Healthy Data Podcast Sandra Scott & Ron Goldman (One Brooklyn Health) & Jordan Cooper (InterSystems)-20250709_150256-Meeting Recording
July 9, 2025, 7:02PM
25m 33s
Jordan Cooper started transcription
Jordan Cooper 0:03
Data Podcast We are here today with Doctor Sandra Scott, the CEO of One Brooklyn Health, and Ron Goldman, the Chief Information Officer of One Brooklyn Health. For those who don’t know, One Brooklyn Health is a safety net health system based in Brooklyn, NY with 581 providers spread across three hospitals, community based practices and long term.
Term care facilities. Sandy, Ron, thank you for joining us. Glad to have you.
Scott, Sandra 0:28
Thank you for having us.
Jordan Cooper 0:29
So the topic of today’s conversation is the intersection of data integrity and remote patient monitoring to manage population health. I know that there, Doctor Scott, there’s a a program at One Brooklyn Health to ensure data integrity today.
Some of that is manual processes to encourage intake personnel to be precise with data entry, and I know there are other efforts. So I’d like to ask you just right off the bat, how is 1 Brooklyn Health ensuring data integrity today?
Scott, Sandra 0:59
Well, I think one of the most important things is to have your frontline staff recognize that they are responsible for data integrity. And I think a lot of time those who are responsible for registration both in the ambulatory setting, the emergency department setting, don’t necessarily embrace their role.
With regards to data integrity. And so we’re doing two things. One, there’s the education that what they enter on the front end of the visit has a huge impact, you know, with data for the patient care and then also at the at the back end when we’re actually trying to drop claims, et cetera and the second.
Jordan Cooper 1:22
Mm-hmm.
Scott, Sandra 1:39
Part is we are a Epic shop, so we implemented Epic throughout the entire system in 2021 and there are lots of reports and data available in Epic to tell you about the integrity of the data that’s entered, but I don’t know.
If you want to chime in a little bit on that one.
Goldman, Ron 2:01
Right. So while intake and clinical personnel are sort of responsible, to Sandy’s point, for the accuracy of the data entered into the EMR, I would say from an IT perspective, the department plays a critical role in maintaining.
The structural integrity of the data once in the system. So specifically, you know we have controlled vocabularies that we leverage such as SNOMED and LOINC to minimize variation. There is validation logic.
And error checking in the form of required fields, format options, etcetera. We also have role-based security and access controls. We prevent unauthorized or inappropriate data edits.
I would say change management protocols are a big one in the form of, you know, we have governance or IT forms, committees, right and and governance structures that sort of, you know, oversee what gets changed in the system. We also have audit trails, right?
Right. So from monitoring improper use or or errors in inputs. So I would say from from an IT perspective, we really partner with our clinical and operational leadership to make sure that we flag as much as possible sort of the.
High risk of any high risk data entry issues.
Jordan Cooper 3:40
I appreciate that, Ron. And the reason I started off with data integrity is I’d like to transition into the remote patient monitoring conversation from a data perspective. Many of our listeners across the United States are currently engaged in finding ways to provide care in the community, whether it be hospital.
Home or telemedicine or other remote patient monitoring programs. Now in January 2024, One Brooklyn Health announced A partnership between One Brooklyn Health, Cane Health and Cyber Med Health, announcing that there would be access for patients around the clock care with wearable devices to monitor vitals from the comfort of their home.
With no out of pocket cost to patients. So a question on this, a number of questions actually. What kind of alerts or messages are triggered for the clinical care team if there’s an abnormal pattern on the wearable device?
Scott, Sandra 4:34
So there’s two options. In some circumstances, for example, with our diabetes population, we have staff that are dedicated to monitoring the data for those fragile diabetics so that when they notice, for example, the blood sugar is is creeping up and moving in the wrong.
Jordan Cooper 4:49
Yeah.
Scott, Sandra 4:53
Direction they actually reach out to the patient and help to mitigate worsening of their condition. So in really high risk situations we have people who are assigned to monitor the data as it comes in and other situations for example like with monitoring weight, so maybe someone with.
Jordan Cooper 5:01
Oh.
Scott, Sandra 5:13
Fail.
Who they’re weighing themselves once a day. You know that that data doesn’t require the same intensity of monitoring in in most circumstances, and so a provider could review that data once a week or every three or four days. So it depends on the severity of illness, the condition, and how.
You know how how closely the data needs to be monitored.
Jordan Cooper 5:39
And Ron, if you could follow up on that, how I understand from Sandy that the staff are monitoring these devices, but are the devices transmitting data through your enterprise integration engine? Are there FHIR or API calls? Is there a FHIR repository? How are you accomplishing real time?
Time data monitoring for those patient populations and getting alerts for those aberrant patients who are experiencing adverse events as opposed to not being alerted to those who are just stable and healthy.
Goldman, Ron 6:11
Right. So at this time there is currently no integration into the EMR, but I believe the physicians or the clinicians are monitoring it within the system itself, right. So as far as what protocols that they use, those can be found within the system.
Jordan Cooper 6:30
And we say the system, do you mean epic?
Goldman, Ron 6:33
No, not not in Epic through Kane and and those correct, correct.
Jordan Cooper 6:34
OK, OK, got it. Clean and cyber-med. OK, so it’s external applications external to the EHR, correct? Got it. And so does your current integration engine support data ingestion from your RPM program?
Scott, Sandra 6:35
Good.
Goldman, Ron 6:44
Correct.
Jordan Cooper 6:53
Into the EHR or care management, I’m hearing you say not into the EHR. Does it integrate into the care management system or any other system or they just live in kind of in different silos and you have to have the care managers kind of active proactively reach out when they see a patient?
Who? Who needs care?
Goldman, Ron 7:13
Correct. Yeah. So they have to monitor it in the respective system. So that doesn’t mean that the the the capability exists in Epic. We’re just not there yet.
Jordan Cooper 7:25
And within the system, are there automated text messages or direct messages or emails or any kind of communication within a patient portal in order to communicate with the patient that they need to do something? Or is it more of like a a manual process? I ask because our listeners are trying to implement similar programs.
Scott, Sandra 7:45
Right. So ours is a manual process, but Ron, you might be able to speak to what’s available with the with the software that’s actually able to integrate with with Epic.
Jordan Cooper 7:55
OK.
Mhm.
Goldman, Ron 7:57
Right. So once configured, obviously we’d be able to leverage you know HO7 and and fire interfaces etcetera. Those can be mapped very easily into our Epic EMR is so so that way the data can be viewed.
Jordan Cooper 7:58
OK.
Mhm.
Goldman, Ron 8:15
You know, we can trend the data and insert that data into clinical workloads without users having to leave the EMR. But again, that’s a step that we have not embarked on quite yet and something that we’re looking at.
Jordan Cooper 8:22
Mhm.
Done.
What kind of thresholds or abnormal values would you want to automatically alert a care team about that is monitoring cane or cyber Med?
Scott, Sandra 8:42
So again, it would depend on a condition. I gave you an example of blood sugar for diabetics. There’s blood pressure readings, right? There’s weight readings. I think those are the most common ones that that we use, I think.
Jordan Cooper 8:46
Right. Heart failure.
Mhm, mhm.
Scott, Sandra 8:58
Blood sugar, blood pressure, I mean, your weight shouldn’t change that much from day-to-day other than a little bit of water weight. And so, you know, it would depend on the metric that you’re actually following. But again, the more critical ones I think would be blood sugar followed by followed by blood pressure.
Jordan Cooper 9:04
Mm-hmm. Yeah.
Got it. And so I think our listeners would love to hear about the current existing escalation workflow for the care management team that’s in place today once there is an alert about blood pressure, blood, blood sugar or weight.
Scott, Sandra 9:34
Right. So on our on our Diabetes Center of Excellence, we actually have nurse practitioners that are specifically trained, you know, have specific training to monitor the blood sugar, manage the equipment and be able to provide timely feedback to the patients.
Jordan Cooper 9:51
Mm-hmm.
Right.
Mhm, mhm.
OK.
Scott, Sandra 10:03
Center of Excellence can escalate to a endocrinologist, but she’s specifically trained to handle most of the issues that arise. So that’s a circumstance where we actually have a provider monitoring the data. The other circumstances we have maybe like a care manager, not a not an NP or an MD that’s necessarily.
Early monitoring those. In those circumstances, there’s an escalation to the provider.
Jordan Cooper 10:24
M.
Got it. And is there an opportunity for patients to view their own data in a digital front door or any kind of patient portal or is this data mostly for clinical care providers and case managers at One Brooklyn Health?
Scott, Sandra 10:43
Clinical care providers and case managers, unless you Ron, you have something to to add there.
Goldman, Ron 10:49
I think that’s accurate, yeah.
Jordan Cooper 10:51
Yeah. And has there, I guess let’s take a step back for a second. What was the impetus for rolling out this remote patient monitoring program? There’s many different options across the country for different health systems to pursue. Why did you choose this option at this time?
Scott, Sandra 11:11
So you mean choose this particular vendor or or the method that we have set up?
Jordan Cooper 11:13
No, just generally a remote patient monitoring program with manual workflows as you’ve described it so far.
Scott, Sandra 11:21
Sure. So for number one, it was our first kind of entry into this, this type of workflow. So the education and adoption on the part of the providers and the patients was really, you know, the the heavy lift before we went into a more complex technological solution and.
Jordan Cooper 11:40
I.
Scott, Sandra 11:41
You know, I think you and I spoke about this, but the highest cost of care in health care are patients with chronic conditions. And so chronic conditions are the diabetes, hypertension, emphysema, asthma, those are the patients that have the highest cost of care. So when you.
Jordan Cooper 11:51
Mhm.
Right.
Scott, Sandra 12:00
Think about population health, right? And you think about how does a health system reduce the total cost of care for a population? It’s managing those patients with chronic conditions and we know that remote patient monitoring.
Jordan Cooper 12:02
Mhm.
Mhm.
Scott, Sandra 12:15
If done properly and you have the buy in from the patient to manage the devices in the home to use the devices and you have the workflows and buy in from the providers, you can actually prevent hospitalizations, have better disease management and therefore the cost of care, right?
Jordan Cooper 12:22
Hmm.
Yeah.
Scott, Sandra 12:35
The cost that it the healthcare costs for that individual actually goes down. And you can imagine if you take a population of patients with high blood pressure and you and you work with them with the technology to ping them, make sure they’re compliant with their medications, their diet, they understand.
Jordan Cooper 12:40
It’s.
OK.
Mhm.
Scott, Sandra 12:55
Their blood pressure readings and they stay out of the emergency department or stay out of the hospital and that drives down the total cost of care. So that’s really I think the the, the, the impetus is better population, health management, healthier people, lower cost of of care.
Jordan Cooper 13:07
Mhm.
So when you’re managing population health, analytics plays a huge role in figuring out where you are and where you’re going, how effective you’ve been. This remote patient monitoring program has now been live for 18 months at One Brooklyn Health.
Has there been any evaluation, any analytics reports have been generated to demonstrate financial ROI or improved health outcomes as a result of this program?
Scott, Sandra 13:38
So both in heart failure, I I think we just we were just notified. We are I think about the get with the guidelines heart failure award for one Brooklyn Health. But with heart failure, much better disease management for that population, good outcomes and like I said, we even received an.
Jordan Cooper 13:41
Mhm.
Scott, Sandra 13:57
Award for that and then our Diabetes Center of Excellence. We actually have patients who would not traditionally have been offered technology that you know, might be someone who’s homeless, unemployed, might have, you know, not been considered a good a good client for these.
Jordan Cooper 14:03
I.
Mhm.
Scott, Sandra 14:17
Of technology and they’re doing extremely well, right. So with the right education, the right navigators, the right providers, the right support, even populations of one would think are traditionally not capable of complying with the complexity of of remote patient monitoring, they’re doing extremely.
Well, and and both of those populations say for sure we’ve had, we’ve had excellent outcomes.
Jordan Cooper 14:43
Just from an operational point of view, you’re distributing physical devices and they sometimes break, especially if you’re a homeless population. Are you cycling through and getting alerts if a feed from one of the wearables goes offline?
Scott, Sandra 14:56
Absolutely, absolutely, yes. And like I said, you would imagine that it would be a difficult population to manage, but they’re doing quite well, particularly actually in both heart failure and and diabetes. They’re doing quite, quite well.
Jordan Cooper 14:59
Um.
Have providers requested integration of this data into the EHR? Are they and are they is is this working in concert? I guess how well are the Epics best practice advisors meeting your clinicians need for real-time clinical decision support?
Scott, Sandra 15:16
Oh.
Jordan Cooper 15:27
And would it be? I mean, is there a request for this to be integrated to support that?
Scott, Sandra 15:31
So, so Ron, you wanna talk about all all the requests we have for integration? Absolutely, yes.
Jordan Cooper 15:36
Hmm.
Goldman, Ron 15:37
Right. So, so there’s always, there are always requests for integration, right. So from a BTA perspective, best practice advisory perspective, just to be more specific, you know obviously the.
Jordan Cooper 15:38
I.
Mhm.
Goldman, Ron 15:53
Functionality exists within Epic. You know they they effectively support our clinicians in making real-time decisions. So as far as the BPA effort altogether, we maintain a structured review process that includes.
Jordan Cooper 15:56
Mhm.
Goldman, Ron 16:13
Includes regular meetings, right. So just to see how effective the BPAS are, we evaluate that with clinical leadership and you know make sure that the the impact to workflows.
Are optimal. We adjust the thresholds to try to limit alert fatigue, right? So this helps us ensure that the BPAS are clinically relevant, actionable and aligned, you know, with patient safety goals, right? So.
We work, I would say we work collaboratively with stakeholders, clinical stakeholders to make sure that we’re, you know, alerting appropriately and effectively.
Jordan Cooper 16:57
And is there any kind of how, how would you say you’re you plan on responding in the future? Do you have any road map to combine clinical claims and device data to create a kind of source of truth on each of these high risk patients? Is there any any value that one Brooklyn Health would see?
See in in integrating all those different disparate data sources.
Goldman, Ron 17:21
Absolutely, yeah. So Epic would be our source of truth. So we would look to create those integrations into our EMR and taking take full advantage of that single pane of glass so that our clinicians, you know, don’t have to jump from solution A to solution B.
Jordan Cooper 17:28
Mhm.
And I did notice online there was an announcement that that One Brooklyn Health has a cloud enabled version of an enterprise integration engine. Any reason why that integration engine is not pulling in this wearable data into Epic?
Goldman, Ron 17:58
Right. So it’s just a question of timing, right, and making sure that we prioritize all of the various integration requests that we have. You know, to Doctor Scott’s point earlier, we have multiple requests for integration. It’s just a question of of slotting it and make sure making sure that we can facilitate.
Jordan Cooper 18:06
Mm-hmm.
I.
Got it. And then kind of backing up to a question about population health management, technically, how do you identify rising risk patients within your total patient population prior to a patient encounter before they become high cost?
Goldman, Ron 18:18
Yeah.
Jordan Cooper 18:34
So we think that of these 15,000 people, these 500 are really going to be the high priority chronic condition people. They haven’t seen a doctor in the last year, but we think they should. How do you target that cohort?
Scott, Sandra 18:48
That’s an excellent question. So we’re actually, you know, many health systems have already put in place a chronic disease management program. We’re a relatively new health system and so our.
Our one of the the initiatives we’re embarking upon now is to create a for the entire system, a registry of patients, for example, who have hypertension. I mean that Epic, Epic facilitates those types of registries. Today we largely focus on those patients who are already high risk.
Jordan Cooper 19:06
To.
OK.
Mm-hmm.
Scott, Sandra 19:23
But you make a very good point, right? From that registry, you can include patients who you can divide the patients into those who are extreme high risk, those who are in trouble and those who are, who are, you know, potentially will be in trouble. So I know that many organizations, we’re a relatively new health system.
Um.
Jordan Cooper 19:48
Mhm.
Mhm.
Scott, Sandra 20:06
We will be able to not only look at our system, but we’ll be able to look at the population beyond our system and the population of patients who have a chronic condition that we share with other health systems. So ideally it’s not hospital system based and it’s regionally based, right and so that.
Jordan Cooper 20:26
Right.
Scott, Sandra 20:26
The multiple health systems within one region can manage the same population together. That’s really the ideal state and both those that are, for example, pre-diabetic and those that are actually diagnosed with diabetes.
Goldman, Ron 20:40
Right. I would just add to that if I may. So Epic has a solution called Healthy Planet, right. And this, this is how we were able to leverage sort of like what’s happening across various other systems, right and pull the information in.
Scott, Sandra 20:54
Oh.
Goldman, Ron 20:56
So and we can also leverage a predictive analytical tools as well as risk stratification models based upon that solution.
Jordan Cooper 21:06
I appreciate that, Ron. And I guess you’re probably generating a lot of those dashboards in radar in order to create those analytical reports that Doctor Scott was speaking about. Doctor, we are approaching the end of the podcast episode, but a few more quick questions.
Goldman, Ron 21:18
Correct.
Jordan Cooper 21:23
You raise an interesting point. One Brooklyn Health is managing high risk patients in a dynamic geographical footprint, where these patients may easily find themselves in an emergency room of a different health system. They may be in Mount Sinai one day, New York City Health and Hospitals, One Brooklyn Health on.
Tuesday and three weeks from now they may be in Northwell, right. It’s a very mobile population. It could be homeless. Now there are HI ES in the area. There’s health X for one at how and there’s National Health Exchanges. You mentioned how you’re managing patients that are wholly within your population, but of course.
Patients are getting care everywhere. How do you see yourself other than care everywhere through Epic, managing these patients as a move between different health systems?
Scott, Sandra 22:16
So our payers have actually been really good partners, right? So the the the payers, for example, Health First, a large percentage of our patients are insured by Health First and we share data with them and they share data with us. So if the patient is receiving care in.
Jordan Cooper 22:24
Mhm.
Mhm.
No.
Scott, Sandra 22:35
Multiple locations, their payer knows this. And so one of the ways we help to manage certain populations is in collaboration with our payers and the data that they also provide to us. So we’ll have a specific metric. Today I was actually talking about substance abuse.
Disorders and how we can facilitate more touches with patients who present to the emergency departments with substance use disorders. Well, our payers can also provide information about where that patient might be landing, you know, in the emergency department across Brooklyn. But Ron, did you want to?
Jordan Cooper 23:04
I.
Scott, Sandra 23:12
How do you think to that one?
Goldman, Ron 23:12
Right. Sure. Excellent point, Doctor Scott. So we also participate in Healthix, right. As a matter of fact, last year we were coined when Brooklyn Health was coined as data champions, right, based upon our participation with with Healthix. So.
Number of different ways that we participate and can share there.
Jordan Cooper 23:36
Got it. We are approaching the end of the episode, so I’d like to ask each of you for a final statement. Our listeners are across the United States in comparable positions in large health systems everywhere. On the topic of intersection of data integrity and remote patient monitoring to manage population health, what would you say? I’ll start with Doctor Scott and then I’d love to.
To end up with Ron here, what would you say to someone listening who’s wondering how to improve data integrity in their organization? How to better manage their population health of their patient population? And is remote patient monitoring the right direction that they’d like to go in order to help achieve those ends?
Scott, Sandra 24:14
Absolutely. And I think our story is a good story because we didn’t start with the most complex technology and workflows. So the most important thing is to put your toe in the water of remote patient monitoring and if you don’t have the resources to to have the fancy bells and.
Vessels. There are many ways that you can institute remote patient monitoring to help the populations that you serve, and I think the most important thing is to to give it a try. Technology absolutely can improve population health.
Jordan Cooper 24:34
OK.
Scott, Sandra 24:48
And I encourage people to go for it.
Jordan Cooper 24:51
Thank you, Doctor Scott. Ron.
Goldman, Ron 24:53
Sure. So, so I would say data, data, data, right. So it’s important to make sure that we are facilitating and arming our clinicians with as much data as possible. And while we’re still in our early stages of remote patient monitoring, as far as integration goes, we’re looking forward.
To facilitate that integration so that clinicians are armed with as much information and making informed decisions as possible.
Jordan Cooper stopped transcription
