Digital Innovation At Seattle Children’s, A Look Back 2013-2019 • Dr. Wendy Sue Swanson MAMA DOC

I began the Seattle Mama Doc blog in 2009 as the first-ever, solely pediatrician authored blog on behalf of a children’s hospital. After nearly a decade of blogging, some 800 posts and hundreds of hundreds of videos and podcasts, it is bittersweet for me to announce that this is the end for the Seattle Mama Doc podcast and blog. I have learned so much about pediatrics, innovation, and caring for children and their families from Mama Doc followers around the world. Thank you!

I founded the Digital Health department at Seattle Children’s Hospital in 2013. My goal was to leverage the wisdom of clinicians, patients, and researchers to transform health care delivery in the digital age. The vision that a world where healthcare providers and patients use new technology to collaborate more closely and build deeper relationships, that wasn’t mine alone, certainly. I’m indebted to so many internal and external partners who guided and partnered with this transforming work, along the way.

“I’ve always believed innovation must embody “duel-centricity”: novel solutions must be both patient-centered but also clinician-centered to create long-lasting change and staying power. Striking a balance with that dual-focus is key for successful innovation. The other thing key: integration into the EHR. Just no way around that reality.”

As I begin the transition out of the role of Chief of Digital Innovation, I wanted to leave behind a quick reference and highlight some of the amazing work that has been produced out of our Digital Health team over the past 6 years. My hope is that you find this both informative and inspirational, but I also wanted to share our failures and lessons we learned in these early innovation pilots and programs. Of note, the majority of the Seattle Mama Doc blog will live on for some time on www.seattlechildrens.org, but the posts will also live on my new website www.wendysueswanson.com. And of course, I’ll be online – in minimum on Twitter and Instagram. My commitment to prevention, digital health, public health, and translation will not fade.

8 Highlights: Seattle Children’s Digital Health Projects

Virtual Handshake: solid-organ transplant education (using Tonic)
Transplant And Pharmacy iPad Co-Designed Education: Liver and renal solid-organ transplant education (using Tonic technology)
Digital clinical intake: information on iPads using Tonic software
PRISM app: built for researchers in oncology and endocrinology thanks to an amazing donation of services from Artefact and General UI
Post-Operative Pain app (P.O.P. Care): built with ENT surgeons & medical informatics, and our internal developers to evaluate how we can support parents with in-home instructions and support for both OTC pain medications and opioids
iPads in all patient rooms: thanks to an incredible donation from the Bungie Foundation
Seattle Mama Doc: blog, podcast, Twitter, Instagram, Facebook, and media.
Alexa skill – Flu Doctor: using voice technology for the public and for our clinical waiting rooms. We partnered with Boston Children’s to build and deploy this.

Virtual Handshake

Even after authoring 800 blog posts and doing hundreds of media interviews every year, I observed that families left my office without online tools to research their child’s disease or condition. One strategy for Digital Health is to use one-to-many communication to select personalized, relevant health information to increase patient education and learning when families are searching online even prior to meeting in clinic or at the hospital. We also wanted to reduce redundancy in clinician work and education. In designing Virtual Handshake the hope was to learn about increasing engagement and efficiency using patient-centered tools. We wanted to deliver education before and after clinical visits.

There is a need for a convenient tool that gives patients, families, relatives and friends information about providers and care teams they’ll meet during visits, relevant education and tips, care coordination and online educational links before, during and after their appointment or hospital stay to facilitate deeper understanding about a child’s health condition. Thus began our first project, Virtual Handshake™.

Pilot Summary
Virtual Handshake™ was built in partnership with the team at CareHubs & launched in 2014. We provided patients and families information about the doctors & care team they would meet during visits, as well as education & tips to help before, during and after their appointment or hospital stay. Virtual Handshake™ welcomed patients and families with a personalized message, curated health information, text reminders, introductory videos from their doctor, tips from other parents, maps, and videos to help them navigate parking and the check-in process. With Virtual Handshake™, we began to share our commitment to patients and families even when we’re not together, in smarter ways.

Pilot Goals

Introduce patients and families to care teams and provide relevant health information prior to visits. This includes online resources, video education, hand-outs, and text message patient reminders.
Provide family members and caregivers the opportunity to create a community around a child.
Reduce redundancy in clinician and nurse work by providing education online before and after visits.
Build comfort for providers using digital tools to communicate in the one-to-many format. Improve the efficiency of face-to-face visits.

Findings & Reach

Conclusions

This tool supplemented provider’s teaching and helped families understand their child’s conditions better.
Connecting with patients and families before their visit to meet their providers and obtain information from these experts did reduce pre-visit anxiety and better prepare them for the visit.
Offered an educational delivery method more convenient for families.
Improved connections between patient families and providers.
Increased provider awareness, comfort, and support of digital tools.
Offering the tool to a family at the time of appointment scheduling is ideal.
Department staff need a champion to drive family experience vision, agreement of workflow and content creation. Need for RN assistance posting content and viewing data.
Overlaps with patient portal need a champion to provide clarity of purpose.
Text messaging reminders were not widely adopted, family invites were not heavily used.
Although pilots in GI, General Surgery, and Neurology were successful we did not have funding to iterate the technology to continue to advance the software.

Tonic Transplant Education

We built a peer-to-peer and expert-to-family educational app co-designed with patients and families that leveraged pharmacist and sub-specialist expertise for solid organ transplant patients and their families. The app helps support families’ understanding of necessary medications and care after transplantation. During the inpatient stay for a liver and renal transplant, all patient & family/caregivers need to complete transplant medication education as a prerequisite for discharge. Before we built the educational software with families, pharmacists were delivering approximately 6-12 hours of oral education at the bedside. Without a fully documented curriculum, there was variability in what the pharmacists delivered orally and subjective review was used primarily to determine how well the patient & family understood the education and the material. At times, patient discharge could have been delayed because of the didactic nature of training with pharmacists and the daytime need to have families and pharmacists in the same place to do the teaching. Digital Health partnered with the Transplant team and Transplant Pharmacy teams to digitize post-op medication curriculum for liver transplant. Patients and families co-designed the entire curriculum and helped guide the creation of work flows. After liver transplant completed their work and curriculum, we completed a delta and gap analysis for our renal team. Thereafter, the renal transplant team and many teen patients created a second curriculum for patients and families. The practice of using the iPad curriculum for teaching has also been integrated into both the Pharmacists’ workflow and our CIS via a Pharmacy Note.

Pilot Goals

Learn about patient and family co-design for digital software, invest in digital health for care delivery and education.
Support patients and families’ schedule (let families learn when children sleep or at times convenient to them).
Improve standardization of post-transplant medication education.
Decrease bedside teaching time for pharmacists.
Improve patient and family confidence in medication administration.

Conclusions

Pilot was continued and this is now our standard of care after solid-organ transplant.
Parents/caregivers and patients review education throughout the day and night (the majority of viewing was after-hours).
Standardization in material improves patient outcomes.
Ability to review material at leisure and have access to it post-discharge is desired and reduces pharmacist teaching time thus cost-saving.
Transplant teams received national attention for this work as an innovative and safety/quality improvement in care delivery.

Tonic For Diabetes Clinical Intake

Diabetes clinic uses a form for intake data called the “pink sheet” on all patients. This data can be collected prior to the appointment to maximize the provider’s response to the patient’s concerns and compare outcomes to previous appointments. In an iPad format (using technology by Tonic Health), we designed online intake surveys to collect relevant clinical data prior to the patient visit. The digital survey questionnaire enables patients to self-report their glucose and insulin levels as well as set goals for their routine diabetes management on iPads, while checking in for appointments. This information is vital to the visit, but can be cumbersome to complete in clinic before seeing their provider.

Proactively serving up the questionnaire pre-appointment allows patients additional time to complete the survey from home in a convenient platform. Their answers can be confirmed at the visit and more rapidly reviewed by the care team, which improved clinic flow as well. Families can also opt-in to learn about research opportunities.

Pilot Goals

Improve patient and family experience completing standard paperwork.
Improve clinic flow by decreasing wait time prior to visit to complete the form and allow providers access to data ahead of the visit.
Create a sense of being “known” by provider/clinic because information is already cued up for them.
Develop a comprehensive database for intake results.

Findings & Reach

Conclusions

The only solution in digital health that has been integrated into the EPIC scheduling which is a key factor in optimizing workflow and standardizing care.
The ability to pull through patient demographic information and prior answers improves patient and family experience and improves patient-provider communication.
Initially, there was an adjustment for providers not to get the pink sheet. We worked at length to optimize flow for MAs by emailing completed survey to group inbox. Integration of this information back into the EHR could be desired (current workflow is for MAs to email/print report for physicians) as structured data to improve outcomes and reduce further inefficiencies.
Full end-to-end integration is key to efficiency and success.

PRISM APP

Seattle Children’s doctors, Dr. Abby Rosenberg and Dr. Joyce Yi-Frazier created an intervention called Promoting Resilience in Stress Management (PRISM) for patients in multiple units. This intervention model is designed to teach teen patients resilience – the ability to maintain psychological and physical well-being in the face of stress – to buffer the impact of serious illness.

The Digital Health team supported the researchers and their assistants in partnership with generous donated services from Artefact and General UI, two premier, local designers and developers respectively. Their services were provided pro-bono as a donation to the hospital, valued at over $170,000. Through this collaborative partnership, a proof -of- concept app was created to help support PRISM learning, digitizing four tools in the PRISM toolkit, to supplement the in-person intervention.

Pilot Goals

Increase the impact of the intervention: The digital tool can be delivered to a virtually unlimited number of patients if or when it is finalized by researchers and patients. Once fully developed it would be possible to deploy PRISM education not dependent on the availability of researchers at the bedside. In addition, the partnership aimed to reach teens and their families on personal devices when not at the hospital, to coach and nudge them to continue in their practice. Exploring engagement with the curriculum in the beta-version in hopes that the digital interface enhanced participation.
Accelerate an understanding of the effectiveness of resilience techniques in digital environments: Through focus group discussions and user evaluations, as well as analysis of the longitudinal usage data, we sought to gain clear understanding of the patient experience and the effectiveness of the different training modules.
Demonstrate how thoughtful design and outcome-focused thinking, technology can augment the impact of the work of researchers, scientists and healthcare providers. In addition, we hope to show that digital interfaces like this expand the impact research-driven interventions in hospitals can have on patients across the US and beyond.

Findings & Reach

Conclusions

Working with external firms provides areas for growth and opportunity as well as presenting challenges in workflow, adjusting to outside timing, heavy legal involvement and additional layers of communication.
It is hard to get apps into the hands of teens. Downloads and testflight protocols were a barrier to engagement. Workarounds began immediately after the pilot.
Paper instructions and multistep processes are a barrier for uptake, we rely heavily on our provider and clinical staff partnerships to enroll patients onto the app.
Collecting feedback to understand engagement via surveys was challenging due to low response rates.
Outside designers built a beautiful, intuitive app for v1.
We had to strike a balance between wanting the curriculum to be widely available while protecting the IP of researchers’ protocols.

Bungie iPads For Kids

The Bungie Foundation aims to reduce distress and suffering in children through entertainment. The iPads for Kids program reduces distress and suffering in children by providing patients with fully customized, age-appropriate entertainment that allows for distraction, therapeutic play, and a sense of normalcy that is vital to creating a positive hospital experience in an otherwise stressful and scary situation. While donated iPads from the iPads for Kids program began in 2013, a more formal effort to deploy across nearly every in-patient room of the hospital kicked off in summer 2018.

Pilot Goals

Deploy iPads to all in-patient rooms at Seattle Children’s.
Partner Get Well Network with each iPad to improve patient /family engagement in their care.
Create new clinical and technology workflows to allow for implementation.

Findings & Reach

Conclusions

Generous donations were able to be accepted with digital health support staff ready to get into hospital environment.
Many troubleshooting processes had to be built and hardware solutions created (chargers, wiping, software wiping, etc).
Operational support needed to support project for seamless experience for patients and families.
We must continue to expand on how these iPads could be leveraged to deliver more data, information, education, and entertainment. We aim to have this be a place not just for entertainment but a place for children and families to learn about their care.
Must partner with a dedicated point person in each department for success for organizational success.

Post-Operative Pain App (P.O.P.)

This app was built entirely in-house with a multi-disciplinary team to learn how to support patient and families with pain control after surgery. We sought to learn more about how to guide families to use OTC medicine for pain and when/if to use opioids.

Dr. Michael Leu a medical informaticist, and otolaryngologist, Dr. Sanjay Parikh submitted an idea for a pain management app to the 2016 Microsoft Hack-for Good competition which began the journey. The pitch was selected and over the course of one week a team of Microsoft employees coded a very rough prototype of the app. SCH e-Health team then took it from there and committed to internal development of app. Tonsil and adenoidectomy (T&A) surgeries are the 2nd largest volume procedure in the Otolaryngology department and were targeted as a place to demo and beta-test the app. Team provided families with a digital tool that provides pain medication tracking and reminders as well as education regarding post-operative care. The pilot ran with patients having T&A procedures at Bellevue Surgery Center (site was selected because of their higher volume, throughput process, ease of implementation, engagement with parents, more uniform in complexity of cases for pilots).

Pilot Goals

Understand the typical post-op pain pattern.
Quantify how much pain medication is needed.
To keep patients safe from overuse of opioids via pain management education and tracking (long-term goal).
Educate families on what to expect as normal side-effects after surgery.

Findings & Reach

Conclusions

Parents watched videos & read content early in post-op period.
Opioid use and pain curve not assessable:
Limited knowledge collected because uncontrolled use of app.
No single individual matched the expected pain curve.
Key requests from parents include single sign on and push notifications with alarms for medication administration.
Apps can be used to provide education for post-operative pain but many iterations will be needed to see if we can help guide medication administration and ultimately reduce the use of unnecessary opioids while also maintaining excellent pain control.

Propeller – Remote Care

Propeller is a digital inhaler and asthma monitoring app. Propeller sensors attach to the inhalers you already have. The sensors automatically track how often you use your medication, and they chime when it’s time to take a dose. The sensors send information to an app on your phone. Over time, the app learns about your flare-ups and medication use and can help you become an expert at managing your symptoms and identifying your triggers. We were able to successfully create a new care management model by centralizing alerts and escalation protocols.

Pilot Goals

Digital health team, general pediatricians, and numerous staff in care-coordination deployed an intervention for children with asthma to monitor and track inhaler usage to identify exacerbations early to decrease ED visits.
We introduced a remote monitoring device with a patient-facing app and a provider care management portal.
We wanted to enable our patients to build self-efficacy in their disease management.
Provide patients a way to connect directly with their providers without having to navigate a complex phone tree or have an asynchronous phone or portal interactions.
We provided high ED/in-patient utilizers with a device to monitor their own inhaler usage, provided coaching on medication adherence and identify an exacerbation by remote monitoring. Our hope was to prevent acute asthma episodes, thus decreasing ED utilization.

Findings & Reach

Conclusions

Confirmed that partnerships with childrens’ general pediatrician is critical for population health management.
Patients signed up, but roughly only 50% completed full enrollment.
Parents expressed to the team they felt more connected & appreciated being checked in on with this digital connection
Tested multiple enrollment channels and had superior enrollment with mail vs. email. Our engagement was higher than industry standard.

Seattle Mama Doc

The Seattle Mama Doc blog was launched in November of 2009 and was the first-ever pediatrician authored blog on behalf of a hospital at the time. The blog catered to one principle I’ve learned along the way as a practicing pediatrician and parent to two: parents just want to do what is right. The desperate love we have for our children can shock us into good and sometimes bad decisions. I believe parents search for and sincerely desire simple answers to the How-What-Why-Who of parenting, the essence of doing right for their children. And, the abundance of online noise invokes fear in all of us when making decisions for our children.

Over time, I hoped to illuminate the reality that in pediatrics, doing less is often more. Prevention reigns.

Parents just want to do what is right. It’s the defining what’s right that, on occasion, remains elusive. The blog, a sincere attempt to help.

Goals

Build trust in the science and safety of vaccines and the evidence for science-based decision-making.
Meet parents where they are online, making trusted data available in real-time.
Share and scale my knowledge as a pediatrician, mom to two boys, and spokesperson for the American Academy of Pediatrics.
Leverage partnerships with trusted outside organizations (CDC, NFID, AAP, WA DOH, ACIP, & KYOTCs) to build trust and share timely recommendations.
Create digital media assets and channels that build upon the SMD brand that allowed for parents to learn around the world (Facebook, Instagram, Twitter, podcast, etc.)

Findings & Reach of Blog and Podcast

Blog received 12M pageviews since inception. Several posts #1 in Google SEO.
7,600 Facebook followers.
40,000 Twitter followers.
3,100 Instagram followers.
82,000 podcast episode plays.

Conclusions

The Seattle Mama Doc blog allowed for a trusted voice for pediatric science that was read by parents and clinicians around the world.
Best performing content for all years was content written about sleep.
Parents want access to information from pediatricians in real-time, not just in the time shared during clinical visits.
Leverage social media channels to move communication from 1:1 to 1:many. This will allow for individual clinicians and surgeons to share knowledge efficiently.

Flu Doctor Alexa Skill

Seattle Children’s Hospital partnered with Boston Children’s Hospital to create an Alexa skill to build trust in the science and safety behind the flu vaccine. Seattle Children’s contributed the knowledge and my recorded voice (Dr. Wendy Sue Swanson) to write the scripts for the skill. Boston Children’s hospital contributed the back-end development of the skill. We timed the launch of the skill around the 2018 NFID Flu Press Conference which Dr. Swanson was invited to speak at and announce the content would live inside the Alexa smart speakers.

Goals

Build trust in the science and safety of the flu vaccine.
Create a cross-country partnership between two leading children’s hospitals.
Work to create a capacity for voice projects at Seattle Children’s.
Leverage partnerships with trusted outside organizations CDC, NFID, AAP, and WA DOH to vet and partner on the script, education used, and the Alexa skill.
Create and launch a communications and PR campaign to promote the skill and gain users.

Findings & Reach

PR & Media Efforts About The Skill

96 total media placements
198.8 million of readers in reach, $385,000 in total estimated earned publicity

Conclusions

Skill enablement (you have to turn on a “skill” in your Alexa app on the phone to get them to play on the speaker) is a known barrier to engagement. Many users don’t know how to go enable a skill within their Alexa app.
Whatever you prompt users to do first within your skill will typically have the most engagement.
Partnering with AAP, NFID, CDC, and WA DOH added a layer of endorsement, trust, and reliability for influenza vaccine content.
Having a shared skill sit in 1 developer console presented challenges (access to metrics, etc.) but a bountiful partnership between two leading hospitals to do something new.

Alexa “Flu Doctor” Ambulatory Pilot

The Digital Health team wanted to continue to promote and build trust in the Alexa Flu Doctor skill built in partnership with Boston Children’s Hospital. After meeting with senior leaders, we also wanted to support our USNWR rankings on flu vaccine uptake — we wanted to help guide families to trust in and get their flu vaccines while in our clinics. We piloted 4 devices in an ambulatory waiting area over the course of 5 months. We targeted patients at high risk of flu-related complications (diabetes, pulmonology, and kidney/liver transplant clinic waiting rooms).

Goals

Build trust in the science and safety of the flu vaccine.
Gain approval for the first ever voice-enabled pilot inside a patient-facing space in a children’s hospital.
Support flu vaccination rates & education efforts at Seattle Children’s.
Work to unravel challenges with getting smart speakers inside the hospital environment.

Findings & Reach

Number of Times Flu Doctor Was Opened: 239
Total Invocations Within Flu Doctor Skill: 785
Extrapolated Total Number of Invocations With Devices (ANY question asked to Alexa + Flu Doctor): 5,500