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August 24: Today on TownHall we are looking back at a TownHall episode from May of last year. In this episode, Jake Lancaster, Chief Medical Information Officer at Baptist Memorial Health Care interviewed Priya Ramaswamy, MD, Clinical Informatics Fellow/Anesthesiologist at UCSF. What is sustainable healthcare informatics? Not just in the US but across the globe, healthcare organizations are taking a stance to make a healthier ecosystem for people. Anesthetic gasses have damaging effects on the environment that contribute to global warming. The government is going to start requiring all organizations, including hospitals and healthcare systems to report on their admissions. What technology did UCSF develop within their Epic EHR to help with this? What are the elements needed to develop a clinical decision support alert system to remind anesthesia providers to turn down their fresh gas?

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Today on This Week Health.

Sustainability informatics in healthcare looks at the ways that we can use data-driven solutions and data science to help health systems reduce their ecological footprint or develop sustainable measures in health care practice or reduce carbon emissions. The healthcare sector in the United States accounts for about 8% of all greenhouse gas emissions. And so of my strong opinion as healthcare providers, we have a duty to not only help the patients that we have now, but also all people in this world. we have to do our part in developing sustainable solutions in healthcare.

Welcome to TownHall. A show hosted by leaders on the front lines with interviews of people making things happen in healthcare with technology. My name is Bill Russell, the creator of This Week Health, a set of channels dedicated to keeping health IT staff and engaged. For five years we've been making podcasts that amplify great thinking to propel healthcare forward. We want to thank our show partners, MEDITECH and Transcarent, for investing in our mission to develop the next generation of health leaders now onto our show.

Hello, I'm Jake Lancaster. I'm an internal medicine physician and the chief medical information officer for Baptist Memorial healthcare based out of Memphis, Tennessee. And today I'm going to be talking with Priya Ramaswamy, an anesthesiologist and clinical informatics fellow at UCSF. Priya. Welcome to the program.

Thank you so much for having me.

Can you just tell the audience a little bit about yourself and your background?

Sure. I think so. As you mentioned, I May 2nd year clinical informatics fellow at university of California, San Francisco, and also a trained anesthesiologist. I completed my residency from Beth Israel, Deaconess medical center in Boston. But prior to that, I studied electrical engineering and computer science and did my undergrad and master's in those subjects from MIT. So I've always been very passionate about technology and its applications specifically in healthcare. So that was one of the motivational factors that got me to do this.

thankful to have you on. And today we're going to talk about a subject that is pretty foreign to me, and I would think to most listeners, we're gonna talk about sustainable healthcare informatics. Can you just walk us through what that term means?

Sustainability informatics in healthcare looks at the ways that we can use data-driven solutions and data science to help health systems reduce their ecological footprint or reduce or develop sustainable measures in health care practice add value or save cost and, or reduce carbon emissions from either for example, I work on a project related to anesthetic gases but also the waste that goes into the dumpster can also end up releasing being bad for environment and releasing CO2. And so that's what I'm here to talk about today. And the healthcare sector in the United States accounts for about 8% of all greenhouse gas emissions. And so of my strong opinion as healthcare providers, we have a duty to not only help the patients that we have now, but also all people in this world. And we have to do our part in developing sustainable solutions in healthcare.

Thank you for explaining that. And I want to talk about your specific project and just a little bit. But actually this topic came up in one of the meetings I was having recently, where I believe the government is going to start requiring all organizations, including hospitals and healthcare systems to report on their admissions. So it's certainly going to be something that is, if people are not already thinking about it, they're going to have to start thinking about it going forward. any comments on, on that?

Well, I think it's a movement in the right direction. I think that many organizations, not just in the us, but across the globe or healthcare organizations are taking a stance to make a healthier ecosystem for people. And so I do believe that that's the right way to go.

so tell me just a little bit about how you got into this niche. You're interested in this topic from your background.

Yeah. So first I have to give credit to one of my amazing mentors, Dr. , who is the director of sustainability university of California, San Francisco. And shortly after I started my fellowship I was lucky enough to start working with her in some of the ways that in, from the informatics capacity to help her help her with solutions on how we can improve the ecological reduce the EqualLogic footprint that a place like university of San Francisco healthcare system does for the.

And so more than a year ago I was invited by her due to my informatics and technical capacity to help launch a clinical decision support tool across all of the UCs in the operating room and this tool to reduce the Carbon emission footprint of anesthetic gases was developed by Dr. Rabinovitz and Dr. Gandhi in 2018 in at UCSF. And so it was my role to take this tool and figure out from the informatic standpoint, how we can roll it across all of the UCSF.

Yeah. I want to hear a lot more specifics about this particular tool, but let's just start with kind of defining the datasets and the problem. So you're talking about anesthetic gases, and you talked about how US healthcare, amounted to 8% of emissions. Is that what you're talking about?

Yes. And that's a paper from Chung and military in 2009. Specifically about anesthetic gases. So volatile anesthetic agents like Siva, fluorine isoflurane and does flooring have global warming potentials that are about 300 to 3000 times greater approximately than carbon dioxide over a 20 year time period horizon. And so historically Sevoflurane one of the most commonly used gases in addition to isoflurane does Florin, which are less used, but still used in the operating rooms. Generally. However circuits work is that we have the fresh gas flows, which is generally a mix of air and oxygen at a set rate that is the carrier for these anesthetic gases and just historical practice has been that anesthesiologists or anesthesia providers in the operating room used to back in the day run their fresh gas flows more than two or three liters per minute. Because in the past there were concerns about developing toxins within the anesthetic Curt circuit that can end up going to the patient, however, with newer technology and better absorb absorption systems within the anesthetic machines, those concerns are no longer valid.

And so in 2018 UCF. UCSF developed a technology that within our EHR, we use epic that would alert the clinician real time if they're fresh gas flow rate was at that time greater than one liter a minute for CBO flooring and 0.7 liters a minute for ISO flaring and. And this was a clinical decision support alert system that was non interrupted, but active.

So it would display on the sidebar of our anesthetic module within epic. And we, it would alert the clinician whenever the flows were greater, the flows were greater than that limit for five minutes. After the start-ups. And so this was rolled out successfully at UCF in 2018, prior to my arrival and studied.

So there's a paper potentially coming out by one of our prior faculty Andrea almost with the Sima Gandhi and Dr. Rabinowitz looking at the before and after effects in 2018 and how much we reduced that. And I mean, in summary this clinical decision support tool did show that at UCF, we were able to reduce our consumption of anesthetic gases safely.

And we also saved the department money and also re reduced or carbon emissions. And so now we had this tool that is now in like a commercial EHR. And so my role was to figure out, okay, we have this tool about how can we encourage an advocate, other health systems within the UC system to also deploy this clinical decision support tool in their own hospitals.

let me try to rephrase a little bit, so these gases that you'll use in anesthesia contribute to global warming. They, cause levels of, of increase greater than CO2, which would commonly think about and the reason you all were kind of had them turned up so high is because there is a concern in the past about toxins developing in there. was that the only reason to have it up high or was it a sedating property that you want to make sure the patient was properly asleep or anything like that. And is there been any with your reduction? Was there any issue with patients waking up or anything like that?

No. So yeah, generally the flow rates were higher specifically for CBO flooring because there was. Something that can develop called compound a, which is nephrotoxic. When historically you would run low flows in the anesthetic machine based on older formulations of our CO2 absorption mechanism that chemistry of the absorbers has changed in more recent years.

And so the development of compound a. Not an issue anymore for the modern anesthetic machines that use state of the art and modern absorption absorbers, CO2 absorbers specifically. So that was one of the main reasons. And secondly, I think it was just a habit that even though modern absorbers case, To the operating rooms. It was just habit. From old literature that you study that the whole, like keep your flows greater than two liters. So I think part of it was just getting rid of old habits. And then yeah, I think in it's possible that with older machines there possible that there could have been leaks. So historically people may have ran their flows higher. And surely like with higher flows, like the anesthetic definitely does build up in the body faster.

Especially if you're a dial setting for CBO flooring is high. However you can still safely get the patient to the right amount of anesthetic and then lower the flows. I mean, you don't need to be running that high amount of flow for the entirety of the case. And so that's what we decided to do at UCSF. And it's not something that's like novel to use CSF. So I remember my mentor who did her training in the UK historically in European countries like the UK, anesthesiologists would use lower flow rates and would have been doing that safely for a years. And so I think it's time us anesthesia providers caught up in that behavior.


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It's a great example of, of an area of waste within our healthcare system, that most of us didn't realize existed. And y'all created this algorithm that safely reduced it and save some money and also helping the environment. Did you have any issue with transferring it from UCF to other hospitals within the system?

Yes. So one technically, so that's where my role came in. Dr. was like the champion of this idea and Dr. David Rabinovitz had developed this technology at UCF in 2018, but there were several challenges to now deploying it across. Other UC systems. So part of it is one finding the right physician champions and stakeholder buy-in at each of the institutions.

Which Dr. Gandhi had been doing for the last couple of years to try to gain support from each of the UCS. But once you had buy-in now, how do you take one technology that works at UCLA and now deploy it to a place like UC Irvine, for example, they have a different team of. EHR analysts.

They have a different team of the or technologists that help with the hardware integration. And then they have a different team that does like data reporting. And we were lucky at UCF where we have a pretty robust. Data reporting and analyst team. And so we needed also get buy-in from the tech stakeholders too, that would actually be now deploying this technology within their health system.

And so what really helped Me and our team make sure that the technical process went smoothly was having set multi-institution meetings monthly, but often more than monthly, especially with specific institutions and making myself available for any technical support on an as needed basis.

What was the major hindrance. Was it more people getting people on board or was it the technical piece that was the most difficult to transfer?

It was more the technical piece because there were some small differences between our EHR and other EHRs. also this is more of a customer CDS that we developed on epic. But you can develop it if you have a epic and buy the package where you can develop a BPAs. And so one translating that and making sure that data reporting was done seamlessly because it's one thing to now deploy this technology.

But it's another thing to then determine if The technology that you deployed actually is doing what it's supposed to do. And so working with the analysts at other institutions who had never done like these types of queries before was challenging, but I was excited. All of the analysts that I worked with at other institutions, we're also excited and passionate about this project. So overall I think part of it was luck and part of it was having a great team and a lot of enthusiastic people wanting to make this happen.

how easy would you think it would be for somebody kind of outside your system to recreate this in their own healthcare environment without having the technical knowledge that you'll have.

Yeah. So these are the elements that I think you would need to develop a clinical decision support alert system to remind anesthesia providers to turn down their fresh gas flow. So as long as your anesthetic EHR is pulling in the set concentrations for CBO flooring does foreign and isoflurane, as long as it's pulling in the information for the fresh gas flow rate.

And as long as also for tracking purposes, specifically, you are able to capture the anesthetic agent liquid consumption, which several machines do output and also the end title anesthetic concentration of the CBO for industrial printer ISO flooring. Then I believe that any anesthetic Anesthesia information management system would be able to develop a similar alert system for anesthesia providers.

It does require some hardware integration. So it could be that the anesthetic machine does have this information or is displaying this information one, but you would have to make sure that you're pulling it into your EHR. And remember, this is on a per. Level. So our B our clinical decision support tool runs its algorithm every minute of the case.

And so which is different from many of the other clinical decision support tools that are deployed in like outpatient or inpatient settings. And so as long as you have all of these factors that you can pull into your EHR and your EHR is customizable enough where you can develop some sort of alert that can run in the background every minute of the case then I do think that you can develop a alert system for your operating room.

Okay. And what sort of outcomes real measuring, how did you know it was a success? Was it the flow rate, like average flow rate or was it total volume of gas? What were you looking at.

Right. So we were certainly looking at fresh gas flow rates before and after. for example, like after I joined my fellowship, the department we decided to lower our. Gas flow rate threshold to 0.7 liters a minute, which is now the lowest in the country that any like institution runs. So we run it at 0.7 liters a minute, that threshold for all gases now. So we're looking at that.

We were also looking at firing rates, which I started looking at after I joined to see like how frequently would the alert fire and what you'd saw was. Looking back. For example, when we reduced the threshold from one leader to 0.7 liters last year in our institution, we saw a spike in firing rates. And then like a a spike and then the number of firing coming down over time within like a couple months period to a study. And then lastly, we also looked aggregate consumption of the IMLS is saved of these gases by deploying this technology. And lastly we looked at so it's MLS per Mac hour utilized Aggregate averaged per case.

And so you can think of like MLS of CBO flooring per Mack hour as think of it as a gas mileage of a car, for example. And so our goal was to improve the gas mileage of the the anesthetic machine or like our anesthetic use. And so we also tracked.

Very nice. Well this is certainly, like I said, kind of a new area for most of us didn't have this on our radar, but what other areas do you see the opportunity for as far as sustainable healthcare informatics?

Right. So certainly there's a lot of potential in for data science and informatics for sustainable outcomes in healthcare. So one great project. I also worked and led on the technical side at this past year was reducing waste in the operating room and really supporting a team using data-driven measures. And so as a clinical informatics fellow at UCSF I'm very fortunate to have training for clarity access, for example, which is the epic data warehouse that we can tap into. And at UCF, we also have very robust supply chain and purchasing data. And so more than a year ago, I teamed up with several of our anesthesia residents for a yearly qui project.

And the goal was to focus on sustainability and try to reduce The consumption of single use plastics in the operating room that are disposable and just go to landfill and also reduce the use of costly medications, where they were Less costly and equivalently safe alternatives. So what I was able to do before the project started was pull data to look at what medications in the operating room are we utilizing frequently.

And also what are the. That's for each vial or unit of medication. And from that list, we were able to target several medications that were extremely costly to the healthcare system, where there were alternatives to using those medications and an additionally we noticed that there were some, there were in our institution, at least there was. A large waste of hotlines, for example, which is a blood transfusion set up that would warm the blood in the Orr. So a lot of times the technicians in the or would open that and have it hanging for the case for the anesthesiologist to use if needed, however, It wasn't majority of times it was not needed or not even hooked up to the patient at all.

And so these are all single use items. You shouldn't be saving it for the next case because once you open it, it's kind of contaminated. And so we were wasting a lot of those too, and then some other single use plastic items as well in the operating room. And so with these residents once we identified which ones were very costly. Also being wasted frequently, we were able to develop fast like three PTSA cycles each several months long where we would introduce one medication and one single use plastic to reduce for those three months. And then the next cycle we would Add on like two other medication or a single use plastics.

And with my informatics training, I was able to track these elements over time by querying the different databases and also teaming up with the the supply chain and purchasing folks in order to get pretty much like monthly savings of each of these No medication as single use plastics. So I realized that a lot of clinical informatics oftentimes looks at like patient outcomes and optimizing the healthcare system in more of the clinical setting. But I think especially now that sustainability is such a hot topic and healthcare systems are caring a lot about these areas.

And we should too, as human beings, there's so much potential for. Clinical informaticians to help guide these guide and champion these measures, especially because we bring so much value to the table in terms of analytics and EHR, domain and domain expertise.

No, that's great. And I'm sure your CFO really appreciate it as well. All of us are trying to save money as well. So great efforts. And thank you so much for joining us today and thank you everybody for listening.

Thank you for having me.

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