How to Navigate the Digital Health Ecosystem with Dr. Oliver Aalami
In this episode of Scrubcast, we delve into the fascinating world of digital health and its implications in surgery with Dr. Oliver Aalami, a clinical professor at Stanford Surgery. Discover how Dr. Aalami's passion for innovation led him to specialize in vascular surgery and to create VascTrac-the world's first peripheral artery disease (PAD) study powered by a smartphone.
Dr. Aalami shares how his experience led him to create educational programs that bridge the gap between healthcare and technology. Learn about the challenges and opportunities in digital health projects and how researchers can effectively use technology for patient monitoring while still emphasizing the importance of data privacy and secure systems.
Learn about Spezi (formerly CardinalKit), Stanford’s free, open-source framework for developing health applications here: https://spezi.stanford.edu/
Transcript
Rachel Baker: [00:00:00] Welcome to Scrubcast. Where we take a closer look at the research happening at Stanford University's Department of Surgery. I'm your host, Rachel Baker. Today, we're speaking with Dr. Oliver Aalami. Welcome to the show.
Dr. Oliver Aalami: Thank you for having me. Very excited to be here.
Rachel Baker: It's great to have you here. Dr. Aalami, you are a clinical professor in our Division of Vascular Surgery.
Why did you choose vascular?
Dr. Oliver Aalami: Yeah, that's that's a great question. Everybody has a journey. And mine actually started, uh, being very, I knew I wanted to do surgery. You know, I had that gut feeling as a med student and initially I wanted to do cardiac surgery. So I actually did my postdoc here at Stanford.
Between 2000, 2001 with Randall Morris, who is a transplantation immunologist within the Department of Cardiac Surgery and super fun, but I did a lot of moonlighting and I noticed that there's all this new technology coming, especially in the [00:01:00] cardiovascular space and, you know, cardiologists were doing more and more and more.
And it seemed like they're eating more The cardiac surgeons lunch, you know, they're coronaries replacing valves, you know, doing all this stuff. And it seemed like the cardiac surgeons were very happy just the way things were. We're really embracing new technology. And however, the vascular surgeons who do similar work, but outside of the heart and outside of the brain on vessels, we're embracing all this technology.
And that's something I really enjoyed. So that's, that's how I landed in vascular surgeries as specialty.
Rachel Baker: This is making a lot of sense because you are also a director at Stanford Center of Biodesign, which I usually think is a synonym for innovation. But what exactly is biodesign?
Dr. Oliver Aalami: That's a great question.
Biodesign is actually center, as you correctly mentioned, uh, at Stanford, and it sits, it's not, uh, Associated really with any department and it's a needs [00:02:00] based center for innovation. So we pride ourselves on saying like the product are the students when they finish and the crown jewel of the program is this fellowship.
We have 12 fellows a year that spend a year learning this needs based innovation process, and it's actually very simple. But having a very structured way of going through the innovation process can really help you identify a need. And that that's really at the core, you know, there's a saying that within the DNA of any great invention is a very well-defined need.
So there's a lot of obsession around that. And they have these simple tools, such as creating a need statement, which identifies a very specific need. problem, specific population, specific measurable outcome that you're trying to affect. And then, you know, there's this process that you go through within the program, and over the years, it's grown.
So there are a lot of courses that are taught on campus in addition to the fellowship. And over the last 12 years, they've been teaching [00:03:00] digital health courses. It used to be called mobile health. I've always been really passionate about this space, and I took over these courses about eight years ago.
And that's how I got involved. So we, you know, we run these two courses. We also have our own students that come and rotate through. So it's really exciting to be able to. Focus on translation. That's really the work we do. We do a lot of research and translation in the digital health space within the center.
Rachel Baker: I was looking at the listing for this course, building for digital health, and it's cross listed with the med school and computer science, which I was like, that doesn't happen every day. One. Okay. I wanted to, I want to go back to why did you switch from mobile health to digital health, but then also what are they learning in this class that they are taking?
Medicine, and I guess, are they, they're combining it with code?
Dr. Oliver Aalami: Exactly. You nailed it. You nailed it. Absolutely. So going from mobile [00:04:00] to digital, mobile was, seemed very narrow, you know, as a definition. And so as you know, the world became digitized, as did our electronic health records, you know, in 2009 with the high tech act, billions of dollars was poured into the health systems as incentives to convert from paper charts, electronic charts.
And we, you know, now have these connect. Patients, you have all these sensors devices. So we thought digital kind of was a nice, broader description of everything that could be included in this type of work. And there are two classes we teach. One is a very generic, it's called the by design for digital health, which kind of goes through the by design process.
Through the lens of digital health. And what does that mean in the framework of, for by design, the first step is what's called needs finding and by design first started over 20 years ago, when the fellows came in, they did all their needs finding within the four walls of the hospital. They were told, okay, go to the OR, go to the clinic, watch, you know, the nurses, watch the [00:05:00] doctors, watch what the patients are struggling with.
Identify a need, but what digital provided was taking this needs-finding process. outside of the four walls of the hospital where we spend 99 percent of our time, but are still, you know, dealing with chronic conditions and so on. That's the basic class. And then the building, I realized I myself had worked on a lot of projects in the cardiovascular space, kind of seeing what kind of signals can we get from.
Wearables, smartphones, in patients with cardiovascular disease. And what can we learn in terms of a better prediction, better prevention of disease? Are there signals and what do they look like? And after having done this work here at Stanford, I've got a lot of requests from other faculty members. I want to do a digital health project.
Can you help me, you know, start a digital? What do I need to do? How do I do it? You know, what's step one, two, three, four? And, uh, I realized that there was a need to, you know, with this translation.
Rachel Baker: You identified a need!
Dr. Oliver Aalami: Yeah, I identified a need. [00:06:00] And, uh, to help others with this translation, we thought, why not just start a class?
Where we take literally five projects from the hospital. And then in the winter, when the class starts, we actually work with computer science students. There's some med students. I'm telling you the new triple threat for students that are coming through, you know, many of them know how to code, you know, they're going through med school.
It's really, really bad. Crazy impressive what these young kids can do. And they're very interested. They're like, I want to work on an impactful project. You know, sometimes they're computer science, master's students, computer science, undergrads who don't want to just build another Twitter, you know, they want to do something meaningful.
And every one of these projects that we build. ends up going through IRB and touching real patients. So that's super impactful. We do exactly as you described. I mean, we actually build, you know, MVPs, the minimal viable products of each of these projects with the students and the health of our TAs and our, our instructors.
So I think it's a pretty cool class. You know, [00:07:00] when faculty find out about it, You know, if you were to outsource this sort of work, it can cost anywhere from 20 to a hundred thousand, if not more
Rachel Baker: absolutely
Dr. Oliver Aalami: to get this built. So they're getting it on the, you know, getting at least the initial MVP for a really good price.
And to boot, we have a really good relationship with Stanford's TDS, which is the it department that have to approve these apps when you run your study. And because they know us so well, and they, you Trust what we build, they waive the evaluation fee, which is like 10, 000 for TDS just to look at you because they, you know, they see it as a consulting fee to see, okay, what is it going to take to get this application through the data risk assessment and all that.
So there are a lot of benefits to work together. So that's the building for digital health class. It's in the winter quarter. It's only 10 weeks, but it's amazing what we can accomplish.
Rachel Baker: Very cool. So I remember your VASC track app and I looked up the study. It was [00:08:00] in PLOS One in 2021 and it was built on Cardinal kit, which I think is now called Spezi.
But talk a little bit about this study. I remember being really excited because my dad had PAD at the time and I was like, Ooh. Can I stick an iPhone in his pocket and what can I learn?
Dr. Oliver Aalami: VascTrac, that was my baby. That was, again, I'm a vascular surgeon. So for me, I had seen people in the ER who had interventions that had failed.
And they would tell me, Oh, you know, about three months ago, I noticed I just wasn't walking as well. You know, it was affecting me, but I thought it would just go away. So I didn't do much about it. And now I'm here and you know, the stents were occluded and all this, it was much further along. And I thought, Hmm, I mean, they're basically telling me they had issues with their activity, their physical activity.
So could we leverage passively just collecting or monitoring the daily step counts on someone's phone after an intervention, see how things [00:09:00] improved, and then also maybe follow the trends. It's to predict if something we're ready to include or we're about to include and intervene before it completely blocks because everybody responds differently to intervention.
And I liken it to scarring. You know how when some people get a cut on their skin, some people get tumors, you know, that are a keloid, right?
Rachel Baker: And mine they kind of cave in.
Dr. Oliver Aalami: Do they? Well, you're lucky you're not going to have issues because the kind of reaction you get in an artery when you blow up a balloon or deploy a stent is very similar, you know, you cause actually a lot of injury initially as you're stretching the artery, but then the body wants to heal and that healing process.
And some people, they develop keloid inside, right? They scar tissue, whereas others don't
Dr. Oliver Aalami: Yeah. And it's hard to, well, I'm calling it, I'm calling it keloid, but it's basically scar tissue. It's fiber, you know, fibroblasts and scar tissue. Yeah. I was like, Oh my gosh. Okay. I'm going to develop this app.
It's going to be great. I blah, blah, blah. I'm going to do all this amazing stuff. And then I [00:10:00] had to, you know, when you actually go through the process of setting up, you realize, wait a minute, I don't even know what baseline looks like. Be honest. I'm sure the Apple team or. You know, whoever develops these algorithms initially is working with young, healthy triathletes, right?
Well, or
Rachel Baker: Dr. Mary Hawn.
Dr. Oliver Aalami: Yeah.
Rachel Baker: did you see her step count?
Dr. Oliver Aalami: Yeah, no, that's true. That's crazy. Uh, but the, so the, um, You know, I realized I had to start from square one, so we did a lot of validation studies and that's plus one study that you're talking about. It was a really cool study, pretty simple. We had people that have PAD come to the office and there is this classic validated functional capacity test called the six-minute walk test.
Rachel Baker: Right.
Dr. Oliver Aalami: And you walk up and down the hallway. And so we had them wear an ActiGraph on their hip, they had the phone in their hand, and we literally had a research coordinator watch them and do the six minute walk test and count every step so we could compare all the numbers. [00:11:00] And it turned out the phone was pretty good.
You know, it was very accurate when it came to accurately measuring the step count. So the study you're describing was that study and you're right. Initially we took VascTrac and we basically made it into CardinalKit. And what CardinalKit was, it was very useful. The first iteration, when I started the class, the building class was with CardinalKit, and that's basically a template application.
So a template application means, you know, everything was kind of blank and you could put in what you wanted for your application, but in the first few years of this class, we noticed. That if you, when you start with a template application, the way it's architected, you, you know, let's say you didn't want certain components in that application, you have to break it apart and then put it back together as an application.
So we thought, you know, we could do this better. Let's modularize everything and make it like a headless app. It sounds horrible, but it's just means that it doesn't have a [00:12:00] persona yet. And then let's say you need Bluetooth connectivity. You get that module, you need consenting module, you get that module, and then you can piece it all together and all the marks.
Rachel Baker: It's a little like Frankenstein.
Dr. Oliver Aalami: Kind of like that, but it works a little better than Frankenstein. And so that's what this new Spezi, formerly CardinalKit, that's what Spezi is. And we took it even a step further. We said, okay, We are all about standards. So out of the box, it uses the HL7 FHIR standard, F H I R, which is the nationally recognized standard for what's called interoperability, for how we send data back and forth.
We are HIPAA ready out of the box, meaning that from our end, So HIPAA is an interesting thing. HIPAA is kind of a shared responsibility. So the app does its thing, you know, you as a developer still have to set things up and configure things correctly. The backend database has to be configured correctly and so on, but it's, so it's HIPAA ready.[00:13:00]
That's why I use that term. So you're getting all these things that we've abstracted away from what's typically required in an application to make it so that the researcher doesn't have to worry about all that. There are so many things you would have to otherwise worry about before you can even get to your research question.
Right. So now you kind of have an easy button. you still need a developer, right? You need someone who can code, but at least for that person, you know, they're not making all these mistakes. You know, we've made all the mistakes and now we've learned and we're kind of providing it for free. It's all open source, you know, on GitHub for anyone to take and piece together.
Rachel Baker: Super cool. Um, I want to kind of go back to that HIPAA piece because on the one hand, all of this sounds awesome. Like you're going to be, all of my health is going to be digitized and you're going to have all of this information about me from my wearables and my phone and all of this. And then at the same time, I'm thinking about meta [00:14:00] and are they going to be like targeting me?
Based on, you know, whatever data my phone collects or even worse, like, is my employer going to get a hold of this information or my insurance company and be like, well, Rachel, you didn't hit 5,000 steps a majority of days last year. So we're going to increase your premium or whatever.
Like I catastrophized a little bit.
Dr. Oliver Aalami: No, I definitely hear you. And there's always, you know, there's always that concern. That's why for every application as part of the onboarding, there's the consenting process, and there are all these permissions that you have to provide. So part of the onboarding for any application is two, three pages that are kind of templated and blank or the consenting process where you as the investigator need to be very transparent.
This is an application, let's say for QDG, one of the apps we built for Helen Bronte Stewart, who's a neurologist [00:15:00] here. She created this amazing finger tap test device. And she has it in her lab. She has it in her clinic connected to some MATLAB computer. She's like, I want people to do this at home. So we helped her build the end to end system.
And during her onboarding, you know, she's very clear with the patients. Like, listen, this application is meant to monitor your motor function. And this is what's happening to the data. It's going to go from the device to the phone, to our secure cloud. And we're going to use that to monitor your motor function and decide how to manage your medication from home.
Rachel Baker: It's like, that would be great for like a Parkinson's patient.
Dr. Oliver Aalami: Exactly. And so it's up to the researcher to explain and clarify. And you know, we're very clear, like any. Data element that you're sharing from your phone or device. It's all itemized. Like, do you agree to share your step count? Do you agree to share this?
And you have to, each one of those, you have to say yes or no, depending on what you're willing to share. And in order to [00:16:00] be HIPAA compliant, you're not allowed to share this with third party people or anything. So you have to be transparent as the researcher, but there needs to be trust. One thing I have to say that a lot of people worry about, they say, well, if my health data is on my phone.
Is Apple going to see it? You know, I don't want to give all my health data to Apple. Everybody says this. And I know that even a lot of police officers can't break into the phones. I mean, they're very hard to break into an even Apple themselves. You know, I can't guarantee it, but the statements they make and so on.
Is that they're not going into our phones, looking into our personal data. I think Apple is one of the few companies that definitely takes privacy security very seriously. And I think they've done a very good job in building secure encrypted systems.
Rachel Baker: That's making me feel much better. Well, we are at that time in our show where we ask our guests the same two questions, but I wanted to make sure that for all you health-conscious coders out there, Spezi is open [00:17:00] source and free for anyone to use.
It's available on GitHub. We'll put a link in the episode description so you can learn more. So, Dr. Aalami. The first question we ask everyone is, who is a surgeon you admire and why?
Dr. Oliver Aalami: There's one surgeon, I actually have the photo of this surgeon, you know, over my desk in between all my, you know, all my certificates.
His name is Claude Organ. And he is the surgeon that gave me wings, so to speak. I mean, surgery is a tough specialty. And you know, when people believe in you and it's authentic, it's a superpower. So for me, you know, that means a lot. Who's an, uh, a black surgeon grew up in the South during segregation, got into med school, but didn't get to go because of his skin color.
Uh, ended up going to Creighton and, you know, was able to finish there, did his internship, surgery. And back then, surgery [00:18:00] was what they called a pyramidal system where, you know, you hired more people than you would graduate.
Rachel Baker: Right.
Dr. Oliver Aalami: And then every year you like chop, you know, chop the, the number of people who could get advanced and get cut.
So that was brutal. You know, and you lived at the hospital, I mean, it was, you were,
Rachel Baker: That's why they call them residents.
Dr. Oliver Aalami: Yeah, residents. Exactly. It was a brutal time. And the fact that he, despite all that and his stature, you know, he ended up becoming the president of the American College of Surgeons and all this other, had all these other accolades, but the fact that he was very personable, was, uh, approachable and just believed in people.
And what I remember most is that he, he really emphasized just providing excellent care for everybody, no matter what, no matter when. You know, he's just obsessed about that. So he's someone I truly admire given, you know, what he's, where he came from, what he got through, what he accomplished, you know, is, and that he believed in me, of course, that was, that was a big one for me.
Rachel Baker: Sounds super inspiring. I'm [00:19:00] excited to look him up after we finish our conversation. Um, but we have our second question first, and that is the best advice you have received in 10 words or fewer.
Dr. Oliver Aalami: Yeah. I mean, I, this is going to come from kind of the innovation lens. You know, because I work with a lot of students, and we're always focused on translation, and people have a lot of ideas.
So, kind of the best advice would be, you know, ideas are a dime a dozen, but execution is hard. And, because I know there are a lot of people who come with an idea, and they're very protective of their idea. You know, they almost don't want to tell me what their idea is. They're like, I can't tell you cause you're going to run with it and you're going to go steal it.
And my response always is, well, good luck executing, you know, ideas are easy, you know, getting things done. And it's the perseverance that really matters. Pushing and pushing and failing and trying again, trying something and just, you're just believing in something. And that's really [00:20:00] powerful. And that's what moves the needle.
So I'll stop there.
Rachel Baker: Absolutely. No, I mean it reminds me so much of my conversation last month with Dr. Dunn who has been working so hard on this spring and 30 papers 40 papers He's just he's just been persevering through red tape from the FDA and just, wow. So I think that your advice is spot on.
Dr. Oliver Aalami: The idea was there early, but the execution is very hard.
So you just have to persevere.
Rachel Baker: Gotta stick with it. Well, it has been an absolute pleasure chatting with you. Uh, before I go, one last question. What is next for Dr. Aalami?
Dr. Oliver Aalami: Ooh, you know, we're starting the building class next quarter. So I'm on call this weekend and then starting the building class. And. Yeah, I'm just excited to push this Spezi as well, the open source framework and just a lots of collaborations and helping people kind of build their first MVP. I help that execution process to [00:21:00] try to make it easier, you know, when it comes to
Rachel Baker: help people have their digital baby
Dr. Oliver Aalami: there you go.
Rachel Baker: Well, thank you again. It's been a pleasure.
Dr. Oliver Aalami: Thank you.
Rachel Baker: And that brings us to the end of another episode. If you like Scrubcast, we hope you'll tell your friends and subscribe wherever you get your podcasts. Scrubcast is a production of Stanford University's Department of Surgery. Today's episode was produced by Rachel Baker. The music is by Midnight Rounds. And our chair is Dr. Mary Hawn.