>> HELLO, EVERYONE.
GOOD AFTERNOON.
I'M JILL WITH THE DEPARTMENT OF
PEDIATRICS, I WANT TO WELCOME
YOU TO TODAY'S CLINICAL CENTER
GRAND ROUNDS THE CME ACTIVITY
CODE FOR TODAY'S GRAND ROUGH
ATOM ROUND SYSTEM 57879.
PLEASE TEXT THIS TO THE NUMBER
ON THE LECTURE, BY THE QR CODE
SHOWNOT CME SLIDE, FOR THOSE
APPLYING YOU WILL RECEIVE THE
SURVEY FOR FEEDBACK ABOUT THIS
PRESENTATION AALLOWS TO YOU
SUBMIT ANY SUGGESTIONS FOR GRAND
ROUNDS TOPICS, FOLLOWS THE
PRESENTATIONS, QUESTIONS WILL BE
TAKEN BY SPEAKERS FROM THE
AISLES.
ADDITIONALLY VIDEOCAST VIEWERS
CAN SUBMIT QUESTIONS ANY TIME
DURING THE LECTURE BY SCROLLING
DOWN AND SUBMITTING DURING THE
LIVE WEBCAST.
AS TIME PERMITS WE WILL TAKE
QUESTIONS AT THE CONCLUSION OF
THE PRESENTATION.
THE CLINICAL CENTER GRAND ROUNDS
PROGRAM WAS CONCEIVED BY
DR. PAUL PLOTTS, OF NIAMS, WHO
RECENTLY PASSED AWAY, THE
PURPOSE IS TO BRING THOUGHT
LEADERS, SCIENTISTS AND LEADERS
TO SHARE IDEAS ON WHICH THEY ARE
PASSIONATE ABOUT AND INSPIRE
OTHER INVESTIGATORS IN THE
PURSUIT OF CAREERS AND
BIOMEDICAL RESEARCH.
TODAY WE ARE EXCITED HOST
PEDIATRIC GRAND ROUNDS AND
HONORED TO HAVE AS OUR SPEAKER
DR. LOUIS BELL, HE SERVED AS
PEDIATRICIAN FOR THE GENERAL
PEDIATRIC IN-PATIENT SERVICE.
FOR MANY YEARS HE SERVED AS THE
PASSPORT'S IN-PATIENT INFECTIOUS
DISEASE SERVICE AND THE
EMERGENCY DEPARTMENT C BELL HAS
SUBSPECIALTY BOARD
CERTIFICATIONS, AND CLINICAL
FOCUS IS PEDIATRIC HOSPITAL
MEDICINE AND INFECTIOUS DISEASES
DR. BELL EARNED HIS BACHELOR'S
DEGREE.
IN 1986, HE JOINED THE FACULTY
OF THE UNIVERSITY OF
PENNSYLVANIA SCHOOL OF MEDICINE.
OVER THE COURSE OF HIS CAREER AS
A PHYSICIAN AND EDUCATOR, HE
RECEIVED NUMEROUS TEACHING
AWARDS INCLUDING CHOPS TEACHER
OF THE YEAR AWARD ON 2
OCCASIONS, THE UNIVERSITY SCHOOL
OF PENNSYLVANIA DEAN'S AWARD FOR
EXCELLENCE IN CLINICAL TEACHING
AND THE 2009 LYNN BACK AWARD FOR
DISTINGUISHED TEACHING,
UNIVERSITY OF PENNSYLVANIA'S
MOST PREOF THE EEMGIOUS TEACHING
AWARD.
DR. BELL PUBLISHED MORE THAN 90
PEER REVIEWED RESEARCH
PUBLICATIONS AND OVER 90
CHAPTERS REVIEWS AND BOOKS WITH
A FOCUS ON UNDERSTANDING THE
EPIDEMIOLOGY AND IMPROVING THE
TREATMENT AND MANAGEMENT OF
PEDIATRIC INFECTIOUS DISEASES
AND GENERAL PEDIATRIC HOSPITAL
CARE.
DR. BELL IS THE FOUNDER AND LONG
TIME DIRECTOR OF THE PEDIATRIC
RESEARCH CONSORTIUM AT CHOP, A
PRACTICE BASED RESEARCH NETWORK
THAT SEEKS TO IMPROVE
AMBLATTATORY CARE OF CHILDREN
THROUGH CLINICAL RESEARCH.
A NETWORK TODAY THAT INCLUDES 31
PRIMARY CARE PRACTICES WITH MORE
THAN 200 PROVIDERS IN THE
GREATER PHILADELPHIA AREA.
IN ADDITION TO ALL THESE
INCREDIBLE ACCOMPLISHMENTS, ON A
MORE PERSONAL NOTE, I HAVE KNOWN
DR. BELL FOR 30 YEARS, OVER 30
YEARS.
MY FIRST ROTATION AT CHOP AS AN
INTERN IN JULY 1992 WAS IN THE
EMERGENCY DEPARTMENT AND
DR. BELL WAS 1 OF THE FIRST
ATTENDINGS I WORKED WITH AS A
PEDIATRIC INTERN.
I WAS LUCKY ENOUGH TO HAVE HIM
AS MY MENTOR, HE WAS KIND,
PATIENT AND CALM AND PROVIDED
THE TRAINING FOR MY TRAINING AND
DEVELOPMENT THIS PEDIATRICS.
I AM THRILLED DR. BELL COULD
YOIN US TODAY.
THE TITLE OF TODAY'S
PRESENTATION IS LESSONS LEARNED
IN THE PATH TOWARDS OUTCOMES IN
CHILDREN.
PLEASE WELCOME ME IN JOINING
TODAY'S GRAND ROUNDS SPEAKER
DR. LOUIS BELL EMPLOY
[ APPLAUSE ]
>> THANK YOU VERY MUCH FOR THAT
KIND INTRODUCTION.
WE HAD A REALLY NICE DINNER LAST
NIGHT AND I WAS REMINDED BECAUSE
I HAVE SENT PATIENTS OVER MY
CAREER TO THE NIH WITH
PARTICULARLY RARE AND COMPLEXES
DISEASES AND I WAS JUST REMINDED
ABOUT THE UNIQUE CARE MODEL AND
CARE YOU PROVIDED ASK WAS
EXCITED TO LEARN ABOUT THE
ADDITION OF THE HOSPITAL
MEDICINE GROUP TO THAT
PARTNERSHIP IN COLLABORATION.
I HAVE NOTHING TO DECLARE.
SO A BIT ABOUT MY JOURNEY BEFORE
WE DELVE INTO THE MEAT OF THE
TALK TODAY, I STARTED AT CHOP IN
83, AS A FELLOW, I REALLY WAS IN
THE LAB DOING VIROLOGY AND I
REALLY ENJOYED TAKING CARE OF
PATIENTS.
I MISS THAT AND SO I STARTED
MOONLIGHTING IN THE EMERGENCY
DEPARTMENT AND THAT LED TO A
CAREER IN BOTH I.D. AND E. D.
AND THE FIRST PART OF MY CAREER
AND THEN I HAD A LOT TO DO AND I
WAS GETTING OLDER AND HAVING A
HARDER TIME RECOVERING FROM MY
SHIFTS IN THE EMERGENCY
DEPARTMENT AND I STOPPED DOING
THAT FOCUSED ON INFECTIOUS
DISEASE AND HOSPITAL MEDICINE,
TEACHING, MENTORING AND
SPONSORSHIP AT CHOP HAS BEEN A
JOY AND A PRIVILEGE.
THERE'S AMAZING TALENT THERE.
AND THEN MY RESEARCH HAS BEEN
REALLY EPIDEMIOLOGY TO A FOCUS
ON HEALTH SERVICES RESEARCH TO
QUALITY IMPROVEMENT AND NOW, AS
YOU'LL SEE, TRYING TO LEARN A
LITTLE BIT MORE ABOUT
IMPLEMENTATION SCIENCE.
I WAS THE DIRECTOR OF THE
INFECTION, PREVENTION AND
CONTROL GROUP, THE DIVISION OF
GEN PEDs FOR 21 YEARS AND
ASSOCIATE CHAIR FOR CLINICAL
ACTIVITIES AT CHOP FOR 15 YEARS.
PERSONALLY I HAVE A BLENDED
FAMILY OF 7 KIDS, 10 GRANDKIDS
AND YOU CAN SEE THAT FRONT 1 IN
THE BLUE CODE THERE, SHE'S GOT A
LOT OF WONDERFUL ATTITUDE WHICH
IS A LITTLE BIT OF AN INDICATION
OF HER PERSONALITY.
SO LET'S THINK ABOUT THIS
TOGETHER.
AT THE CONCLUSION OF OUR TIME
TODAY, I HOPE YOU WILL BE ABLE
TO UNDERSTAND THAT THE U.S.
HEALTHCARE AT LARGE IS THE
COSTLIEST IN THE WORLD.
AND LET'S THINK ABOUT TOGETHER,
WHETHER WE'RE GETTING A RETURN
ON THAT INVESTMENT AND THEN
THINKING ABOUT THAT IS THE
BURNING PLATFORM FOR CHANGE AND
IMPROVEMENT.
I WOULD LIKE TO SUGGIEST SOME OF
THE CORE SERVICES AND CORE
COMPETENCIES THAT I'VE BEEN
INVOLVED WITH DEVELOPING OVER MY
CAREER THAT I'M -- I'M HOPING
CAN BE SUSTAINED AND WILL
IMPROVE HEALTHCARE OUTCOMES FOR
KIDS AND WILL MENTION THOSE
SERVICES AND CORE COMPETENCIES
AND THEN WE WILL LOOK AT IT IN A
CASE EXAMPLE, AND THIS WILL TAKE
ABOUT 50 MINUTES I THINK TO DO.
SO WHAT'S THE STATUS OF THE U.S.
HEALTHCARE.
HOW ARE WE DOING?
WELL, WE SPEND A LOT ON
HEALTHCARE IN THIS COUNTRY,
ABOUT 4 HADN'T $5 TRILLION SPENT
ANNUALLY, THAT'S 17, MORE THAN
17% OF OUR GROSS DOMESTIC
PRODUCT.
THE 13, OVER 13,000 PER AMERICAN
PER YEAR IS A 2024 NUMBER.
AND THEN ABOUT $1.4 TRILLION ON
HOSPITAL CARE.
THAT'S A LOT.
AND WHEN WE COMPARE OURSELVES TO
OTHER RESOURCE RICH COUNTRIES,
LIKE AUSTRALIA, BELGIUM, CANADA,
JAPAN, SWITZERLAND.
YOU CAN SEE THERE'S QUITE A GAP
BETWEEN WHAT WE SPEND AND WHAT
THOSE COUNTRIES SPEND.
THIS IS THE PERCENTAGE OF GROSS
DOMESTIC PRODUCT.
HERE IS A GRAPH THAT'S A LITTLE
BIT OLDER, 2019.
AGAIN, I MENTIONED THAT NOW
CURRENTLY IN 2024, THE PER
CAPITA SPENDING IS OVER $13,000,
BUT THESE PROPORTIONS ARE STILL
-- STILL HOLD IN 2024.
YOU CAN JUST SEE THESE ARE
COMPARING US TO RESOURCE RICH
COUNTRIES AND HOW MUCH WE SPEND.
NOW IF WE SPENT THIS MUCH AND WE
HAD AN AMAZING RETURN ON OUR
INVESTMENT, WE WOULD AS A
SOCIETY THINK, OKAY, WE'VE
INVESTED APPROPRIATELY AND WE'RE
HAPPY WITH THAT RESULT.
BUT IF WE LOOK AND THIS -- WE
COULD GO ON IN TERMS OF THE DATA
AROUND THIS BUT IF WE LOOK AT
SOME OF THESE BIG POPULATION
HEALTH METRICS, WE CAN START TO
SEE THAT WE ARE SPENDING A GREAT
DEAL BUT HOW ARE WE DOING IN
TERMS OF THESE INFANT MORTALITY
RATES FOR EXAMPLE, BY COUNTRY.
AND YOU CAN SEE THAT OURS IS IN
2022 WAS 5.6 PER THOUSAND LIVE
BIRTHS AND THAT'S ABOUT A 3%
INCREASE IN INFANT MORTALITY
FROM 2024 TO 2022.
AND SO WE RANK 54th IN THE 227
COUNTRIES AND TERRITORIES IN THE
WORLD.
YOU CAN ALSO FIND THE INFANT
MORTALITY RATES BY STATE.
THIS IS THE COMMONWEALTH FUND
WHICH HAS A LOT OF THIS TYPE OF
DATA.
I HAVE A DAUGHTER WHO LIVES IN
BIRMINGHAM ALABAMA.
SHE'S HAD 2 KIDS.
JUST HAD A BABY WHO'S 5 MONTHS
OLD NOW AND YOU CAN SEE WHAT
THAT INFANT MORTALITY RATE IS IN
THAT STATE, 8.5 PER THOUSAND
BIRTHS, HERE'S PENNSYLVANIA AND
HERE'S THE NATIONAL AVERAGE SO
IT VARIES OVER STATE BY STATE.
WHAT ABOUT LIFE EXPECTANCY AT
BIRTH?
AGAIN, OUR LIFE EXPECTANCY IS
ABOUT 81 YEARS WHICH RANKS
49th.
IN ADDITION, AND SOMEWHAT
INEXPLICABLY TO ME BUT I THINK
WE COULD PROBABLY TOGETHER COME
UP WITH IDEAS ABOUT WHY THIS IS
HAPPENING, MATERNAL MORTALITY IS
GOING UP AND IT'S UP 200% SINCE
1993.
NOW THIS IS A GRAPH FROM 2016
THAT CURRENTLY IN 2024, WE'RE A
A
LITTLE BIT BETTER.
THE MATERNAL MORTALITY IS 22,
AND THAT RANKS 25 OUT OF THE
COUNTRIES AND TERRITORIES.
NOW IT'S IMPORTANT TO NOTE, AND
WE WILL TALK ABOUT DISPARITIES
AND CARE, THAT BLACK MOTHER
MORTALITY IS ABOUT 2 AND HALF
TIMES THAT OF WHITE WOMEN.
SO LET'S THINK ABOUT INIQUITIES
IN HEALTHCARE.
AND THAT'S ANOTHER LITTLE BIT OF
A PROBLEM THAT WE HAVE IN U.S.
HEALTHCARE AND WE HAVE
DISPARITIES PARTICULARLY BY
EDUCATION AND INCOME AND BY
RACE.
THIS WAS A NEW YORK TIMES SUNDAY
MAGAZINE ARTICLE THAT
PARTICULARLY CAUGHT MY ATTENTION
IN TERMS OF INFANT MORTALITY BY
RACE AND YOU CAN SEE, THAT IT'S
AT LEAST IN THIS WAS 2.3 TIMES
HIGHER FOR BLACK BABIES THAN
WHITE BABIES AND THEN BLOW BIRTH
RATES, THIS IS A 20-22 YEAR
AVERAGE.
BLACKS ARE BORN MORE FREQUENTLY
LOW BIRTH WEIGHT RATE THAN WHITE
INFANTS BY ALMOST, WELL, BY
GREATER THAN A HUNDRED PERCENT,
LIKE 14-TO 7%.
IT'S A PROBLEM, IT'S A PROBLEM
WE FEED TO ADDRESS.
IT'S A PROBLEM THAT AFFECTS
TRUST.
I REFERENCE THIS ARTICLE WHICH I
THINK IS A GOOD THOUGHT
PROVOKING PEACE BY HOWY
BACHENER, THE EDITOR OF JAMA,
AND HE TALKS ABOUT COST OF CARE
LEADING TO DISPARITIES AND
RATIONAL AND THE DECLINE IN
TRUST.
I DIDN'T THINK ABOUT THE
RATIONING OF HEALTHCARE, AT
LEAST THAT'S NOT MY EXPERIENCE
AT CHOP AT THE BEDSIDE.
BUT WE DO ACCESS IT IN THE
COUNTRY BY ACCESS TO CARE BY
COST AND AGAIN INCOME
DISPARITIES, WE HAVE BIGGER GAPS
IN OUR INCOME DISPARITIES THAN
OTHER RESOURCE RICH COUNTRIES.
BY RESTRICTION, SO WE WON'T
OFFER CERTAIN SERVICES, IMAGING,
THERAPIES AND CERTAIN PARTS OF
THE COUNTRY AND LONG WAITS AND
THAT LEADS TO A DECLINE THIS
TRUST.
SO ARE WE GETTING RETURN ON OUR
INVESTMENT AND I WOULD SAY NO, I
THINK THE VALUE THAT WE GET AS
U.S. CITIZEN BY THE AMOUNT WE
SPEND IS NOT REALIZED.
[INDISCERNIBLE] EMANUEL WROTE
ANOTHER SORT OF INTERESTING
COMMENTARY IN JAMA IN 2018 AND
HE IS IN THIS ARTICLE, TALKS
ABOUT, WELL WHAT ARE THE DRIVERS
OF THAT, THAT GAP IN HOW MUCH WE
SPENT PER CAPITA AND HOW MUCH
OUR RESOURCE RICH COUNTRIES THAT
WE'RE COMPARED TO AND HE SAID
DRUG PRICES IS 1 AND IN THIS
ARTICLE, HE SAID IT'S OVER $1400
PER CAPITA EXTRA TO OUR U.S.
CITIZEN.
AND THIS IS NOT, THIS IS NOT
VOLUME, IT'S NOT INCREASED
VOLUME OF THE PRESCRIPTIONS IN
OUR COUNTRY, IT'S REALLY JUST
PRICE.
WE ALSO AS A GROUP HAVE HIGH
MARGIN, HIGH VOLUME PROCEDURES
IN IMAGING AND IT'S BOTH
PRICING, HOW MUCH WE CHARGE OUR
PATIENTS FOR THOSE BUT IT'S ALSO
VOLUME, WE ORDER MORE MRIs AND
CT SCANS ON OUR PATIENT
POPULATION THAN WHEN WE COMPARE
THEM TO OTHER RICH COUNTRIES AND
IN HIS ANALYSIS, HE SAW A
SEIVET% OF THE PER CAPPAIT
DIFFERENCE IN THE GAP BETWEEN
THOSE COUNTRIES THAT WE'VE BEEN
COMPARED TO.
SO THAT'S THE BURNING PLATFORM
ABOUT HOW TO IMPROVE AND SO I
WANT TO TALK A LITTLE BIT NOW
ABOUT, WE WILL TALK ABOUT CORE
SERVICES AND CORE COMPETENCIES.
TWO CORE SERVICES AND 3 CORE
COMPETENCIES TO TRY TO IMPROVE
AND WE'RE TALKING ABOUT
HEALTHCARE DELIVERY IMPROVEMENT
IN THIS SETTINGS, IN THIS TODAY.
WE WILL NOT TALK ABOUT HEALTH
IMPROVEMENT AND THE WONDERFUL
WORK IN TERMS OF HOW DO WE --
HOW DO WE CREATE A HEALTHY
NEIGHBORHOODS AND WHAT'S
STUDYING THE IMPACT OF HEALTHY
NEIGHBORHOODS, GREEN SPACE, FOOD
SECURITY, HOW DO WE FOSTER THOSE
THINGS TO HELP OUR PATIENTS AND
FAMILY BE HEALTHIER.
IN THE CLINIC NOW, IN OUR CLINIC
SETTING, IN THE URBAN CLINICS,
WE HAVE HIRED LAWYERS TO HELP
THE FAMILIES WITH THEIR LEGAL
PROBLEMS AND HOUSING MAINLY.
WE HAVE A FOOD PANTRY WHERE WE
CAN GIVE THE FAMILIES A
PRESCRIPTION FOR FOOD FOR 3 DAYS
UNTIL WE CAN SORT OF GET THEM ON
-- GET THEM OTHER SUPPORT.
WE HAVE TAX PREPARATION TO HELP
THE FAMILIES GET EARNED INCOME
TAX CREDITS WHICH ARE OFTEN LEFT
ON THE -- JUST NOT -- THEY DON'T
EVEN APPLY FOR THEM.
AND ALL THESE THINGS I THINK, WE
HAVE BEEN STUDYING THEM AND
HOPEFULLY THEY WILL HAVE AN
IMPACT.
WE ARE NOT GOING TO TALK ABOUT
THOSE THINGS TODAY.
WE'RE GOING TO TALK ABOUT THESE
CORE SERVICES, PRACTICE BASED
RESEARCH NETWORK ANDS CLINICAL
DECISION SUPPORT JUST BRIEFLY
AND WE'RE TAKING, FOR ALL OF
THESE THINGS WE'RE GOING TO TALK
ABOUT, WE'RE JUST TAKING A DIP
OF OUR TOE IN THIS PUDDLE TO
TALK ABOUT THEM IN THE INTEREST
OF TIME, BUT THESE ARE THINGS
THAT I'VE BEEN INTERESTED OVER
THE LAST 25 YEARS OR SO, SO THIS
IS [INDISCERNIBLE] WASSERMAN WHO
IS LEADER OF THE PEDIATRIC AND
OFFICE RESEARCH SETTINGS, PROS
NETWORK AT THE AAPP SPONSORS AND
HE JUST TALKS ABOUT THE
COLLABORATION, PARTNERSHIP OF
PRACTITIONERS AND RESEARCHERS
WHO OVERTIME CONDUCT STUDIES TO
IMPROVE OVERTIME WITH THE
ULTIMATE GOAL OF IMPROVING
PATIENT HELP AND THE AHRQ HAS
BEEN A NIETION CONVENER OF THESE
PRACTICE BASED RESEARCH NETWORKS
OF WHICH THERE ARE -- THERE'S A
CHILD ABOWS RESEARCH NETWORK,
THERE'S BEHAVIORIAL HEALTH
RESEARCH NETWORKS, OF COURSE,
THE ONCOLOGY GROUP HAS, YOU KNOW
HISTORICALLY DONE THIS VERY WELL
AS WELL BUT THIS -- THIS
INVOLVES A LOT OF PATIENTS AND
WE WERE LUCKY ENOUGH TO HAVE OUR
OWN PEDIATRIC RESEARCH
CONSORTIUM, IT WAS ESTABLISHED
IN 2002 WITH A GRANT FROM THE
AGENCY FOR AHRQ, AND THEN IF WE
FLASH FORWARD TO TODAY, WE
SUPPORTED OVER 300 CLINICAL
STUDIES, 300 PEER REVIEW
PUBLICATIONS AND IT REALLY
SUPPORTS RESEARCH FROM ALL OF
THE SUBSPECIALTIES AND DREXEL,
JEFFERSON, SO SOME OF THE
OUTSIDE INSTITUTION CANS TAKE
ADVANTAGE OF THIS LABORATORY IF
YOU WILL.
THIS IS THE CHOP CARE NETWORK,
THE STARS THERE ARE THE PRIMARY
CARE PRACTICES OF WHICH THERE
ARE 31 AND YOU CAN SEE THE
VISITS, THE PATIENT COHORT THAT
WE HAVE, IN THIS IN THE PRIMARY
CARE NETWORK, PEDIATRICIANS AND
NURSE PRACTITIONERS AND WE
USUALLY HAVE BETWEEN 25 AND 40
STUDIES GOING ON PER YEAR,
CURRENT WE WE HAVE 40 AND
CURRENTLY THE PRACTICES
PARTICIPATE, SOME OF THE
PRACTICES HAVE 5, SOME OF THEM
HAVE 1 BUT ALL OF THEM ARE
PARTICIPATING.
THE STRENGTHS -- WE WERE REALLY
LUCKY WHEN WE STARTED IN 02
BECAUSE WE HAD A VERY -- AND
YOU'RE THINKING ABOUT HOW YOU'RE
DOING A STUDY, HOW YOU'RE
ENROLLING PATIENTS AND YOU WANT
A DIVERSE GROUP OF PATIENTS, SO
WE HAVE URBAN, WE HAVE SUBURBAN
POPULATIONS, WE HAVE SOME MORE
RURAL PRACTICES AND THE CULTURE
OF THE PRACTICES ARE ALL
DIFFERENT, SO WE DIDN'T BUILD
THESE CHOP DIDN'T BUILD THESE
PRACTICES, WE ALL HAVE SLIGHTLY
ORGANIZATIONAL DYNAMICS AND THEY
FLOW THEIR PATIENTS THROUGH,
THEY COMMUNICATE WITH THEIR
PATIENTS SLIGHTLY DIFFERENTLY
WHICH WE THINK IS A STRENGTH AS
WE LOOK AT HOW DO THESE
PROTOCOL, HOW CAN WE DO THOSE
PROTOCOLS AND STUDIES IN THE
REAL WORLD, WE WERE ALSO
INCREDIBLY LUCKY BECAUSE WE HAD
A SINGLE INSTITUTIONAL REVIEW
BOARD.
OTHER PRACTICE BASED RESEARCH
NETWORKS PARTICULARLY PRIMARY
CARE WOULD HAVE TO HAVE
DIFFERENT IRBs DEPENDING ON
WHERE THOSE PRIMARY CARE
PRACTICES WERE FACILITATED SO WE
WERE REALLY LUCKY IN THAT WAY
AND THEN WE HAD 1 ELECTRONIC
HEALTH RECORD.
AND I WAS VERY INTENTIONAL IN
HIRING AND SUPPORTING OUR
FACULTY IN THE DIVISION OF
GENERAL PEDIATRICS TO GET
BOARDED CLINICAL INFORMATICS AND
IT STARTED WITH, AND I DON'T
KNOW IF YOU GUYS WORKED WITH BOB
[INDISCERNIBLE], I'M NOT SURE.
HE WAS LITERALLY A PROPULSION
SCIENTIST AT M. I.T. WHO DECIDED
HE WANTED TO BE A PEDIATRICIAN.
AND HE CAME TO CHOP AND HE COULD
PROGRAM EPIC IN THE EARLY DAYS.
SOMEHOW HE GOT ACCESS TO, AND HE
WAS ABLE TO DO SOME AMAZING
THINGS FOR US WHICH I WILL JUST
MENTION AS WE GO THROUGH THIS
TALK.
SO BOB WAS VERY IMPORTANT TO BE
ABLE TO MINE THIS DATA.
THE GUIDING PRINCIPLES AND THE
LESSONS OTHER THAN LEARNED IN
SUSTAINING OUR PRACTICE BASED
RESEARCH NETWORK, WE HAVE TO
PROTECT AND RESPECT THE
LABORATORY.
THE LABORATORY ARE THE CLINICAL
PRACTICES, AND WE DON'T CAN THEM
TO DO ANYTHING, AT FIRST WE DID
STUDIES WHERE WE ASKED THEM TO
DO CERTAIN THINGS FOR US AND IT
JUST FAILED.
SO WE BRING EVERYTHING INTO THE
PRACTICES AND THAT WORKS.
MAKE IT EASY FOR THE
RESEARCHERS, TOO, WE HAVE A
FAMILY COUNCIL WHICH I'LL
MENTION AND THEN JUST MAKING
SURE THAT OUR GROUP,
[INDISCERNIBLE] WHICH IS A SMALL
GROUP BUT WE JUST MANAGE THE
COMMUNICATION, THE EXPECTATIONS
AND THE HONESTY BETWEEN THESE
PARTNERS, THE PRIMARY CARE
PRACTICES AND THE RESEARCHERS.
IN IS THE [INDISCERNIBLE]
APPLICATION THAT WE NEED IN
ORDER FOR THEM TO HAVE A
[INDISCERNIBLE] STUDY, THEY
WON'T GET APPROVAL UNTIL THEY
APPROVE THE STUDY IF IT INVOLVES
THE PRIMARY CARE PRACTICES.
HERE'S OUR WEBSITE AND YOU CAN
SEE HERE WE HAVE INFORMATION FOR
GRANT PROPOSALS, SO WE HAVE
BOILER PLATE LANGUAGE THAT THE
RESEARCHERS ARE GOING TO PUT IN
THEIR GRANTS.
AND WE'LL HELP THEM ALSO
POPULATE THEIR GRANTS WITH THE
PATIENT DEMOGRAPHICS AND PROFILE
THAT THEY MIGHT NEED TO MAKE THE
CASE IF YOU WILL THAT WE HAVE
THE PATIENTS THAT THEY WANT TO
STUDY.
SO BOB WAS ABLE TO CREATE A POP
UP THAT WOULD MAGICALLY APPEAR
IN AS THE PHYSICIAN IS SITTING
WITH THE PATIENT.
IF THAT CHILD WAS ELIGIBLE FOR
THAT STUDY, THIS IS THE
PARENTING WITH DEPRESSION STUDY
THAT WAS ONGOING.
JIM [INDISCERNIBLE] RAN THIS, 1
OF OUR HEALTH SERVICES
RESEARCHERS, IT GIVES SOME -- A
BRIEF SYNOPSIS OF THE STUDY TO
REMIND THE PROVIDER AS HE'S
SITTING IN FRONT OF THE PATIENT
AND THEN HE ASKS, WOULD YOU LIKE
TO TALK TO SOMEONE FROM THE
STUDY TEAM?
SO IF THE PATIENT SAYS YES, TO
CLICK THE PROVIDER FOR CONTACT
AND IT WILL BE SENT TO THE WERE
TEAM AND THEN THEY CAN --
RESEARCH TEAM AND THEN THEY CAN
REQUEST THE ELIGIBLE FAMILIES
AND CHILDREN WHO SAID THEY WERE
INTERESTED AND THEY CAN BE GIVEN
REPORTS, AND WE CAN SEND THEM
WEEKLY, DAILY, WHATEVER THE
STUDY TEAM WOULD LIKE.
SO THAT'S BEEN A REAL BOONE TO
HELPING US ENROLL PATIENTS.
SO WE HAD A PATIENTS ADVISORY
BOARD SINCE 2016 AND THE SAME
PARENTS ARE STILL DOING THIS AT
THIS TIME AND THEY'VE REVIEWED
OVER 250 STUDIES AND THE -- I
WOULD SAY OF THOSE 250, MAYBE
20% OF THE TIME THEY HAVE
QUESTIONS AND MAYBE 5% OF THE
TIME THE RESEARCHERS WILL CHANGE
THEIR PROTOCOLS BASED ON WHAT
THE FAMILIES SAY.
AND IN SOME STUDIES IT'S QUITE
HELPFUL.
ALL RIGHT, THAT'S PRACTICE BASED
RESEARCH, A SERVICE FOR YOUR
RESEARCH COMMUNITY AND THEN
CLINICAL DECISION SUPPORT IS
REALLY IMPORTANT.
NOW CLINICAL DECISION SUPPORT
WHEN IT WAS FIRST BEING TOUTED
AND BEING SUPPORTED TO IMPROVE
CARE HAD SOME DISCUSSIONS,
LIMITS AUTONOMY A BIT, A
CLINICAL PATHWAY OR A PROTOCOL
THAT WE WANT PHYSICIANS TO AND
PRACTITIONERS TO FOLLOW BUT WE
WANT TO MAKE IT EASIER TO DO
THINGS RIGHT AND DRIVE DOWN
VARIATION.
IN 2014 THE NATIONAL LIBRARY OF
MEDICINE BEGAN EXPORTING
CITATIONS 7 DAYS A WEEK SO THEIR
-- THEIR EXPORTING MORE THAN
15,000 ARTICLES PER WEEK AND A
LOT -- MANY OF THOSE ARE
RANDOMIZED CLINICAL TRIALS, BUT
REALLY, IT'S COMPLICATED AND WE
NEED TO GET THAT INFORMATION IF
WE'RE GOING TO IMPROVE CARE AND
THAT'S WHERE CLINICAL DECISION
SUPPORT COMES IN, NOW THIS WAS
MY CLINICAL DECISION SUPPORT AND
WHEN I WAS DOING THE RESIDENT
CLINIC, ALL SORTS OF PAPERS TO
TELL ME, DON'T FORGET TO DO
THIS, DON'T FORGET TO DO THAT
AND IT REALLY WASN'T PROBABLY
VERY EFFECTIVE.
SO WITH WE DEVELOP CLINICAL
DECISION SUPPORT, WE WANT TO
HAVE -- THESE ARE THE SO CALLED
5 RIGHTS OF CLINICAL DECISION
SUPPORT, THE FRAMEWORK THAT YOU
SHOULD THINK ABOUT AS YOU CREATE
CLINICAL DECISION SUPPORT.
SO IT'S THE RIGHT INFORMATION IT
HAS TO BE ACCURATE.
I REMEMBER GOING UP AND TALKING
TO MY FRIENDS AT BOSTON
CHILDREN'S EARLY IN THE DAY THEY
HAD A DECISION SUPPORT TOOL THAT
WAS GOING TO TELL THE PRIMARY
CARE PEDIATRICIANS WHAT VACCINES
THE CHILD NEEDED ON THE VISIT.
SO THE CHILD WOULD SIT IN THE
CHAIR, THE PRIMARY CARE PROVIDER
WOULD BE THERE, THEY PULL UP THE
CHART AND THEN THIS DECISION
SUPPORT SAID WHAT VACCINES IN
AND WITHIN 2 WEEKS, THE PRIMARY
CARE PEDIATRICIANS DISCOVERED
THIS WASN'T ACCURATE.
IT WASN'T GIVING THEM THE RIGHT
INFORMATION AND THEY ABANDONED
IT AND IT HAD TAKEN LIKE 2 YEARS
TO CREATE THIS PROGRAM.
SO IT HAS TO BE REALLY, REALLY
GOOD INFORMATION.
IT NEEDS TO BE THE RIGHT PERSON
WHO NEEDS THE INFORMATION.
IS IT THE PHYSICIAN?
IS IT THE NURSE PRACTITIONER?
IS IT THE PHYSICAL THERAPIST?
AND IT NEEDS TO BE THE RIGHT
FORMAT, IS IT BEST AS A ORDER
SET, IS IT BEST AS A POP UP ON
EPIC AS A BEST PRACTICED ALERT?
AND THESE, YOU KNOW, THESE, IT
TAKES SOME STUDYING TO FIGURE
OUT HOW TO DELIVER THIS
INFORMATION BECAUSE YOU CAN
OVERWHELM PHYSICIANS AS THEY SIT
IN FRONT OF THEIR MEDICAL RECORD
JUST LIKE WE SAW THE PAPERS.
SO YOU CAN HAVE TOO MANY
PRACTICE ALERTS, YOU CAN HAVE
TOO MANY THINGS GOING ON.
IT NEEDS TO BE THE RIGHT TIME IN
THE FLOW AND THE RIGHT CHANNEL.
SOMETIMES IT'S BEST DELIVERED AT
EPIC, SOMETIMES IT'S BEST
DELIVERED ON YOUR SMART PHONE,
YOU HAVE TO -- YOU HAVE TO MAKE
THESE DECISIONS.
SO THIS IS A STUDY WE DID EARLY
ON IN 2009 THAT I DID AND I WAS
THINKING WELL, LET'S USE THIS
CLINICAL DECISION SUPPORT, AND
AGAIN, I HAVE TO GIVE CREDIT TO
BOB AND ALEX FIX AND OTHER WHO
IS HELPED ME WITH -- BECAUSE I
NEVER PRACTICED PRIMARY CARE BUT
AS A HOSPITAL BASED PEDIATRICIAN
I WAS ALWAYS FRUSTRATED WITH THE
RETURN VISITS WITH OUR ASTHMA
PATIENTS AND IT WAS SOMEWHAT OF
A BLACK BOX WHEN I SENT THEM OUT
IN TERMS OF DID THEY GET THEIR
PRESCRIPTIONS FILLED?
HOW OFTEN WERE THEY REALLY
COMPLYING WITH THEIR CONTROLLER
MEDICINE?
HOW WERE THEY DOING?
AND I THOUGHT PERHAPS THIS COULD
HELP US DO THE RIGHT THING.
WE CREATED A CLINICAL DECISION
SUPPORT TOOL, IT WAS INTEGRATED
INTO THE EHR AND WE FOUND WE
COULD SIGNIFICANTLY INCREASE
PRESCRIPTIONS FOR CONTROLLER
MEDS BASED ON HOW SEVERE THE
ASTHMA WAS, WE COULD
SIGNIFICANTLY INCREASE THE
FILING OF UP TO DATE ACTION
PLANS AND WE COULD SIGNIFICANTLY
INCREASE THE USE OF SPIRITUAL
STRUGGLES ORDER OF MICRONSETRY
IN RELATED TO CARE.
AGAIN, ALL RELATED TO FIGURING
OUT HOW SEVERE THESE PATIENTS
ARE AND THEN GIVING THEM THE
RIGHT THERAPY.
THIS IS OUR -- THE NURSE OR
WHOMEVER WOULD TRIAGE THE
PATIENT WOULD DO THE ASTHMA
CONTROL TOOL IN TRIAGE.
NOW IN THOSE DAYS, THE NURSE DID
IT BUT NOW THE PARENTS DO THIS
IN THE WAITING ROOM.
AND THEN THAT AUTOMATICALLY
POPULATED THIS CARE ASSISTANT,
IT'S CALL EXCLUDE THAT WOULD
COME DOWN INTO THE EPIC CHART AS
YOU WERE -- AS YOU WERE SEEING
THE PATIENT AND IT WOULD TELL
YOU WHAT TO DO AND IF IT WAS
RED, MAKE IT GREEN, THAT WAS THE
MANTRA FOR THE PROVIDERS WHO ARE
CARING FOR THE PATIENTS.
ANOTHER KIND OF CLINICAL
DECISION SUPPORT WHICH I THINK
HAS BEEN QUITE IMPORTANT ARE THE
CHOPPED CLINICAL PATHWAYS, WE
HAVE OVER 200 NOW AND THEY'RE
ONLINE, SO ANYBODY CAN HAVE
ACCESS TO THEM.
IF YOU GOOGLE CHOP CLINICAL
PATHWAYS, YOU WILL GET ALL OF
THEM AND THEY'RE DIVIDED UP BY
ED, HOSPITAL, INTENSIVE CARE,
BEHAVIORIAL HEALTH AND YOU CAN
-- YOU CAN LOOK AT THOSE, THE
CLINICAL PATHWAYS.
ALL OF THEM ARE DECISION
SUPPORT, IT PROVIDES A COMMON
MENTAL MODEL FOR HOW WE WILL
CARE FOR PATIENTS.
IT'S EVIDENCE BASED IN TERMS OF
WHAT THE BEST PRACTICE IS, IT
EDUCATES US AND IT CAN BE
UPDATED AND USUALLY IT MANAGING
QUALITY AND COST.
THERE IS A DOWN SIDE TO PATHWAYS
AND WHEN I'M ON SERVICE, THE
PATIENTS WILL COME UP ON ED ON A
PATHWAY AND I ALSO HAVE A LITTLE
TALK WITH MY TEAM BEFORE WE
START THE WEEK TOGETHER AND I
SAY, YOU WILL EARN YOUR MONEY IF
YOU TAKE YOUR PATIENT OFF THE
PATHWAY.
BECAUSE THESE PATHWAYS ARE
DESIGNED FOR 75% OF PEOPLE WITH
THOSE TYPES OF SYMPTOMS AND IT'S
IMPORTANT IN EACH TRANSITION OF
CARE, WE REEXAMINE WHAT OUR
ASSUMPTIONS ARE AND WHAT THE
APPROPRIATE PATHWAY OR NOT BE.
FOR EXAMPLE, I HAVE HAD 2 PAIBS
WHO CAME UP WHO HAD VASCULAR
[INDISCERNIBLE] AND WHO WERE
WHEEZING, SO THAT'S AN IMPORTANT
CAVEAT.
THEY'RE WONDERFUL, 75% OF THE
TIME THEY'RE TERRIFIC BUT WE
DON'T WANT THAT TO BIAS US.
ALL OF THE PATHWAYS HAVE
CLINICAL STANDARDS, THE GOALS
AND METRICS, YOU CAN SEE WHO
WROTE THEM AND WHEN THEY WERE
POSTED AND WHEN THEY WERE
REVIEWED AND WE HAVE A PROGRAM
WHERE THEY'RE CONTINUALLY
UPGRADED, ALL OF THE REFERENCE
MATERIAL HERE CAN BE ACCESSED
AND THEY ALL LOOK THE SAME SO
FOLKS CAN SORT OF SEE.
SO THOSE WERE THE CORE SERVICES.
PRACTICE BASED RESEARCH,
CLINICAL DECISION SUPPORT,
TRYING TO DEVELOP THOSE AND NOW
LET'S JUST SORT OF EXPLAIN WHAT
I'M MEANING ABOUT THESE CORE
COMPETENCIES AND THEN WE WILL GO
INTO THIS CASE STUDY TOGETHER.
SO THE HEALTH SERVICES RESEARCH
DISCOVERS NEW KNOWLEDGE.
THE QUALITY IMPROVEMENT TAKES
THAT AND THEN TWEAKS IT WITH A
PROJECT TO REDUCE THE VARIATION
AND DELIVERING THAT CARE AND
IMPLEMENTATION EVIDENCE AND
DISCOVER KNOWLEDGES ABOUT,
REDUCES VARIATIONS OF AND
EVIDENCE PRACTICE INTO THE
STRUCTURE, PROCESSES AND EFFECTS
OF HEALTH SERVICES FOR
INDIVIDUALS AND POPULATIONS AND
LEADS TO CHANGE AND SO IT'S A
CONTINUUM.
LET'S LOOK AT PRESCRIBING
PRIMARY CARE?
YOU WILL ALSO NOTICE THIS IS
THESE ARE YEARS OF BABY STEPS.
THIS ISN'T LIKE A BREAK THROUGH,
AND EVERYTHING'S PERFEC, SO
IT'S KIND OF SLOGGING ALONG, AND
USING THESE TOOLS TO TRY TO MAKE
A CHANGE SO THIS IS RESEARCH TO
DISCOVERING NEW KNOWLEDGE TO
QUALITY IMPROVEMENT AND
IMPLEMENTATION SO OBVIOUSLY WE
ALWAYS HAVE TO REDEFINE THE
PROBLEM, SO WE CONTINUE TO HAVE
OVERUSE OF ANTIBI BIOTICS IN
CHILDREN.
AT LEAST 30% OF ASPECT BIOTICS
IN OUT PATIENT SETTINGS ARE
PROBABLY UNNECESSARY AND IT'S
EVEN MORE APPARENT TO ME THAT
THE USE OF ANTIBIOTICS HAS SOME
DOWN STREAM EFFECTS NOW, WHEN I
FIRST STARTED WORRYING ABOUT
THIS IN THE LATE 80S, EARLY 90S.
ANTIBIOTIC RESISTANCE, WE WERE
ALWAYS WORRIED ABOUT ADVERSE
DRUG EFFECTS, WE WERE ALWAYS
WORRIED ABOUT, BUT WHAT ARE THE
LONG-TERM IMPACTS ON THE
MICROBIOME.
THERE ARE SOME CONFLICTING DATA,
I ADMIT ABOUT ANTIBIOTIC USE,
MULTIPLE COURSES OF ANTIBIOTICS
IN THE FIRST 2 YEARS OF LIFE AND
OBESITY.
THERE'S A PARTNERSHIP I JUST
READ 2 DAYS AGO ABOUT MULTIPLE
ANTIBIOTICKINGS IN ADULTS AND
THE DEVELOPMENT OF IBD.
THERE'S A RISK FACTOR FOR THAT.
SO I THINK WE NEED TO BE MORE
PRECISE ABOUT HOW WE PRESCRIBE
ANTIBIOTICS, I WAS WORRY BODY
THIS FOR A LONG TIME.
THIS A BOOK FOR PARENTS CALLED
BREAKING THE ANTIBIOTIC HABIT
AND I'M NOT SURE, AGAIN, BABY
STEPS.
SO WE STARTED LOOKING AT THIS
AND I GIVE JEFF [INDISCERNIBLE]
THE PROPS FOR THIS BECAUSE WE
CONTINUE TO DO IT EMPLOY WE HAVE
WITH THIS LARGE PRACTICE BASED
RESEARCH NETWORK WE CAN LOOK AT
PRESCRIBING RATES IN THESE 31
DIFFERENT PRACTICES.
SO THERE WERE -- THERE WERE
VARIED RATES OF DIAGNOSIS ACROSS
THE NETWORK, SO, SOME PRACTICES,
THE DIAGNOSTIC RATE WAS 8% OF
OTITIS MEDIA, SOME 20, SIGNUE
SIGHT ISOTOPE, STREP AND
PNEUMONIA, SO THERE'S A
VARIATION OF HOW OFTEN THESE
DIAGNOSIS ARE BEING MADE ACROSS
THE NETWORK.
SO WE DECIDED TO LOOK AT THIS
CAREFULLY AND OUR GOAL FOR THIS
STUDY WAS TO HELP PROVIDERS USE
THE MOST NARROW SPECTRUM
ANTIBIOTICS FOR THE ACUTE
RESPIRATORY TRACT INFECS THAT
ARE THE MOST COMMON REASONS THEY
COME TO EITHER THE EMERGENCY
DEPARTMENT OR PRIMARY CARE.
WE USED A CLUSTER RANDOMIZED
TRIAL WITH OUR PRACTICES AND WE
GAVE AUDIT AND FEEDBACK REPORTS
TO THE INTERVENTION PRACTICES
COMPARED TO THE CONTROLS WHO
DIDN'T GET ANYTHING.
AND I LOVE AUDIT AND FEEDBACK, I
THINK IT'S 1 OF THE MOST
POWERFUL TOOLS WE CAN USE IN
QUALITY IMPROVEMENT AND WE
WANTED THE APPROPRIATE
ANTIBIOTIC FOR PNEUMONIA,
SIGNUEICITIS, AND STREP, USUALLY
AMOXACILLIN, THIS IS THE REPORT
WE WOULD GIVE TO THE
PEDIATRICIANS; YOU, THE
ANTIBIOTICS FOR ACUTE SINEW
SITIS THAT YOU PRESCRIBED, TO
BASE LINE, QUARTER 1, THIS IS
YOUR PRACTICE AND THIS IS THE
NETWORK.
SO EVERYBODY GOT THESE REPORTS
IN A STANDARD WAY, PUSHED OUT TO
THEM AND WE SAW A NICE -- WHEN
WE STARTED GIVING THE REPORTS WE
SAW A REALLY NICE EFFECT.
THE PHYSICIANS WHO WERE GETTING
THE REPORTS STOPPED PRESCRIBING
BROAD SPECTRUM ANTIBIOTICS AND
BECAME MORE APPROPRIATE.
SO THAT WAS WONDERFUL.
WE WERE SO HAPPY, WE PUBLISHED
IT.
IT WAS MY FIRST ARTICLE THAT I
HAD EVER GOTTEN PUBLISHED IN
JAMA, I WAS REALLY HAPPY ABOUT
THAT AND THEN LOOK WHAT
HAPPENED, WE STOPPED THE STUDY
AND WHAT HAPPENED?
THEY TARTED PRESCRIBING BROAD
SPECTRUM ANTIBIOTICS AGAIN.
SO IT WAS GREAT BECAUSE WE GOT
THAT PUBLISHED TOO.
[LAUGHTER]
SO THERE'S A PROBLEM THERE,
RIGHT?
SO WE DECIDED THIS IS HELT
SERVICES RESEARCH.
THIS IS DISCOVERING NEW
KNOWLEDGE, NOW LET'S BRING IT
INTO QUALITY IMPROVEMENT.
OH, ALSO, ALSO ALWAYS LOOK FOR
WHEN YOU'RE DOING THESE DATA
ANALYSIS FOR DISPARITIES BY
INCOME, RACE AND GENDER.
THAT'S 1 TENET THAT I THINK WE
REALLY NEED TO MAKE SURE WE DO
AND WE DID FIND RACIAL
DIFFERENCES IN ANTIBIOTIC
PRESCRIBING BY PRIMARY CARE
PHYSICIANS, SAME DATA SET THIS,
IS A WHOLE OTHER THING THAT WE
POPPED UP THAT WE'RE SURPRISED
ABOUT AND RUSS WASAUR
BIOSTATISTICIAN AND WAS JUST
TEARING HIS HAIR OUT TO MAKE
SURE THAT THIS ANALYSIS WAS DONE
PROPERLY AND THAT WE WEREN'T
MISSING SOME BIAS HE THAT WAS
SKEWING THE DATA AND HE'S
FANTASTIC AND I THINK HE, HE DID
THAT, AND WE FOUND THAT BLACK
CHILDREN IN OUR PRIMARY CARE
NETWORK RECEIVED FEWER
ANTIBIOTIC PRESCRIPTIONS THAN
WHITES, WERE DIAGNOSED WITH
FEWER ACUTE RESPIRATORY ATTACK
INFECTIONS AND HAD A LOWER
PROPORTION OF BROAD SPECTRUM
ANTIBIOTICS.
SO IT'S SORT OF THE REVERSE
DISPARITY, THEY GOT BETTER CARE
BECAUSE THEY WERE BLACK, THE
WHITE FOLKS GOT BROAD SPECTRUM
ANTIBIOTICS THEY GOT MORE X-RAYS
TOO, WE FOUND OUT AND THIS WAS
AT THE LEVEL OF SAME CLINICIAN,
IT WASN'T THE LEVEL OF THE
PRACTICE, IT WAS THE SAME
PROVIDER THAT THIS ANALYSIS WAS
DONE.
SO VARYY, VARY INTERESTING.
SO WE'RE GOING TO MOVE FROM THAT
STUDY WHICH WAS DISCOVERING NEW
KNOWLEDGE ABOUT [INDISCERNIBLE]
FEEDBACK AND HOW WE CAN IMPACT
THE PREKRIPGZ AND BROAD SPECTRUM
-- NOW WE'RE GOING DO QUALITY
IMPROVEMENT TO REALLY TRY TO
REDUCE THE VARIATION OF
PRESCRIPTION IN THOSE 31
DIFFERENT PRACTICES.
EDWARD DEMMINGS WAS A VERY
FAMOUS INDUSTRIAL QUALITY
IMPROVEMENT PHYSICIAN -- NOT
PHYSICIAN, ENGINEER WHO DID A
LOT OF QUALITY IMPROVEMENT FOR
THE WEAPONRY THAT WE WERE
PRODUCING IN WORLD WAR II BUT HE
ALSO WENT OVER TO JAPAN, AFTER
WORLD WAR II AND REALLY
REDESIGNED ALL THEIR
MANUFACTURING, IN TERMS OF THE
QUALITY.
YOU CAN'T MANAGE WHAT YOU DON'T
MEASURE, SO MEASUREMENT IS A
VERY IMPORTANT PART OF QUALITY
IMPROVEMENT AND A BAD SYSTEM
WILL GET A GOOD -- BEAT A GOODN
EVERY TIME.
SO THIS IS A SYSTEM ANALYSIS.
PAUL [INDISCERNIBLE] IS A FAMILY
DOCTOR AND HE LIKES TO LINK THE
OUTCOMES, PATIENT OUTCOMES TO
SYSTEMS TO WELLNESS FOR
PROVIDERS.
HE THINKS THAT'S THE LENGTH THAT
WE SHOULD REALLY START BECAUSE
THE MORE EFFICIENT THE SYSTEM,
THE BETTER OFF WE'RE FEELING
ABOUT THE OUTCOMES FOR OUR
PATIENTS.
EVERY SYSTEM IS DESIGNED TO GET
THE RESULTS IT GETS, SO IF YOU
WANT DIFFERENT RESULTS, YOU HAVE
TO CHANGE THE SYSTEM, SO THIS IS
A SYSTEMS APPROACH TO EVERYTHING
WE DO.
SO I DID TAKE A SEBATICLE IN
2012 AND SPENT TIME AT
INTERMOUNTAIN HEALTH AT A COURSE
AND IT WAS 160 HOURS OF TEACHING
ABOUT QUALITY IMPROVEMENT AND
THESE ARE THE 5 THINGS THAT THAT
IF YOU COULD REALLY DISTILL
EVERYTHING DOWN FROM THAT 160
HOURS, THIS IS WHAT I LEARNED.
VARIATION IN HEALTHCARE IS BAD.
AND THEN THERE'S THIS
PROVOCATIVE SENTENCE IN RED,
IT'S MORE IMPORTANT TO DO IT THE
SAME THAN TO DO IT THE RIGHT
WAY.
SO THAT MEANS YOU'RE IN A ROOM
AND YOU'VE GOT A PROBLEM WITH
SOME ASPECT OF THE CARE AND YOU
HAVE 5 PEOPLE WHO HAVE
FUNDAMENTAL KNOWLEDGE OF THE
PROCEDURE OR FUNDAMENTAL
KNOWLEDGE OF THE PROTOCOL AND
THEY ALL HAVE A DIFFERENT VIEW
OF HOW TO DO IT THE RIGHT WAY.
AND WHAT YOU NEED TO DO AS THE
LEADER OF THIS PROJECT IS TO
CONVINCE THEM, ABANDON WHAT YOU
THINK IS RIGHT AND ALL AGREE ON
DOING IT THE SAME WAY AND I WILL
AND NUMBER 2, I WILL MEASURE IT
AND I WILL MEASURE THE OUTCOMES
AND I WILL GIVE YOU -- I WILL
GIVE YOU FEEDBACK ABOUT
EVERYTHING THAT'S HAPPENING.
IT'S HARD TO DO THIS SOMETIMES
AND I DON'T KNOW IF THERE ARE
ANY SURGEONS IN THE ROOM BUT
IT'S PARTICULARLY HARD TO DO IT
WITH SURGEONS BUT I DON'T WANT
TO OFFEND ANYBODY.
AS QUALITY IMPROVE, SAFETY AND
EQUITY IMPROVE AND COST GOES
DOWN AND THEN THIS IS A REALLY
IMPORTANT 1, THE SUCCESS OF THIS
PROJECT DEPENDS ON THOSE WITH
THE FUNDAMENTAL KNOWLEDGE OF
WHAT YOU'RE DOING.
YOU DON'T WANT THE SECTION
CHIEFS, YOU DON'T WANT THE
DIVISION CHIEFS, YOU WANT THE
NURSE PRACTITIONERS, YOU WANT
THE RESPIRATORY TECHNICIANS, YOU
WANT FOLKS IN THE ROOM WHO KNOW
WHAT THE PROCESS AT THE BEDSIDE
IS, AND IT'S INNOVATIVE.
IT'S AN INNOVATIVE PROCESS, SO
HERE'S MY FAVORITE CLASSIC
ARTICLE, AND AGAIN, I'M A FAN OF
AUDIT AND FEEDBACK.
SO THIS IS FROM 1977.
THESE AUTHORS ARE PRETTY FAMOUS
AND THEY DID A AUDIT AND
FEEDBACK IN CHANGES IN
TONSILLECTOMY RATES IN REVIEW,
THIS IS WHAT THEY FOUND IN 1969
THIS, IS THE RATE PER 10,000
KIDS OF TONSILLECTOMY AND THESE
AT THE AMONG 13 VERMONT
HOSPITAL, AND YOU CAN SEE
THEY'RE DOING A WHOLE LOT OF
TONSILLECTOMYS SO THEY DID
FEEDBACK, SO WHEN YOU START A
PROJECT AND YOU DO AUDIT AND
FEEDBACK, THESE ARE THE STAGES
OF GRIEVE OF WHAT THE COMMITTEE
AND WHAT THE GROUP IS GOING TO
SAY TO YOU WHEN YOU PRESENT THEM
WITH THE AUDIT AND FEEDBACK.
THEY WILL SAY THE DATA IS WRONG,
YOU HAVE THE WRONG DATA AND SO
THEN YOU WILL HAVE TO MAKE SURE
THE DATA IS RIGHT AND THEN
THEY'LL SAY THE DATA IS RIGHT
BUT ASTERISKS NOT A PROBLEM
BECAUSE WE'RE THE CHILDREN'S
HOSPITAL OF PHILADELPHIA.
AND OUR PATIENTS ARE MUCH SICKER
THAN EVERYBODY ELSE, SO WE'RE AT
A DIFFERENT STANDARD WHICH IS
NEVER THE CASE.
AND THEN STAGE 3 IS THE DATA'S
RIGHT, IT'S A PROBLEM BUT I'M
PRETTY GOOD.
IT'S NOT PRY PROBLEM.
AND THEN THE FOURTH STAGE IS I
ACCEPT AND I WILL CHANGE.
AND THIS IS REALLY CONSISTENT
WITH YOUR DISCUSSIONS IN THESE
PROGECS AND YOU CAN SEE IN THIS
CLASSIC PAPER, YOU CAN SEE, WHAT
HAPPENS AND WE IN MEDICINE ARE
TYPE A.
THIS IS NO MONEY EXCHANGED HERE,
THIS WAS NOT TRANSACTIONAL AT
ALL, THIS IS JUST GIVING THEM
THE REPORT AND EVERYTHING
IMPROVED.
SO, WE HAVE THIS IDEA THAT WE
ARE GOING TO GIVE AUDIT AND
FEEDBACK AND WE'RE GOING TO
IMPROVE THE PRESCRIBING AND
DRIVE DOWN BROAD SPECTRUM
ANTIBIOTIC USE FOR THESE ACUTE
RESPIRATORY INFECTIONS IN KIDS,
YOU CAN SEE THE PNEUMONIA
PATHWAY, JEFF GERBER AND SOME OF
US WERE INVOLVED IN AUTHORING IN
PATHWAY AND IT'S A PROCESS TO
COME UP WITH THIS AND IT'S -- WE
STARTED GIVING AUDIT AND
FEEDBACK, SO ALONG THE X-AXIS OR
ALL THE PRACTICES, AND THIS IS
THE PERCENT PRESCRIBING
APPROPRIATE ANTIBIOTICS.
AND WE HAD A BAR AND YOU CAN SEE
GREEN, THESE PRACTICES ARE DOING
PRETTY WELL AND WE HAVE
SIGNUEICITIS, OTITIS MEDIA,
PHARYNGITIS AND PNEUMONIA, THEY
CAN CLICK ON THIS DATA AND OVER
TIME IN 2013, 2012 AND IT'S
CONTINUING AND THE APPROPRIATE
ANTIBIOTICS ARE IN THE 98-100%
NOW.
SO, BUT WHAT ABOUT LENGTH OF
THERAPY SO WE KNOW THAT
PNEUMONIA IS 5 DAYS RIGHT?
SO WE NEED TO LOOK AT THAT PIECE
WHICH WE ARE.
WE ALSO NEED TO LOOK AT, I WAS
JUST ON SERVICE AND PATIENTS WHO
ARE IN THE FIRST -- WHO ARE
PRESCHOOL AGED WHO HAVE
PNEUMONIA HAVE AN INFILTRATE,
85% OF THE TIME THAT'S A VIRUS,
AND THEY DON'T NEED AN
ANTIBIOTIC, BUT IT'S REALLY HARD
TO WITHHOLD ANTIBIOTICS FOR
PNEUMONIA BECAUSE THERE'S
DIAGNOSTIC UNCERTAINTY, THE
PARENTS HAVE A CERTAIN
EXPECTATION, PNEUMONIA IS A
SCARY WORD AND IF YOU'RE
PRACTICING IN THE EMERGENCY
DEPARTMENT THERE'S GOING TO BE A
FOLLOW UP ISSUE, SO WE'RE
LOOKING AT HOW WE CAN CHANGE AND
THERE'S A LARGE STUDY AT
[INDISCERNIBLE] THAT'S LOOKING
AT THIS AND GOING FORWARD AND
WE'RE ALREADY STARTING TO DO
THIS IS THAT IN THE APPROPRIATE
SETTINGS, PRESCHOOL AGE CHILD,
NOT THAT SICK, LOW GRADE FEVER,
MAYBE HAS AN INFILTRATE, GIVE
THEM A PRESCRIPTION AND TELL
THEM NOT TO FILL IT UNLESS THEY
GET SICKER OR ON FOLLOW-UP WITH
THEIR PEDIATRICIAN.
WE'RE WORKING OUT THAT PROTOCOL,
BUT I THINK THAT MAY BE THE NEXT
ITERATION OF TRYING TO DRIVE
DOWN AND IMPLEMENTATION SCIENCE,
WE'RE LUCKY, I WAS LUCKY ENOUGH
TO BE COINVESTIGATOR ON THIS PC
ORI GRANLT WITH ALEX FIX, AND
THIS IS CALLED THE HEALTH
SYSTEMS IMPLEMENTATION
INITIATIVE, THE
HHS II INITIATIVE AND IF YOU
WERE SELECTED AS AN ACADEMIC
INSTITUTION, WITH THE RIGHT
BONES IF YOU WILL, WITH THE
RIGHT INFRASTRUCTURE TO DO PC
ORI IMPLEMENTATION PROJECTS AND
MEASURE THEIR IMPACT AND PROVE
THAT THEY'VE BEEN SUSTAINED THEN
YOU CAN BE PART OF THIS GROUP
AND THEN YOU ARE ALLOWED TO
RAISE YOUR HAND FOR A REQUEST
FOR PROPOSALS.
THAT PC ORI HANDS DOWN THEY TELL
YOU WHAT THEY'RE INTERESTED IN
AND THESE ARE PROGEBS THAT HAVE
BEEN PROVEN TO WORK IN THE HEGHT
HEALTH SERVICES RESEARCH AND THE
QUALITY IMPROVEMENT REALM AND
NOW THEY WANT TO BE -- THEY WANT
PC ORI TO SPREAD THEM AND
IMPLEMENT THEM ACROSS THE
COUNTRY.
WE'RE CURRENTLY IN OUR CAPACITY
BUILDING PART AND WE JUST WERE
TOLD, LAST MONTH THAT WE HAD
BEEN SUCCESSFUL IN GETTING
SELECTED FOR THEIR FIRST
IMPLEMENTATION PROJECT WHICH WE
WERE LUCKY BECAUSE IT WAS ABOUT
THE USE OF ANTIBIOTICS IN
PRIMARY CARE SETTINGS, SO IT WAS
-- WE'VE BEEN WORKING ON THIS
FOR A WHILE SO WE WERE ABLE TO
DO THAT AND ON OUR CAPACITY
BUILDING, IT DOESN'T -- PC ORI
DOESN'T TELL YOU WHAT TO FOCUS
ON BUT WE'RE DOING AN ORGANIZAL
ASSESSMENT BUT WE ARE GOING TO
FOCUS ON OUR CLINICAL PATHWAYS,
WHO'S USING THEM?
HOW DO WE GET TO THE OUTCOMES
PIECE?
WE HAVE A LOT OF OUTCOMES, BUT
HOW DO WE GET TO THE DATA.
NOW THEN PATIENT REPORTED
OUTCOMES AND IMPORTANT BUT
NONSTANDARD APPROACH BY
DIFFERENT SERVICES, WE HAVE 11
REMOTE PATIENT MONITORING
PROGRAMS AT CHOP AND THEY'RE ALL
THIS DIFFERENT DIVISIONS AND ALL
DONE DIFFERENTLY AND WE REALLY
NEED TO STANDARDIZE THAT
APPROACH, SO THAT'S PART OF THIS
GRANT TO TRY TO MAKE IT EASIER
AND MORE STANDARD AND THEN
MEASURE THE OUTCOMES.
SO LESSONS LEARNED ABOUT THIS
SORT OF BABY STEP SLOW CAMPAIGN
OVER THE LAST 25 YEARS IS U.S.
HEALTHCARE COSTS A LOT AND IT
CONTINUES TO GO UP, WE NEED TO
IMPROVE AND I DO THINK PRACTICE
BASED RESEARCH DOES ALLOW YOU TO
DO HEALTH SERVICES RESEARCH AND
IT CREATES A PLATFORM FOR
INTRODUCING QUALITY IMPROVEMENT
PROJECTS AND HOPEFULLY
IMPLEMENTATION WHICH WE'RE
TRYING TO LEARN MORE ABOUT.
THE CLINICAL DECISION SUPPORT IS
ALSO REALLY IMPORTANT TO DO THE
RIGHT THING AND THEN THIS
CONTINUUM OF COMPETENCIES OF
HEALTH SERVICES RESEARCH, TO
QUALITY IMPROVEMENT, TO
IMPLEMENTATION, IS IMPORTANT AND
YOU KNOW I SUBMIT THAT
INVESTMENT IN THESE SERVICES
PARTICULARLY IN A FREE STANDING
CHILDREN'S HOSPITAL LIKE OURS AS
WELL WILL IMPROVE THE CARE FOR
KIDS OVER TIME BUT IT'S A WORK
IN PROGRESS AND CONTINUES TO BE.
SO I WILL STOP THERE.
THANK YOU GUYS VERY MUCH.
THESE ARE CRITICAL PEOPLE IN MY
WORK LIFE THAT ARE LISTED ON THE
SIDE THERE AND THEN THERE'S JUST
A PICTURE OF SOME OF MY FAMILY.
SO I WILL STOP THERE AND I WILL
TAKE ANY QUESTIONS YOU WOULD
LIKE.
[ APPLAUSE ]
HI, LOU, THAT WAS 8 GREAT TALK.
I HAVE A QUICK QUESTION, THESE
ARE ALL GREAT PROCESSES TO
INSURE WE HAVE BETTER CARE FOR
THE PATIENTS BUT I'M CURIOUS
WHAT YOU THINK THE EFFECTS OF
ALL OF THESE PATHWAYS HAVE ON
MEDICAL EDUCATION WHERE PEOPLE,
YOU KNOW STUDENTS AND RESIDENTS
SORT OF TURN TO THE PATHWAYS SO
THEY DON'T REALLY MAYBE LEARN
THE PATHOPHYSIOLOGY AND THE
REASONING BEHIND THOSE THINGS AS
WELL.
HAVE YOU MEASURED ANY OF THAT.
NYEAH, I HAVE A LOVE-HATE
RELATIONSHIP WITH PATHWAYS BUT
I'M THINKING PERHAPS IT'S
BECAUSE I WAS TRAINED IN A
LITTLE BIT OF A DIFFERENT ERA
BUT I DO THINK IF AS EDUCATORS
AND PROGRAM DIRECTORS IN
RESIDENCY TRAINING THAT WE
ATTEND TO THAT EDUCATIONAL
COMPONENT AND I THINK
PATHOPHYSIOLOGY AND THE
UNDERSTANDING OF PATHOPHYSIOLOGY
AND THE KEY TO MAKING GOOD
DECISIONS ABOUT PATIENT CARE
THAT'S WHY WE HAVE BEEN REALLY
DILIGENT ABOUT THE RESOURCES.
BUT I WORRY ABOUT THAT, TOO, AND
I WORRY ABOUT THE ANCHORING BIAS
OF HAVING PATIENTS ON PATHWAYS
AND THAT'S WHY I THINK FOR ALL
THE TRANSITIONS OF CARE BUT I
THINK WE NEED TO ADAPT TO THEM
AND USE THEM IN THE WAY THAT
WORKS AND ALSO MITIGATE THE
RISKS OF THE PATHWAYS BUT I HAVE
TO -- MEDICINE'S JUST TOO
COMPLICATED.
WE REALLY NEED HELP IN TERMS OF
THE WAY WE NAVIGATE THIS IF
WE'RE GOING TO USE -- I MEAN, I
THINK -- YOU GUYS PROBABLY KNOW
THIS BETTER THAN I DO BUT THE
AMOUNT OF TIME IT TAKES FOR A
REALLY IMPACTFUL RANDOMIZED
CLINICAL TRIAL TO GET INTO
PRACTICE IS DECADES.
YEAH, SO I -- I THINK WE NEED TO
THINK ABOUT IT AS EDUCATORS.
>> SO I WAS PICKING UP, -- I'M
DAVID HARRY AND I WAS PICKING UP
ON YOUR COMMENT ABOUT
SPECIFICALLY SEEKING OUT
PHYSICIANS, BOARD CERTIFIED IN
CLINICAL INFORMATICS AND I'M
TRYING TO UNDERSTAND, DID YOU
SORT OF MAP THAT INTO THOSE
COMPETENCIES OR WHAT ROLE IN
YOUR PROGRAM WOULD -- WHY
SPECIFICALLY THAT ROLE?
FOR THAT?
>> YEAH, THAT'S A GOOD QUESTION
WHAT WE FOUND WAS WE FOUND THAT
WHEN WE AS CLINICIANS AND
CLINICAL RESEARCHERS ASK FOR
DATA TO BE PULLED FROM EPIC THAT
IT WAS OFTEN SUCH A CLUNKY
PROCESS AND IT WAS WHAT WE
WANTED AND WHAT WE NEEDED AND
HOW WE NEEDED TO SEE THE DATA
WAS OFTEN LOST IN TRANSLATION.
SO THE CLINICAL INFORMATICS
GROUP WHO ARE PHYSICIANS,
DEVELOPED A VANDERBILT HAD SOME
OF THE EARLY DEVELOPMENT OF THIS
AND ALSO OREGON.
FELT LIKE ESPECIALLY WITH
ELECTRONIC HEALTH RECORDS HOW
ARE THEY DESIGNED, HOW ARE THEY
USED, HOW CAN THEY BE
MANIPULATED FOR CLINICAL
DECISION SUPPORT.
THIS WOULD ALL BE IN THE REALM
OF A PHYSICIAN, OF BEING ABLE TO
UNDERSTAND THAT AND IN THE FLOW,
IN THE WORK ON THE IN-PATIENT
SERVICE OR THE PRIMARY CARE
SETTING, IN THE WORK FLOW, WHERE
WOULD THAT DECISION SUPPORT BE
BEST PLACED.
HOW COULD IT BE AND THEN, THEN
HAVE ACADEMICS AROUND THAT AND
STUDY IT.
SO WE HAVE, I THINK WE HAVE
MAYBE 8 OR 9, BUT WE HAVE 1 IN
NEOINATOLOGY AND 2 IN CRITICAL
CARE AND SO I THINK THERE ARE
ALMOST A LIAISON IF YOU WILL,
NOT ONLY FOR RESEARCH BUT ALSO
FOR JUST THE WAY WE WERE CARING
FOR PATIENTS.
ONE OF OUR GENERAL PEDIATRICIANS
FOR EXAMPLE, DID A REALLY NICE
JOB IN CREATING A ROUNDING
SHEET, ROUNDING AN EPIC PROGRAM
AND EPIC HAS SUCH AN AMAZING
BUSINESS MODEL, THEY TOOK THAT
INNOVATION AND THEY ADD IT TO
THE NEXT -- THE NEXT ITERATION
OF EPIC.
SO, YOU KNOW, BUT I THINK THAT'S
THE WAY WE USE THE CLINIC ASK
INFORMATICS FOLKS.
>> LAST QUESTION.
>> THAT WAS A GREAT TALK.
VERY THOUGHT-PROVOKING.
SO 1 THING THAT YOU'VE LEARNED,
I THINK SINCE YOU'VE BEEN HERE
IS THAT WE'RE VERY GOOD AT
STUDYING RARE DECS AND I WAS
WONDERING WHAT THE PRACTICE
BASED RESEARCH, IF THAT'S BEING
USED AT ALL TO STUDY THE CARE OF
KIDS WITH RARE DISEASES?
>> WELL, YOU'RE PROBABLY AWARE,
KATE SULLIVAN WHO'S OUR
IMMUNOLOGIST AT CHOP WAS 1 OF
THE LEADERS OF A FEDERALLY
FUNDED GRANT ON RARE DISEASES
AND IT WAS A MULTISITE GROUP AND
THEY -- I MEAN THE IDEA WAS THAT
THESE -- THESE DIFFERENT
ACADEMIC MEDICAL CENTERS WOULD
CARE FOR PATIENTS WITH RARE
DISEASES ASK THEN THEY WOULD ALL
JOIN THE DATA TOGETHER AND I
THINK THE IDEA IS GENO TYPE AND
PHENOTYPE AND JUST TRYING TO
CONNECK THE DOTS AND FIND AS
MANY PATIENTS AS POSSIBLE.
SO THAT -- THAT'S CONTINUING.
>> YEAH AND IS IT THE SAME MODEL
THAT CHOP IS USING WHERE IT'S
KIND OF REAL WORLD DATA
COLLECTION?
>> I BELIEVE IT IS.
I WASN'T INVOLVED WITH KATE'S
WORK, I DO KNOW THAT OUR RARE
DISEASES, THE FOCUS AT CHOP NOW
IS ON PRECISION MEDICINE, I WAS
PART OF THE TASK FORCE AND THE
CLINICAL VOICE TOWARDS HOW DO WE
FLOW PATIENTS THROUGH OUR
INSTITUTION FOR WHAT WE CALL
KITCHEN SINK-OMICs, SO
GENOMICS, METABOLOMICS, RNA,
MIKE ROY BIOME, YOU KNOW, HOW DO
WE BRING PATIENTS IN WHO HAVE
UNDIAGNOSED DISEASES AND HELP
THEM DISCOVER WHAT THAT IS AS
WELL AS CARE FOR THEM.
SO WE'RE EXPANDING THAT PROGRAM
AND THAT'S A FOCUS.
IN TERMS OF COLLABORATIONS
BETWEEN DIFFERENT ACADEMIC
MEDICAL CENTERS AND RARE
DISEASES, WE SHOULD FIND OUT
MORE ABOUT THAT.
I THINK THERE IS SOME, SOME
COLLABORATION THOUGH AND I THINK
IT'S IMPORTANT.
>> THANK YOU.
[ APPLAUSE ]
>> THANKS, EVERYONE THANKS FOR
YOUR TIME.