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As advancements in artificial intelligence (AI) continue to revolutionize health care, data suggest growing acceptance of the technology by medical organizations and patients. Health care providers are spending heavily on IT and adopting new computer-generated tools, and a recent Cleveland Clinic national survey found that 3 in 5 Americans believe that AI will lead to better heart care.
Individuals are still cautious about how they use AI when it comes to their health. The Cleveland Clinic survey showed that 72% of individuals believe the health advice they receive from a computer chatbot is accurate, but 89% said they would still seek doctor’s advice before acting on chatbot recommendations. The online survey was conducted among 1000 people aged 18 years or older. Respondents were nationally representative regarding age, gender, region, education, household income, race/ethnicity, and urban/rural residency.
Most Americans using health monitoring technology are experiencing significant physical and mental benefits. According to survey responses, 79% have noticed positive changes to their physical or mental health. The survey found that 60% of Americans track their daily step count and 53% monitor their heart rate/pulse. It also showed that 40% track their burned calories, 32% track their blood pressure, and 53% say they began exercising more regularly after using wearable technology to monitor their health.
The survey showed that due to monitoring technology, 50% are getting in more steps per day and 34% are improving their eating habits. Further, 27% are more intentional about finding time to de-stress and relax.
Health care providers are spending heavily on IT, suggesting that technology is becoming a leading strategic priority for health care practices. In a survey of 201 health care provider executives in the United States conducted in June 2023 by Bain & Company and KLAS Research, 56% of respondents cited software and technology as among their top 3 strategic priorities compared with 34% in 2022.
The survey showed that 75% of respondents expect growth in software and technology spending to continue over the next 12 months. Revenue cycle management and clinical workflow optimization remain top areas of investment, according to the survey. However, patient engagement has moved up the list of priorities, particularly among more advanced or digitally mature providers.
E. Scot Davis, of Little Rock, Arkansas, a member of the LUGPA (Large Urology Group Practice Association) Board of Directors with nearly 30 years of experience in physician practice management, said the demand for urologic services is increasing while the supply of urologists available to treat patients is suboptimal. “Practices must find innovative ways to meet the needs of our patients,” he said. “Physicians and advanced practice providers can only see so many patient encounters in a day, and burnout among urologists is one of the highest of all specialties.”
The use of AI combined with emerging telephone technologies may offer solutions to ease this challenge. “Perhaps the number 1 complaint heard among my colleagues is the vast number of phone calls that need to be answered on a daily basis,” Davis said. “Practices might consider utilizing interactive voice recognition (IVR) software in conjunction with live operators to be able to meet the patients' needs as well as reduce costs.”
Urology practices must evaluate each touchpoint, from initial patient contact to clinic visit and culminating with billing and follow-up, and consider how AI and technology can help improve the patient experience and reduce costs, according to Davis. Many electronic medical record systems have "bolt-on" products to improve pre-authorization processes. The systems also have automatic coding software, integrated patient responses directly into the patient chart, and methods to improve the collections process.
“Urology practices must embrace and implement AI and technology,” Davis said. “Obviously, any technology that improves the overall patient experience is good for the patient and the practice. Additionally, there will be a positive financial impact to the practices adopting AI and technology, if implemented correctly and timely.”
Emerging trends show technology is improving patient engagement through the use of IVR, triage software utilizing conversational chatbots, and self-scheduling tools for patient ease. From an administrative side, Davis said he foresees practices adopting more pre-authorization software technology combined with billing and coding applications to drop claims quicker with greater accuracy.
“This feature will feed well into an interactive dictation tool for providers to document more easily and efficiently, he said. “All of this technology and AI adoption will require an acceptance and change by the providers who must first believe the software will work, and secondly, will trust it can do it as well as they can do it. Without those, much time and effort and money will be spent without any useful benefits.”
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A recent federal cybersecurity advisory is urging health care providers to immediately adopt phishing-resistant multi-factor authentication (MFA) for all administrative access. Providers should put systems in place that verify implementation of new sign-in procedures, implement network segregation controls, and change and remove or deactivate all default credentials.
The advisory was issued by the Cybersecurity and Infrastructure Security Agency (CISA), which conducted a Risk and Vulnerability Assessment (RVA) last year to identify vulnerabilities and areas for improvement. An RVA is a 2-week penetration test of an entire organization, with 1 week spent on external testing and 1 week spent assessing the internal network. As part of the RVA, the CISA assessment team conducted web application, phishing, penetration, database, and wireless assessments. The team assessed a large organization deploying on-premises software.
During the 1-week external assessment, the team did not identify any significant or exploitable conditions in externally available systems. The assessment team was unable to gain initial access to the assessed organization through phishing. During internal penetration testing, however, the team exploited misconfigurations, weak passwords, and other issues through multiple attack paths to compromise the organization’s domain.
In coordination with the assessed organizations, CISA is releasing a new Cybersecurity Advisory (CSA) detailing the RVA team’s activities and key findings to provide network defenders and software manufacturers with recommendations to improve organizations’ and customers’ cyber posture.
“The threat is greater than ever,” said Tamer Baker, a specialist in cybersecurity and the Healthcare Chief Technology Officer at Zscaler, which has its headquarters in San Jose, California. More than 100 million people and 500 hospitals in the United States alone have been impacted by breaches just in 2023, he said.
IT security equals patient security, Baker said. The average financial impact of a health care breach is now $11 million, which far exceeds the spending required to get proper security, according to Baker. “The advisory is long overdue; however, it is still not enough,” he said. “What’s needed is going to be more along the lines of what the state of New York has been leading the charge with. They are not only going to be putting in more regulations and requirements with some enforcement, but are also providing funding to help health systems achieve these goals.”
Impact on Patient Care
Cyberattacks adversely impact patient care in a serious way, and have been associated with extended hospital stays and increased mortality. “According to a national study conducted by Ponemon Institute, these cyberattacks have led to 56% longer hospital lengths of stay and 53% increase in mortality rate,” said Baker, who assists health care organizations, state and local governments, and educational institutions in their digital transformation efforts. Cyberattacks in just the last 12 months have caused thousands of patients to be transferred or diverted to other facilities. The attacks were associated with delays in procedures and tests, increased complications and poor outcomes.
From a user credential perspective, MFA is a good first step, but not enough, according to Baker. Bad actors have found several ways to get through MFA using vectors like MFA-bombing as an example. This is a social engineering cyberattack strategy whereby attackers repeatedly push second-factor authentication requests to the target victim's email, phone, or registered devices. “We need to stop users from ever reaching phishing sites to begin with,” he said. “A big step will be to have security in place which blocks phishing attempts no matter if the user is on-network or off-network (working from anywhere).”
CISA encourages health care providers who are deploying on-premises software, as well as software manufacturers, to apply the recommendations in the mitigations section of the CSA in the new advisory. It is hoped that these recommendations can harden networks against malicious activity and reduce the likelihood of domain compromise.
Offline Security Systems
“A way to stop attacks directly on applications and infrastructure is to just remove them from the internet,” Baker said. “Hide these applications and infrastructure behind a security cloud so the bad actors can’t even find them on the internet. This same security cloud can connect your users to the applications securely.”
In addition to applying the newly listed mitigations, CISA recommends exercising, testing, and validating an organization’s security program against the threat behaviors mapped out in the advisory.
Frank Nydam, the CEO of Tausight, health care’s first AI-powered data security company, said health care providers remain a prime target of cybercriminals, and there is no sign of this trend abating. In the first 6-months of 2023 alone, he said, 325 covered entities reported data breaches to the US Department of Health and Human Services Office for Civil Rights (OCR). This represents an 86% increase from the same period in 2022. “Not only have cyberattacks become more frequent, but they have also become more costly, both from a financial perspective and a patient outcome perspective,” Nydam said.
Mostly Basic Cyber Hygiene
Many health care providers may think they need multiple layers of advanced tools, but Nydam said most of the time all about the fundamentals: “Basic cyber hygiene and understanding where your data are. That’s critical and often overlooked.” These strategies include regular patch updates for vulnerabilities, basic device encryption, monitoring business associates for their access to your data, and following strict access management practices like MFA. Common mistakes include failing to put a cyber response playbook in place,” Nydam said.
Other common oversights include not encrypting and patching machines, and not having proper data recovery systems in place. The most important items on a to-do list can be summarized simply. “Start cleaning up your house,” he said. This includes a data assessment to understand where your sensitive data lives, Nydam said. “House-cleaning steps like this can significantly reduce the attack surface, so that when a cyberattack does occur, it impacts far fewer patients.”
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Clinically significant prostate cancer is found in a “non-negligible” number of men who have screening PSA levels of 1.8 or higher but less than 3.0 ng/mL, according to recent study findings. It remains unclear, however, if a delay in the diagnosis of these cancers until PSA levels rise to 3.0 ng/mL would lower the likelihood of cure.
The findings are from the population-based Göteborg-2 screening study. Among 17,974 participants, 6006 men with a median age of 55.9 years were included in the current analysis. Of these, 82% had a PSA level less than 1.8 ng/mL, 11% had a PSA level of 1.8 or higher but less than 3 ng/mL (low-PSA group; median PSA 2.1 ng/mL), and 6.3% had a PSA level of 3 or higher but less than 10 ng/mL (high-PSA group; median PSA 3.9 ng/mL). Another 0.5% had a PSA level of 10 ng/mL or higher. Patients in the low-PSA group were recommended to undergo magnetic resonance imaging (MRI). Men with positive MRI findings had 4 targeted biopsies from each MRI-visible lesion.
Prostate cancer was found in 64 patients (41%) with positive MRI findings in the low-PSA group, the investigators reported in European Urology. Of these, 33 (21%) had Gleason 6 tumors (insignificant cancer) and 31 (20%) had Gleason 7 or higher tumors (significant cancer). In the high-PSA group, prostate cancer was detected in 61 patients (56%), including 26 (24%) with Gleason 6 tumors and 35 (32%) with Gleason 7 or higher tumors.
“These results are in-line with previous knowledge of prostate cancer incidence at low PSA levels” said study corresponding author Fredrik Möller, MD, of Skövde Hospital in Skövde, Sweden.
He added, “Our study indicates that MRI could be used as a selection tool to reduce prostate cancer overdiagnosis at lower PSA values, but would lead to a large increase in MRI [use]. We hope our future planned study comparing PSA cutoff of 3 ng/mL to a PSA cutoff of 1.8 ng/mL will show robust evidence regarding the benefits and harms of a lower PSA cutoff as an indication for MRI.”
Due to the limited sensitivity and specificity of PSA screening, it has been proposed that MRI be part of first-line screening for prostate cancer. However, the high costs, limited availability, and large inter-reader variability are significant barriers.
The main strength of the current study is its large, population-based design with a relatively high participation rate. “The results should therefore be generalizable to a screening situation,” Dr Möller said. “The main limitations are the relatively young age group and results that are based on a single screening round and lack follow-up so far.”
Despite the strengths of the study, an important question remains as to whether the lead time in diagnosing these cancers (PSA 1.8 or higher versus PSA 3-10 ng/mL) has a major impact on outcomes, said Aly-Khan Lalani, MD, an assistant professor in the department of oncology at McMaster University in Hamilton, Ontario, Canada, who was not involved with the study.
“The larger point is that population-based screening, with rational guidance of when to leverage adjunctive tests and thereby risk stratify patients, will help ensure the most patients who warrant treatment are caught early,” Dr Lalani said. “By balancing this concept and also limiting overdiagnosis or excessive invasive testing, we can seek to provide survival benefits for our patients.”
Michael Whalen, MD, an associate professor of urology and chief of urologic oncology at George Washington University in Washington DC, noted that the number of positive MRI findings in the low-PSA group (25%) was surprisingly quite similar to the rate of positivity in the high PSA (3-10 ng/mL) group (31%). “However, significant cancer detection rates in the low-PSA group were about half of that in the high PSA group,” Dr Whalen said.
He pointed out that 37,887 men were invited to participate in the study, but only 17,806 opted to do so and 6006 were included in the current analysis. “Compared to other screening trials, this number is actually very low. The European Randomized Study of Screening for Prostate Cancer (ERSPC) trial included about 182,000 men, and the Prostate, Lung, Colorectal, and Ovarian (PLCO) trial in the United States included about 76,000 men. “Thus, the generalizability of the findings may be limited,” Dr Whalen said.
The study had a high biopsy compliance rate, so disease detection rates should be accurate, Dr Whalen said. Also, there was pathologic consensus from 3 different experienced uropathologists. “Although racial demographics were unpublished, it is likely predominately a Caucasian population,” he said. “How the lower PSA threshold of 1.8 ng/mL applies to a population with a higher proportion of African American men is unclear. Also, the influence of family history on acceptable PSA threshold was not explored.”
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It is well known that chronic kidney disease (CKD) has an impact on many body systems. Perhaps underappreciated is the link between the kidney and the thyroid. Increasing understanding of the relationship between the kidney and thyroid offers a largely unexplored opportunity to improve management of patients with CKD, in whom thyroid problems are frequently under-recognized.
An estimated 20 million Americans have some type of thyroid disease. Disconcertingly, it is also estimated that 60% of those with a thyroid condition are unaware of it.1 With regard to CKD, subclinical hypothyroidism has been found to increase from 7% to 17% in people whose glomerular filtration rate (GFR) drops to 60 mL/min/1.73 m2 from 90 mL/min/1.73 m2 or higher.2 Recent research indicates that subclinical hypothyroidism can be considered an independent predictor of CKD in the general population, even when adjusting for other common risk factors such as age, hypertension, and obestiy.3
What is this relationship between the kidney and the thyroid? The effects of poor thyroid function on the kidney are widespread, including reduced renin-angiotensin-aldosterone system (RAAS) activity, reduced GFR, and decreased heart rate and cardiac output that leads to diminished renal blood flow and ischemic kidney injury.4 CKD is thought to negatively impact thyroid function through multiple pathways. One such pathway is reduced expression of 1 5’-deiodinase that leads to decreased conversion of T4 to T3. Indeed, the most common finding is not an elevated TSH, but low T3.2 However, TSH is the most common and typically only laboratory measure used to assess thyroid function, which can result in underdiagnosis of thyroid disease. This is significant because it is estimated that GFR is reversibly reduced by about 40% in more than half of adults with hypothyroidism.4
Providers can improve CKD care by:
- Regularly screening for thyroid issues by ordering a full thyroid panel. Because TSH is not a reliable marker of thyroid issues in patients with CKD, a full thyroid panel including TSH, free T3, Free T4 and TPO antibodies would be more informative. It is important to recheck thyroid function as GFR changes as well.2
- Considering patient symptoms. Subclinical hypothyroidism is common in those with CKD, which may mean laboratory values look normal but patients present with common hypothyroidism symptoms like cold intolerance, fatigue, brain fog, hair loss, joint and muscle pain, increased cholesterol and triglycerides, unintentional weight gain or difficulty sleeping.5 These symptoms can be common in CKD due to anemia or other common coexisting conditions, so testing is important to properly identify the root cause.
- Ensuring adequate micronutrients and amino acids. T4 to T3 conversion and thyroid function require several micronutrients, such as zinc, iodine, selenium, choline, iron, folate, and essential amino acids. This is an important consideration if the patient is on a T4-only thyroid medication or on a low-protein or plant-based diet.6 A dietitian can play an important role in assessing nutrient need, guiding diet changes and recommending appropriate supplements.
- Managing stress. Cortisol can inhibit conversion of T4 to T3 and actually increase conversion of T4 to reverse T3.7 While stress management support is not a typical responsibility of nephrology providers, providing tools or referrals to support patients is appropriate. Measures that can reduce stress include meditation, counseling, and vagus nerve stimulation.8
Thyroid disease is under-recognized in many individuals. Because thyroid disease can affect kidney health (and vice versa), nephrology providers are uniquely poised to investigate and identify thyroid issues. As with many connected issues in CKD, nephrology providers need not shoulder the responsibility of treating thyroid disease, but refer out to dietitians, endocrinologists, and other appropriate providers to ensure the patient is getting the best care possible. It is not fully understood how much of an impact supporting thyroid health can have for those with CKD, but with a few simple proactive steps providers can begin to see possibilities.
Lindsey Zirker MS, RD, is a renal dietitian and Director of Clinical Services for the Kidney Nutrition Institute in Titusville, Florida. She specializes in autoimmune kidney disease and advanced practice medical nutrition therapy for people with kidney disease.
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