with automation, in other ways?

Dr. Jerome Pagani: We talk a lot about the convenience aspect for consumers and the improved engagement and things like that. I hear you pulling on that thread of the clinician workforce as well. There's a positive aspect there. It's more care team management of healthcare, and that's great. So, engagement piece talks about one of those problems in healthcare that retail health can solve. There are other care gaps in healthcare, are there ways for retail health to begin to fill some of those as well?

Dr. Srinath Adusumalli: Yeah. And, so I think that engagement is one of those gaps. But also, I think it really is the foundation. Once you have an engaged patient, for example, into healthcare, you can start, you can open the door to bridging a lot of other care gaps, particularly, for example, in the prevention space, you know, get at being able to facilitate and coordinate and help a patient navigate through healthcare to be able to get their cancer screening, for example. Or, in my world, near and dear, their cardiovascular disease risk screening completed and then to be placed on therapies that might be appropriate or lifestyle modifications that might be appropriate for those. But it all starts with building the relationship, building the trust, engaging with a patient or a consumer, and moving on from that.

Dr. Jerome Pagani: I can see that really clearly. It seems like another way might be in that sort of pharmacy space. You know, there's some stats that that indicate between 20 and 50% of prescriptions don't go filled. It seems like there's an opportunity there as well.

Dr. Srinath Adusumalli: Yeah. It could be pharmacy. Similar statistics exist, for example, for referrals to specialty care from primary care. That's in large part because, you know, tying us back to the nudge aspect, there's the opposite of nudge, which is sludge. And there's a lot of sludge in our healthcare system. And I think helping consumers navigate that sludge and be able to get that appointment for specialty care that's convenient and near and close to them and be able to access care in the timely fashion that they need for their condition. That navigation aspect is another area where retail health can add.

Dr. Jerome Pagani: I love that point. You know, it's not just the convenience for the consumer. It's also removing some of those frictions that make it hard to move from one part of the care continuum to another.

Dr. Srinath Adusumalli: Exactly. Exactly.

Dr. Jerome Pagani: You mentioned care navigation, and healthcare can be really complex, particularly from the patient perspective where they may be going through a clinical process that is new to them. So, tell me a little bit about care navigation, and does that link back to specific learnings from the Nudge Unit?

Dr. Srinath Adusumalli: At each point in the healthcare journey, there's an opportunity to help a patient navigate. And there are multiple ways to do it, whether it's from, you know, a human-to-human connection. And oftentimes, that may be the most beneficial. There could be other ways, you know, using technology to augment that human, for example, a chatbot, which, you know, I think were deployed in many healthcare systems, for example, during the COVID-19 pandemic. It's really everything from how do you help a patient access care and get their foot in the door and then to care to a visit, seeing a patient during the visit, and then you know particularly post visit I think lots of opportunities there to help. There's oftentimes, you know, lots of to-dos, tasks spun off from each visit, whether it's to get labs done, get some imaging done and get seen at a referral at a specialist office and being able to help a patient figure out what is the closest, easiest spot to get their labs done or specialist, I think is all part of that navigation activity. I think another piece of that is, especially as our health systems have focused on social determinants of health, is first, how do we identify, you know, oftentimes the navigation piece relates to social determinants of health, transportation, housing, many others. And so, how do we identify what those barriers might be and then help a patient connect to resources for those aspects? Again, all in service of helping to improve healthcare outcomes. And so how this relates back to some of the learnings from the Nudge Unit, I think, in my mind, could be that, the team has done a lot of work in the area of, if you take the standard prescribing example, of reminding and motivating a clinician at hopefully appropriate times and workflow, and making it easy to help to prescribe that medication for patients. But then, you know, I think there's a navigation aspect in terms of helping a patient to really understand, you know, post-visit, let's say, how is the statin helping them? How are they doing with the statin? What are the side effects they're experiencing if they're experiencing them anyway, how can we help them navigate through those side effects? You know, what's the easiest way to get to a medication, or if the medication is not as effective, for example, in terms of lowering cholesterol, what are next options? Each of those steps require some element of navigation that I think being able to streamline and make those even easier might be sort of additional steps we could take to help not only get patients on statins but stay on those medications or others that might improve their lifespan and also reduce morbidity.

Dr. Jerome Pagani: So, I'm hearing there are a number of ways that that combination of people and technology can help improve outcomes, whether that's through engagement or education or helping clinicians on the workflow side, just make sure everything is seamless and information is going exactly where we want. And we kind of understand the principles by which people interact with one another and interact with technology. So, we understand from a stakeholder standpoint how to best engage them with that combination of tools.

Dr. Srinath Adusumalli: Right. And I think there's a lot more work to be done. It goes back to Craig's comment about the details matter. And there are so many details, there's so much context to be understood. There's so many details also to ideally study and be able to see, okay, is this the right framing? Is this the right time and workflow? Is this the right way even of translating the guidelines? That was another aspect, by the way, that we thought a lot about, is how do we translate the science and the evidence into a form that could be computable, that could be presented within an EHR to a patient? So all of these aspects are opportunities, I think, you know, going forward and not only to statin prescribing, but many other areas of guideline-directed care.

Dr. Craig Joseph: I think that's an excellent point, actually, that’s not talked about enough, that often the guidelines, you know, what physicians are supposed to be doing are written in English, and most humans can look at those and decide what they're supposed to do and try and do the right thing. However, we get into arguments on the IT side because it's hard to make these into computer-readable terms. You had mentioned the guidelines around statin prescribing. As a pediatrician, the one I'm thinking about mostly is immunizations, and the CDC and FDA have long had these very detailed recommendations. But sometimes they said things like has to be at least a year or sometimes two months. And, you know, hey, how do I tell a computer what two months is? Because that's going to be a different number of days, of course, based on where we started and where we're ending. And so being able to take some of the recommendations and the learning and translate them into technology so that they can be acted upon, which is on and off, one and a zero, there's no ambiguity there, is very complicated. And you ran into it here. And it's something that we really do need our policymakers to take into consideration. Certainly, some organizations I know, the American Academy of Pediatrics has a group that looks at their recommendations and their guidelines before they get published to ensure that they can be as easily as possible translated into machine-readable, machine-interpretable guidelines. Are the cardiologists on board with this? Or are you all ahead of us or behind us pediatricians?

Dr. Srinath Adusumalli: I think the cardiologists are very much on board with this. In cardiology, there is lots of randomized clinical trials out there, tens of thousands of patients that sort of comprise the evidence base behind the practices. And that's been sort of a culture, a tradition, lots of work of many people in the field. I think our professional societies have been thinking very deeply about how to then take all of that evidence that then makes its way into guidelines. And then think about how do you actually implement those guidelines? And particularly because EHRs and health information technology are right at the forefront, that is at the interface of where clinicians and patients are at. You know, how do you bring those guidelines to life in that venue particularly? And I couldn't agree with you, Craig, more in terms of the translation aspect. Many things can be written within, let's say, a guideline, but really thinking about how to translate those even in our example, how do you define in a computable fashion, clinical atherosclerotic cardiovascular disease? And then that might be maybe one of the more easier challenges in translation, but still, one that we found in a way that the EHR could consume it, was a challenge. And that's really a role, I think, for a clinical and pharmacist who could sort of bridge both worlds, you know, the clinical aspect, and then also think about, you know, what are the groupers that need to be created to help to really implement this, this guideline as an example?

Dr. Craig Joseph: Yeah. Groupers are the sexy part of IT. Having created more SNOMED groupers than I care to admit to. Let me ask you a very serious question about naming of these studies, because clearly, cardiologists know how to name studies, and they come up with titles that are just amazing. So, is that a year? Is that part of your fellowship, or where do you learn how to name some of these studies? Because I think not all of us non-cardiologists were jealous. We want to know.

Dr. Srinath Adusumalli: It should be a part of fellowship training. Unfortunately, this latest study we did not name it, which we should have. But there is a long tradition in cardiology with fantastic names for studies, and I think really helpful. It helps us keep these studies top of mind and oftentimes do describe what the study is about.

Dr. Craig Joseph: See, there you go. I'm trying to make fun and poke fun at the cardiologists, and you won't have any of it. You're right. Those namings do make sense.

Dr. Jerome Pagani: Sri, you mentioned that intentionality of design is something we understand how to do in sort of small pockets, but how do we begin to apply the lessons learned there to the broader health ecosystem?

Dr. Srinath Adusumalli: That's a great question, Jerome. I think first, as we build upon the pockets of work that have been done to really make sure our stakeholders are at the table from the beginning. And that means clinicians and again, not only physicians, but the entire care team, to go back to another theme we had talked about, that medicine is a team sport. So, at the beginning, users, clinicians are at the table as we're designing interventions, whether that's an alert within the EHR or otherwise, and patients, of course, themselves as well. So, the more we can do that, I think the better. And that's I think one of the lessons also from the nudge unit is, is really, trying to stay in lockstep. And certainly, with every project, we could do it better. But really trying to stay in lockstep with that, with stakeholder groups, with patients, with clinicians who will be seeing these and using these tools. So that's one. But then we should really try to share what we're learning. And that's another thing that the nudge unit, I think is really strive to do, which is share the learnings and create them in scientific fashion using rigorous study designs. But then also share, share what works, the statin study was an example potentially of approaches that could be used and built upon that worked in terms of increasing statin prescribing. But there were other studies, I'd mentioned one we had done in the cardiology world that didn't statistically or clinically significant increases in statin prescribing, but yet there's still learnings to be had from that work. And we published that, it was also published in JAMA Cardiology, even though it was a quote unquote negative study. But those learnings directly informed what we put into this study. And our hope would be that the learnings from this study that then others could take and build upon. I also think that as EHR platforms become more, you know, EHR platforms in general are already widespread. But potentially, as certain platforms do, more users more systems are on them, then that perhaps on those that have higher utilization or adoption, there might be opportunities for partnership and being able to embed in foundational ways these types of tools such that every system doesn't have to recreate them on their own and that we could use evidence-based, let's say, EHR alerts, you know, across platforms.

Dr. Craig Joseph: Yeah. You know what you're saying really resonates with me, and it reminds me of the title of chief innovation officer, and I'm not sure who originated this, but it's pretty popular now. The idea that really, you shouldn't be a chief innovation officer, you should be a chief imitation officer. And so often, it's really not innovation that, you're not doing something de novo that no one has ever done before. You're facing the same problems that others have faced. And a good thing to do would be to learn from others and stand on the shoulders of others. And that's what you're talking about. And so, I do think it's important. The nudge unit, of course, is generating knowledge, which is terrific. But also getting that knowledge out there to the masses is a key part of your role and the role of the nudge unit and your current role too. So, yeah, I can't emphasize that enough. It's not that helpful if you just figure something out and then don't tell anyone. So, thank you for putting all that information out there and then encouraging us to copy it.

Dr. Srinath Adusumalli: And I think it goes both ways, Craig, too, whether we figure something out and it leads to an improvement or whether we don't, you know, what doesn't work, I think, is just as important so that others can move in different directions or take the learnings from there and build upon with their own work.

Dr. Jerome Pagani: Sri, can you tell us about three things that are so well designed outside of healthcare as find that interacting with them really brings you joy?

Dr. Srinath Adusumalli: Yeah, definitely. I think that's a great question. And although these are outside of healthcare examples, it's sort of the same principles that apply. How do you make something simple, easy, convenient, the right thing to do, the easy thing to do that I think we would be, you know, to adopt those within healthcare all the better. But a couple of those include, you know, here on my desk. I have, you know, the company, I think Dyson is known for their vacuums, but they actualy make a variety of other things, including a desk lamp. And it is really fantastic. It knows the time of day. It knows where in the world I'm located. And it creates the exact shade of light for what should be appropriate to reduce fatigue. And, you know, even the way that it's sort of built to be on the desk, is able to be used with a variety of devices, etc. So, you know that does bring me joy in using. That's one example. I think the other two relate to music actually, another joy in general, but one is Sonos. It goes back to simplicity and ease of use that it just is there and available when we need it when we want it. And again, something ideally that we could apply to healthcare as well. And then the third example is the music service, certainly not endorsing any of these, but simply just observing, which is Spotify. The reason why that example is it knows, you know, what music I'm listening to, it knows, it’s able to predict what I might be interested in correctly. And there's an opportunity to interact with and reinforce that learning as well, all sort of concepts that I think could be applied in healthcare as well.

Dr. Jerome Pagani: Excellent. Sri, thanks so much for joining us. This was a fantastic conversation.

Dr. Srinath Adusumalli: Yeah, thank you. Thank you both, Craig and Jerome, so much for the invitation to join. I really enjoyed this.

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