Dr. Blackford Middleton, Chief Informatics and Innovation Officer at Apervita, is a leading pioneer in clinical informatics. He is internationally recognized for his early and continued work in clinical decision support, electronic health records, patient-centered computing, patient safety and quality management, and more. In addition to his role at Apervita, he also serves as Chair of the Steering Committee for the Patient-centered Clinical Decision Support Learning Network. He is past Chairman of the Board of Directors of the American Medical Informatics Association (AMIA), the Healthcare Information Management and Systems Society (HIMSS), and the Computer-based Patient Record Institute (CPRI). Previously, he was CIO at Vanderbilt University, Director of Clinical Informatics R&D at Partners Healthcare, CMO at MedicaLogic/Medscape, and CMIO at Stanford University Medical Center. He has been a professor of medicine and or biomedical informatics at Stanford, Harvard, and Vanderbilt universities.
1. Can you expand on your background and why you came to Apervita?
I spent almost 25 years practicing medicine and leading research on how to improve the way we manage information and make decisions in clinical practice. As a CMIO and CIO, I was unable to find the technology I wanted to achieve the goal of having the best evidence made available to each and every clinical encounter for the decision at hand. I decided to join Apervita to build that technology and enable “best care everywhere.” Academic research allowed me to innovate in exciting ways but it only goes so far. Apervita makes all of this real. It quickly and effectively puts insight into practice at scale.
I found from the very beginning that the management of clinical information in practice was abysmal. I dedicated myself early on to improving the way we manage clinical information and make decisions and use computers. I was very lucky to find the field of clinical informatics. My research for 25 years focused on clinical decision support (CDS) and knowledge engineering. I helped to build one of the early medical record systems at MedicaLogic, known as Logician™. In addition, at MedicaLogic we built the first commercial personal health record system called aboutmyhealth.com. Perhaps one of most notable research projects I had the opportunity to lead was the CDS Consortium, funded by the Agency for Healthcare Research and Quality from 2008 to 2013. In that project we implemented some of the very early web services CDS ideas that we now pursue at Apervita. It’s time now with the great funding we’re fortunate to receive to build industry scale solutions as we are at Apervita.
2. Before diving into the world of healthcare informatics, you went to medical school. How has being a medical doctor changed the way you view healthcare and healthcare technology?
Practicing and teaching medicine as a general internist for over 25 years has given me first hand experience with the challenges of clinical information management, clinical decision making, population health, and communications and coordination with a care team and patients. Combining that with my training in epidemiology (Yale MPH), and health services research/clinical informatics (Stanford MSc), I have enjoyed innovating in the field of applied clinical informatics to improve the doctor-patient experience, clinical decision making, and the costs and quality of care. All too often we practice in a state of incomplete information—and incomplete knowledge—regarding the patient’s problem at hand. My overarching goal has been to improve the way in which doctors and patients make decisions supported by a rich array of decision support tools. I’ve worked in the world of clinical informatics almost since its inception and have seen it advance from the days of one-off solutions that were just starting to collect and analyze data, to today’s solutions like Apervita, a platform that’s creating what was once thought of as impossible — one connected network of data and knowledge across healthcare organizations.
When I started in clinical practice I was amazed that we had to retrieve clinical data from one computer system and often enter it to another. I was also amazed that we were expected to know so much! It’s estimated there are 2 million facts one needs to know in general practice, and another million if you practice in a subspecialty. It was also painfully evident that we couldn’t realistically reason well with so much uncertainty about the relevant knowledge and incomplete data about a patient (the paper medical record often incomplete, or even missing!). My fundamental goal has always been to make it ‘fun’ to practice medicine again—where in the clinical encounter with a patient you have all the necessary information and data on the patient, combined with the best evidence, to allow you to really focus on the patient’s problems at hand and develop a truly healing relationship with the patient (at least in primary care medicine), and come to the best decision. The old paper-based approach to medical records certainly didn’t make this vision a reality, and with the EHR we need to improve the integration of the world’s best evidence at the point of care to support “best care everywhere.” That’s what we’re doing at Apervita.
3. What does your role at Apervita as Chief Informatics and Innovation Officer entail?
I lead our efforts to integrate health science, computer science, information science, and cognitive science in order to build solutions that are transforming the way the healthcare industry manages and uses data and delivers healthcare. I also lead our Pioneer Innovation Projects, which are research and development projects that advance Apervita technologies in new ways, including decision support and ePathways, R&D projects with academics and federal agencies, and our work with AI, machine learning, and natural language processing. For example, we’re currently partnering with the Centers for Disease Control and Prevention, the Public Health Informatics Institute, Arizona State University, Yale University, the Office of the National Coordinator for Health IT (ONC), and the University of Michigan on these types of projects.
4. You have written extensively about the use of technology to turn data into knowledge. What is the difference between data and knowledge and how can the healthcare industry better use technology to get more out of data?
Data, information, knowledge and wisdom comprise the “knowledge pyramid.” Data is a series of facts in raw form, e.g. height, weight, or lab test result. That data is transformed into information by compiling and analyzing it—e.g. producing statistics. That information is transformed into knowledge by synthesizing information into best practices, and even codifying and encoding it. Wisdom comes when we’re able to internalize and act on that knowledge, or benefit from its use in a cognitive aid, like GPS systems providing directions. Technology like Apervita enables the ability to act on knowledge—to improve performance and clinical practice, and support enhanced collaboration. This is what biomedical informatics is doing to transform healthcare delivery—accelerating the translation of knowledge into practice to transform care.
To add value for the clinician end user (and their patients), we need to add knowledge to the EMR system by providing insights at the point of care. This requires us to make available to each and every EMR knowledge in a form that’s at once shareable and computable in the context of that EMR.
Applied wisdom also reduces clinician burden. We want to make it easy to do the right thing every time for the patient, and to gather the data required for patient care first and foremost that will support care optimization & measurement. This can only be done with an industry-scale platform such as Apervita across the full continuum of care, and across multiple disparate EMRs.
5. Where do you see healthcare technology going in the next five years? What types of innovations will support that vision?
In five years, care will be more continuous, virtual, self-directed, and supported by continuous analysis of many data streams with many algorithms. Healthcare is rapidly moving from a discrete and episodic process toward a continuous process. People are increasingly going to be monitored all the time and on multiple channels ,whether it be your daily steps, dietary intake, sleep, heart rhythm, medications as well as potentially monitoring of your ‘digital exhaust’: where you go, what you say in social media, what you buy…too much information! But from this data tsunami we can detect important signals to support health and wellness, and improve care. For example, my Apple watch might detect a worrisome arrhythmia. My provider may preemptively call me if my health is deteriorating, or there is a better medication to use. All of this implies that we can access the appropriate clinical data from not only multiple disparate medical records potentially, but whatever you agree to supply as a patient—patient reported outcomes, patient-generated data, etc.
Thus, I think for providers and patients, computers will increasingly recede into the background, and be a part of the technology fabric that supports daily life. For a patient, this means our wearable technology could also be our clinical technology: monitoring, surveying and reporting, securely and confidentially, as we deem appropriate. For a provider, this means the EMR will become more of a natural and interactive agent, collaborating in the patient’s real-time care. This will occur through increased background surveillance of patient progress and deviations from the expected course for a disease or for wellness, as well as increased cognitive support in the clinical cockpit of the future—helping the physician with key clinical questions and decisions such as the best treatment for a patient’s problems, how to make a correct diagnosis in a cost-effective way, how to efficiently coordinate care for a patient across multiple care settings, and how to support the patient’s care journey at home, work, or anywhere outside of care settings.
This same tsunami of data will also dramatically change the way we make discoveries and generate evidence for best practices. We will learn more and more from our analysis of patient experience and large data sets than we have learned historically from randomized clinical trials or experimental research. Big data will give us insights into both personalized medicine and population health. These insights must be made available at the point of care in the ways described above and personalized for the individual patient at hand. That is the vision for Apervita—best care everywhere—through a combination on our industrial scale platform of the world’s best knowledge and AI / machine learning algorithms with all of the relevant patient data to make the best care decisions not only possible, but routine. Fundamentally, Apervita technologies will make it fun to practice medicine again.