United Network for Organ Sharing’s core mission is to unite and strengthen the donation and transplant community to save lives. A major component that drives this mission is testing products, tools and methods aimed at improving the transplant system.

UNOS Labs^SM , an experimental incubator created in 2018, fills a critical role in bridging resources and research expertise to make innovation happen and bring big ideas to life. It enables our researchers to develop solutions to continuously improve the national organ donation and transplant system and increase organ utilization.

“We’ve begun this endeavor of UNOS Labs to address some of the bigger questions in transplant and try to meet the community where they are, and try and capitalize on a lot of the innovations that are out in the medical space,” said program manager Casey Humphries.

UNOS Labs explores and validates concepts and technologies that may be deployed across the nation’s organ transplant system. It is a place to try out new ideas under the primary pillars of behavioral research, data science and technology through extensive testing and incremental development.

“The emphasis in Labs is that projects have an end goal,” Humphries said. “They’re not academic, they’re not something that we want to just publish on and then store under the pillow. The goal of Labs is to create something that can be used to benefit the system.”

Improving the transplant system through innovation

Among the new technologies UNOS researchers are leveraging is  natural language processing (NLP) to predict which deceased donor kidneys will experience placement difficulties and to forecast which will be accepted by transplant hospitals. Encouraged by the study findings, the UNOS team plans to conduct more research to better understand the potential to enhance existing predictive models.

Humphries said a unique process such as NLP is a great example of data science.

“We have data science, and that’s really looking at understanding data broadly and looking at innovative ways to approach big data,” she said. “We can derive insights from using data science techniques…something that we can’t do with typical statistics.”

UNOS researchers are also partnering with organ procurement organizations (OPOs) nationwide to better predict organ travel time. One of the biggest contributors to prolonged cold ischemic time is coordinating logistics for organ transport. Using data gathered from couriers and pilot OPOs, researchers are also studying the feasibility of real-time tracking of organs shipped via ground and air.

Other partnership projects involving UNOS researchers include developing a series of simulation models to study the impact of possible changes to the transplant ecosystem; measuring physicians’ attitudes and perceptions around predictive analytics; and developing a liver paired exchange pilot program.

Philanthropic support for research and analytics

The Mendez National Institute of Transplantation Foundation recently awarded UNOS a $100,000 grant toward better understanding of the role biopsies play in transplant outcomes. The research further aims to improve the tools that inform kidney offer acceptance decisions.

The F.M. Kirby Foundation has given UNOS $75,000 to help train clinicians in promoting organ donation and increase the number of organ transplants during the COVID-19 pandemic. And the Fresenius Medical Care Foundation awarded UNOS $106,000 to help improve transportation and logistics for organ donation.

“We are challenging ourselves to think more broadly about the technologies we could bring to the transplant system,” explained Humphries. “Grants make this research happen.”

One of the best parts of my job is being able to tell people that America has the highest-performing organ donation and transplant system in the world. We have more organ donors and more annual transplants and we save more lives through organ donation than any other country.

Organ transplantation works for people who have end-stage organ failure. In almost all cases, it works better for people with kidney, liver, and lung failure than any other treatment available. People come to the organ donation waiting list because they know an organ transplant is a gift of life. That means that as good as our system is, it needs to be even better to be able to serve the more than 100,000 people waiting for organs at any given time.

At UNOS, the non-profit network that leads and coordinates the nation’s system of transplant hospitals, organ procurement organizations, and thousands of volunteers from the donation and transplant community, we’re not content with the status quo. Our commitment to continuous improvement has driven seven consecutive years of increases in the number of transplants performed. We also know there’s no quick fix to further strengthen a mature system with decades of experience and an infrastructure that covers the entire nation. And because we have a full view of how every step of donation and transplant works, we know that what we need now is a comprehensive set of reforms.

Earlier this year, the Centers for Medicare and Medicaid Services proposed changing the metrics by which OPOS are assessed. The proposal is well-intentioned and addresses many issues identified by the donation and transplant community. But it relies on faulty data and has met strong opposition from major stakeholders in the professional community — including the American Society of Transplantation, Association of Organ Procurement Organizations, and a number of individual transplant programs and OPOs.

Instead, UNOS proposes a five-part package of reforms, influenced by many conversations with people in the field — from surgeons and hospital staff to OPOs and organ donor families to transplant recipients and those on the waitlist. Some of these steps are within UNOS’ authority as the Organ Procurement and Transplantation Network. Others must be led by federal agencies.

These reforms would build upon our success as one of the leading systems in the world and save even more lives than ever before.

First, we need to automate real-time donor referral. This is a step we could not have proposed just five years ago. But today, hospital electronic health records give us an opportunity to have comprehensive, timely data about all potential donors. We believe we can build on that momentum and take the responsibility for referring donor candidates off the already full plates of hospital staff, who in most cases have to enter referrals manually.

UNOS and others are working to standardize a referral system that can be used by all U.S. electronic medical records providers, because automating donor referral will not only allow OPOs to identify more donors whose organs can be more quickly matched with more patients. It will also enable us to establish better metrics for OPOs and transplant hospitals.

Holding OPOs and transplants hospitals accountable for their performance and helping them to improve and save more lives requires consistent, reliable and timely metrics.

To better measure OPO performance, CMS has proposed a new metric that relies on death certificate data collected by the Centers for Disease Control and Prevention. But the CDC itself has acknowledged death certificates are not consistently accurate. They also lack the level of clinical detail OPOs, surgeons and patients need to determine donor suitability. For example, a death certificate might not tell us if the potential donor died on a ventilator or whether they had a disease that could put the transplant patient at risk. When only about 1% of people die in a way that makes them medically eligible for organ donation, having detailed information is crucial.

Automated donor referrals, on the other hand, would provide an improved, independently-reported and timely data source for understanding donor potential. This hospital-reported, patient-level data could be used to calculate a clear metric that CMS could use to assess and improve OPOs.

We also need to improve the process of getting the right organ to the right patient at the right time.

Organs sometimes go unused because the unique medical circumstances of the donor limit the number of candidates who could benefit from the organ. We’re working on a number of innovative projects to increase OPOs’ ability to place as many organs as possible, such as:

• Incorporating digital medical imaging of the donor into organ offers.
• Giving transplant programs the ability to set more sophisticated screening criteria for offers they will accept.
• Assessing probability models that may guide transplant program decisions based on their patterns of organ usage.

Similarly, we need to remove disincentives to using older and more complex donors when appropriate. Not every transplant candidate needs organs with the same projected life span, and one key step toward increasing organ transplantation is to use organs from older donors, which can be a good choice for some transplant patients, especially those who are older themselves. Unfortunately, today those organs are often rejected by transplant hospitals because they are more complex to work with — and by patients, who may not understand the viability of older organs.

We believe eliminating evaluation and financial disincentives for using these organs will help boost the number of transplants and save more lives.

Finally, we need to enable OPOs to merge or share services to boost their ability to serve hospitals and patients. CMS’ proposed rule provides no detailed transition plan addressing infrastructure in the service area of a decertified OPO, which could lead to ongoing disruption in parts of the country. Replacement organizations would need to rebuild the relationships and public trust necessary to maximize local organ procurement and distribution. Regulations that expedite or incentivize voluntary mergers among OPOs could expand the reach of effective OPO leadership without creating the risk of gaps in the organ recovery network.

There are thousands of things that each OPO, each transplant hospital, each staffer, UNOS, and CMS can do to drive improvement, but we’re targeting the things that we think apply to the whole system and that no individual part can do on their own. Taken together, these reforms will increase the pool of donors and organs, lead to shorter wait times and better outcomes, and mean more people receive lifesaving transplants. I’m excited by the potential for change, because as proud as we at UNOS are of the success of the organ procurement and transplant system, we know it has to keep getting better.

“At CORE we are always looking for new and innovative ways to improve our key processes,” she said.

So when CORE’s involvement in a medical imaging study sharing project led by United Network for Organ Sharing prompted a transplant team to accept a heart that they otherwise had planned to decline, Medwick felt proud of the work she had accomplished. “We were able to save an additional life that would not have been saved otherwise,” she said.

CORE is one of 13 organ procurement organizations (OPOs) across the country enrolled in UNet Image Sharing, a consistent, reliable and secure image sharing platform that provides OPOs and transplant hospitals universal access to high-quality medical imaging studies during the organ offer process. “UNet Image Sharing helps us share real-time images directly with transplant surgeons to help facilitate quicker decision making,” Medwick said.

First national hub

Within a year of enrolling in the pilot in 2019, her OPO was notified of an offer for a deceased donor’s heart that included a medical report saying the organ was functioning poorly. “Based on the report that we had, no one would have been likely to accept the heart,” Medwick said, but by using UNet Image Sharing, she was able to include an electrocardiogram with the offer. The transplant team analyzed the images and determined they didn’t agree with the report, ultimately deciding the heart would be suitable for transplant. “The transplant hospital staff only accepted it because they were able to look at the images and get their own read,” Medwick said.

UNet Image Sharing was created to solve a problem: If a surgeon can’t clearly see the medical imaging study of an organ that is being offered, they might hesitate to accept some offers for fear that it might not meet their patient’s needs. While well-intentioned, this risk-avoidant behavior could result in unused organs that could otherwise help save patients’ lives.

“Having images uploaded directly into UNet allows easy access for all parties involved in reviewing the quality of the organ for transplantation,” said CORE chief information officer Bruno Mastroianni. The former chair of the Association of Organ Procurement Organizations IT Council heard about the pilot in 2018 at an AOPO conference. In conversation with UNOS chief technology officer Alex Tulchinsky and IT Customer Advocacy department director Amy Putnam, Mastroianni discovered that UNOS was planning to pilot a new technology in response to members’ longstanding requests for a consistent and secure high-quality imaging sharing system that is seamlessly woven into the DonorNet platform. “I have been fortunate to have built a wonderful relationship with Alex, Amy and the rest of the UNOS team, and have volunteered to support them to pilot solutions like this before,” Mastroianni said. “It is a great opportunity to provide input and even better to work with a great partner like UNOS.”

Imaging within UNet

Between January and April 2019, UNOS piloted UNet Image Sharing with six OPOs across the country that were already using imaging solutions outside of DonorNet. “We picked OPOs that already had imaging solutions so that if something went wrong in the pilot, they still had a fallback plan that they could work with,” said UNOS business architect Rob McTier.

Expanding beyond the pilot

In June UNOS began making UNet Image Sharing available in a phased national rollout, first to OPOs that expressed interest in it during the pilot period, followed by OPOs in similar geographic areas to those that expressed interest. “That way, transplant hospitals are seeing a consistent way of accessing imaging studies during the transition period,” McTier said. The phased rollout also allows time for training the hospital staff that the OPOs will be sharing imaging studies with. Because of its unique position and ability to integrate all aspects of the organ transplantation system, UNOS will manage the potential impact to support personnel as new users engage with the application. There is no additional cost to Organ Procurement and Transplantation Network members.

Nearly two years since launching UNet Image Sharing, there has been a net increase in image sharing in UNet for each participating OPO, and overall. On average, 41 percent of donors from participating OPOs had images shared before the pilot started, compared to 82 percent after UNet Image Sharing began. The most uploaded type of images to UNet Image Sharing have been CT scans, followed by ultrasounds.

“There are fewer steps in the process of uploading images directly to UNet, compared to what needed to be done with our previous application,” Medwick said, adding that CORE now rarely used the external image sharing solution that they had been relying on before UNet Image Sharing was available.

In organ donation and transplantation, every second counts, and efficiency in the system leads to more lives being saved.

“UNet Image Sharing provides a consistent way for all member organizations to access images,” McTier said. “With a consistent approach, we’re hoping to accelerate the process of getting members access to images and save more lives together.”