Exploring Digital Technology and Wearables to Improve Quality and Outcomes with Dr. Stephanie Carreiro, Medical Toxicologist & Emergency Physician at UMass
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: Welcome back once again to the Outcomes Rocket podcast where we chat with today's most successful and inspiring healthcare leaders. I really thank you for tuning in again and I welcome you to go to outcomesrocket.health/reviews where you could rate and review today's podcast because we have an outstanding guest, an amazing contributor to healthcare. She takes a unique view into the health system the opioid crisis, medical toxicology in general. Her name is Dr. Stephanie Carreiro. She's assistant professor of medical emergency medicine and medical toxicology at U Mass. The University of Massachusetts Medical School and at the University of Massachusetts she really has derived a passion for novel translation research and is specifically interested in the integration of wearable technology with behavioral interventions in the treatment of substance abuse disorders. Her current research pursuits include the utilization of mobile biosensors and micro RNA profiles to evaluate drug toxicity, substance abuse, and addiction. And in this age of the opioid epidemic and a lot of the issues that we're having in healthcare I just thought it was so timely to have Dr. Carreiro on the podcast so I want to give you a warm welcome Dr. Carreiro and open up the mic to you to fill in the gaps in the introduction that maybe you want to fill in.
: Excellent thank you so much, Saul and thank you for the opportunity to be on the podcast and for creating such an interesting forum for knowledge exchange. I enjoy listening and I've actually learned a lot just listening to a few podcasts. So I actually as you mentioned of a medical toxicologist, an emergency physician and a researcher in the health space and I really have tried to focus my interest or my work on wearable biosensor approaches to addiction that build bridges between patients, providers, engineers, scientists to create innovative solutions that work for addiction but also that can create exemplary model for integrating technology into or patient care space.
: It's so fascinating and we share that passion, Stephanie of knocking down silos between different specialties and I love your passion for this particular hot topic. So how would you define the hot topic that needs to be on every medical leaders agenda today and how are you focused on tackling it?
: That's a great question. So I actually think not just in substance abuse space but in health care across the board. We really need to look at how to optimally integrate technology into the provider workflow and the patient lives. There is a phenomenal explosion of both mobile and nonmobile technology and there's a tremendous amount of data coming through. The problem is if the approaches to using it in care are not practical and usable then they're not really yielding much benefit. So poorly designed and poorly executed technology really increase the workload it costs money without any measurable benefit. And when I notice that providers and patients really want is something that seamlessly integrates into their life and workflow in the background it really gives them something to complement and enhance what they're already done not necessarily create more work or more burden. And so that's kind of where I've tried to focus my efforts and I think that's important for the bigger picture as well.
: Yeah, you know seamless integration works within the workflow. These are some common themes that a lot of physicians are just clamoring for in the midst of all this technology that's being pushed into hospitals. Can you give us an example Dr. Carreiro of how you've been able to help this effort?
: One of the things that we work on again is wearable and mobile solutions right. So we have wearable sensors that are simply physiology. We're working hard to create these robust and accurate detection algorithms that identify things like for example in my work. We're looking to identify when patients use drugs like opioids or cocaine when patients are particularly stressed when they're craving drugs et cetera and that science is wonderful and exciting. But if the response to that detection is not something that the patient is poor provider is excited about or fits with what they're doing then all of that work on the detection Divac and detection strategy really goes to waste. So for example patients and providers talk a lot about work fatigue and data overload. And so if we create a system where we detect multiple events in a day and send a provider 50 alerts per patient for example with completely unusable data then again the detection system is essentially useless if we find a way and this is kind of more we're headed to combine all that netted data so to speak into one single alert for a provider that encapsulates really the bigger picture the patient for a day as opposed to minute by minute updates. We've found that that is much more accepted on the part of the provider and provides a much more useful tool for them to go forward and help the patient essentially.
: Yeah this is a really great call out you know listeners how many of you are in a provider setting and you find yourself overwhelmed with alarm fatigue. You find yourself overwhelmed with data that you really don't know what to do with. I think this is very common. So the question that Dr. Carreiro just leaves us with is how can we make this information more exciting, more useful so that we can translate it into actionable results? And she also mentioned the opioid epidemic. I thought this would be a great opportunity for Stephanie somebody that spent a lot of time in toxicology and on this topic of the opioid academic for her to give us a little background like how did this thing all start. You know that question comes up all the time. Maybe you could guide us through the history and how we got to today.
: One of the things that we've seen over the last 10-20 years is really the explosion of prescription opioids that many people feel have driven this epidemic in so 10 to 20 years ago. Physicians were really encouraged to treat patients. Now that's not a bad thing right. We should be attentive to human suffering. All of us and physicians want to alleviate that in any way possible. I think the problem came when people decided that opioids because they're good at doing that they're good at treating pain he decided that opioids should be given somewhat ubiquitously. And also there was a very prominent misconception that if people have legitimate pain they could not become addicted to opioids. That's what I was taught in medical school. Not incredibly long time ago. And that's an egregious misrepresentation to one of the things that I actually asked my trainees to do when a patient presents with an opioid overdose. Once obviously resuscitated and out of the critically ill period. I asked my doctors treating, my residents and my medical student to talk to them about how their first opioid exposure occurred. How did they get to the point where they were in the emergency room and a near death situation as an addiction. And by and large what we hear from people is that they often started with a legitimate prescription from a physician for opiate medication. It's often they had an injury or a surgery or a condition that was painful and some probably well-meaning physician gave them a prescription to alleviate their pain and that often spirals out of control. And so I think we're just probably the last five years come to realize that very altruistic kind of idea that we should treat aggressively treat is coming back to bite us essentially. And so it's led to a lot of talk about how we change our prescribing practices to protect people to balance the need for pain control with the risk that these these strong medications carry. And also coming up with not always to identify who is at risk and protect them. Unfortunately all those efforts will likely make an impact going forward. So people who don't have an addiction problem will benefit from them. But we're also kind of stuck with a large population of people who currently have an addiction problem. And we have to we have to deal with that as well.
: Yeah, this is a great insight and thank you for that timeline and what I love about Dr. Carreiro's story here is that as leaders we have two options we could either look through the window and blame somebody for the epidemic or we could look in the mirror and take responsibility. And what I find is that the leaders in healthcare like Dr. Carreiro, like Dr. Peter Chai who recommended Doctor Carrero to be on the podcast as well. They're taking responsibility for this and they're saying what can we do. And so the message here to the providers but also to industry is look in the mirror instead of looking through the window and pointing your finger because in the end that's how we're going to curb this issue. And so I want to I want to thank you Stephanie for your courage in taking that and saying what are we going to do versus hey they're the ones responsible.
: Absolutely fingerpointing is isn't going to get any of us anyway, right.
: So I think one of the biggest advantages I have in my practice is be able to see this on a daily basis to constantly remind me that it's not a problem we can sweep under the rug. It's not a problem that we can point at someone else to blame or even say their responsibility is sick. I think we all need to own a part of this and move forward.
: Totally and I'm going to take another side street on this one and say so, okay maybe you're not a provider, maybe you're an industry maybe you're a payer. Well guess what? The onus is on you too because a lot of this and my wife have talked about too, Dr. Carreiro like OK if something happens how often are you leaving your medications in a place where they're easily accessible to your child or your child's friends. Part of the effort for this opioid epidemic is for you to safeguard those medications and to talk to your neighbors and talk to your friends during parties about doing the same thing because a lot of these things happen on accident.
: I couldn't agree more. I think it again kind of limiting prescriptions is a fantastic way to present to personally prevents some of the issues we've seen. But there's so much more to it than that. So a responsible opioid prescribing responsible opioid use by patients are responsible opioid disposal. So any time we can get opiates out of the hands of the community is a wonderful thing or limit the opiates in the community to the spots where they're needed but also kind of talking to people opening the discussion decreasing the stigma is huge, you know realizing that this could happen to any one of us it's happening in communities of nice people with wonderful families. No one is really immune to the rest.
: And so I love that you're talking about it and that you're can open this up to everyone's problem as opposed to a problem that we can look that we ascribe to a different group of people or someone else.
: Totally. Yup. So I'm inspired by your accountability Dr. Carreiro and I encourage everybody else to take accountability for this because it's not just our providers, it's us. And what we're doing in this realm I recently found out about about a website called bluelight.org. It's not a Kmart website but it's kind of sickening. It's a site that guides people on how to manipulate their physicians to get more pain meds. And so there are just resources out there to help get and continue this problem. We've got to shed the light on these and turn these things off. But it starts with conversations with our neighbors and it starts with conversations like Dr. Carreiro and I are are having so really really appreciate your shedding light on this problem. Dr. Carreiro the problem will continue to improve as long as we keep talking about it. I'm really glad you brought it up.
: Yeah I think that bringing the epidemic to the forefront has helped but again it has to. That discussion has to proliferate on every level. You know providers in the community and industry think that in order for us to be successful we need to look at addiction the same way that we look at diabetes or high blood pressure or other chronic diseases. We're not blaming the patient or blaming someone that we're actively looking for ways to mitigate or solve the problems.
: Awesome. I totally agree. And what would you say one of your, you've done a lot of really awesome things and up to this point in your career. Dr. Carreiro, what would you say one of your proudest medical leadership experience is to date has been?
: It's interesting so it's always exciting to see something that I have worked on it be a success. But I think actually what makes me the most and in my career is watching my evangelist or my junior colleagues that I've trained go out and solve problems and be successful on their own path kind of taking what they've learned from working with me and using that to dry and something because I feel I think this is a common theme in medicine because we would train people coming up. I feel like that's the most rewarding because then you can really see your work spreading and see younger people with new ideas flourishing. So that's been the most exciting for me.
: So tell us a little bit more about an exciting project or focus that you're working on today.
: So right now we're actually newest and I think one of my most exciting projects to date in is project using wearable sensors to evaluate people who are newly stuck on opioids to try to identify when patients are at risk for developing tolerance and addiction and potentially intervening before that happens. So all of my research to date has really use wearable sensors and mobile apps to monitor and intervene on patients who already had substance use disorder and are either actively using or in recovery. What we're doing now is we're taking all of that knowledge that we gained and all the data that we obtained and we're applying that much earlier in the spectrum before people become addicted to opiates. And to me that that's really exciting because the idea is that we can potentially prevent addiction from happening by studying how people physiology changes every time they are exposed to an opiate for the first time and really identifying when the risk of being on an opioid outweighs the benefit of the pain control that you're getting from it as a potential point of discussion between patients and providers when it's time to transition off it or when when that risk is too high.
: Truly exciting and at the end of the project provision for it like what does this look like?
: What I'd like to have as an end product of this is a wearable and app most likely wearable and app based combination that we can give to providers when they start patient on a new opiate. For example if a patient comes in and has a broken leg from a crack then obviously that's a painful condition in most cases would be reasonable to treat with an opioid if necessary. We'd like to have a product that the physician can use in the healthcare environment where they can watch closely how the patient's response changes to that opiates over the first couple days two weeks and then again have a discussion with the patient about when that potentially becoming too risky and potentially stop therapy before it becomes a problem.
: Very cool. It's sort of opioid risk like real time screening tool.
: Very cool. Very cool. And yeah you know just thinking through every patient's different. You really can't. It's not a one size fits all especially considering even on the back end of it when you're getting put down on your anesthesia every patient will take medications differently for sedation. So I think this is a really cool tool to use outside of the clinic when things do become a little more risky.
: Exactly. And what we're noticing even in our preliminary data collection is that some patients show signs very early for example the first, second or third day after initiating opioid therapy. We're noticing some pretty big red flags in terms of risk whereas other patients can take them for a week and has no perceived change and no difficulty stopping the medication. So this really kind of plays into the idea of personalized medicine and really targeted therapy to meet people where they're at understand how or how their response is changing and how we can help that one patient.
: Awesome. Sounds super exciting and dappling want to stay in touch with you as as you move that project forward. And when it does come out please share it with the listeners. We want to get you back on.
: So Dr. Carreiro let's pretend you and I are building a medical leadership course on what it takes to be successful in medicine. It's the 101 of Dr. Stephanie Carreiro. So we're going to write out a syllabus and I've got four lightning round questions for you followed by your favorite book and podcast that you recommend to the listeners. You ready.
: You're absolutely.
: Awesome. What's the best way to improve healthcare outcomes?
: Key is to get early involvement from all critical stakeholders and end users. So this will identify your barriers early on and also generate early investment in buy in from the people who live in the community that you want to adopt your ideas.
: What's the biggest mistake or pitfall to avoid?
: Definitely would be generating ideas in a vacuum and expecting success on the first try.
: How do you stay relevant as an organization despite constant change?
: Too we're constantly looking for the next step and then using our data and our experience from prior successes to propel us forward.
: And finally what's an area of focus that you think should drive everything in a health organization?
: That would be collaboration. Absolutely. So kind of using the skill sets of others to create something that's better than you could come up with on your own.
: And finally Dr. Carreiro, what book and what podcast would you put at the end of the syllabus?
: Respect to the obesity epidemic specifically. I'm currently reading the book Dreamland which is eye opening even for someone who works with patients with addiction every day. So if you're interested in understanding how we get to where we are in the opiate that make I would definitely recommend checking that out.
: In terms of podcast. Yup, the podcast I'm an emergency physician and so one my favorites actually emergency medicine abstracts on the em:wrap podcast that can help me keep up to date on all the current literature and there's a lot of great toxicology content on there as well.
: What a great resource. Dr Carreiro, thank you so much for that. This whole syllabus is available. Just go to outcomesrocket.health/carreiro. You're going to be able to find all of that there along with a transcript of our conversation, links to the things that Dr. Carreiro mentioned. So excited to have you check that out. So Dr. Carreiro, thank you so much for your time today. Before we conclude I'd love if you could just share a closing thought with the listeners and the best place where they could get ahold of you.
: Absolutely. So the best place to get a hold of me. You could either follow me on Twitter and just at @dr_carreiro on Twitter or you can also check out my team and more about our research and who we are at umasstox.com, talks a little about about our research endeavors and also includes our newest philanthropic initiatives. The overdose prevention fund which is a phenomenal community and research oriented organization you can check that out and I appreciate the opportunity to talk to everyone. I would encourage people to dig a little more. The opiate epidemic is a fascinating issue and it will lead to more people thinking about creative solutions.
: Outstanding Dr. Carreiro, so really want to just say thank you again and listeners feel free to follow Dr. Carreiro on her Twitter. She definitely posts some informative and engaging posts there and again just want to say thank you so much for spending time with us.
: Great thank you, Saul.
Thanks for tuning in to the outcomes rocket podcast if you want the show notes, inspiration, transcripts and everything that we talked about on this episode. Just go to outcomesrocket.health. And again don't forget to check out the amazing healthcare Thinkathon where we can get together took form the blueprint for the future of healthcare. You can find more information on that and how to get involved in our theme which is "implementation is innovation". Just go to outcomesrocket.health/conference that's outcomesrocket.health/conference. Be one of the 200 that will participate. Looking forward to seeing you there.
Recommended Book and Podcast:
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