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>> HELLO, EVERYONE.

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GOOD AFTERNOON.

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I'M JILL WITH THE DEPARTMENT OF

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PEDIATRICS, I WANT TO WELCOME

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YOU TO TODAY'S CLINICAL CENTER

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GRAND ROUNDS THE CME ACTIVITY

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CODE FOR TODAY'S GRAND ROUGH

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ATOM ROUND SYSTEM 57879.

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PLEASE TEXT THIS TO THE NUMBER

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ON THE LECTURE, BY THE QR CODE

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SHOWNOT CME SLIDE, FOR THOSE

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APPLYING YOU WILL RECEIVE THE

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SURVEY FOR FEEDBACK ABOUT THIS

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PRESENTATION AALLOWS TO YOU

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SUBMIT ANY SUGGESTIONS FOR GRAND

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ROUNDS TOPICS, FOLLOWS THE

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PRESENTATIONS, QUESTIONS WILL BE

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TAKEN BY SPEAKERS FROM THE

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AISLES.

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ADDITIONALLY VIDEOCAST VIEWERS

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CAN SUBMIT QUESTIONS ANY TIME

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DURING THE LECTURE BY SCROLLING

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DOWN AND SUBMITTING DURING THE

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LIVE WEBCAST.

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AS TIME PERMITS WE WILL TAKE

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QUESTIONS AT THE CONCLUSION OF

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THE PRESENTATION.

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THE CLINICAL CENTER GRAND ROUNDS

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PROGRAM WAS CONCEIVED BY

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DR. PAUL PLOTTS, OF NIAMS, WHO

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RECENTLY PASSED AWAY, THE

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PURPOSE IS TO BRING THOUGHT

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LEADERS, SCIENTISTS AND LEADERS

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TO SHARE IDEAS ON WHICH THEY ARE

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PASSIONATE ABOUT AND INSPIRE

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OTHER INVESTIGATORS IN THE

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PURSUIT OF CAREERS AND

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BIOMEDICAL RESEARCH.

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TODAY WE ARE EXCITED HOST

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PEDIATRIC GRAND ROUNDS AND

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HONORED TO HAVE AS OUR SPEAKER

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DR. LOUIS BELL, HE SERVED AS

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PEDIATRICIAN FOR THE GENERAL

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PEDIATRIC IN-PATIENT SERVICE.

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FOR MANY YEARS HE SERVED AS THE

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PASSPORT'S IN-PATIENT INFECTIOUS

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DISEASE SERVICE AND THE

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EMERGENCY DEPARTMENT C BELL HAS

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SUBSPECIALTY BOARD

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CERTIFICATIONS, AND CLINICAL

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FOCUS IS PEDIATRIC HOSPITAL

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MEDICINE AND INFECTIOUS DISEASES

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DR. BELL EARNED HIS BACHELOR'S

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DEGREE.

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IN 1986, HE JOINED THE FACULTY

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OF THE UNIVERSITY OF

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PENNSYLVANIA SCHOOL OF MEDICINE.

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OVER THE COURSE OF HIS CAREER AS

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A PHYSICIAN AND EDUCATOR, HE

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RECEIVED NUMEROUS TEACHING

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AWARDS INCLUDING CHOPS TEACHER

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OF THE YEAR AWARD ON 2

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OCCASIONS, THE UNIVERSITY SCHOOL

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OF PENNSYLVANIA DEAN'S AWARD FOR

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EXCELLENCE IN CLINICAL TEACHING

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AND THE 2009 LYNN BACK AWARD FOR

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DISTINGUISHED TEACHING,

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UNIVERSITY OF PENNSYLVANIA'S

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MOST PREOF THE EEMGIOUS TEACHING

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AWARD.

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DR. BELL PUBLISHED MORE THAN 90

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PEER REVIEWED RESEARCH

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PUBLICATIONS AND OVER 90

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CHAPTERS REVIEWS AND BOOKS WITH

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A FOCUS ON UNDERSTANDING THE

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EPIDEMIOLOGY AND IMPROVING THE

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TREATMENT AND MANAGEMENT OF

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PEDIATRIC INFECTIOUS DISEASES

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AND GENERAL PEDIATRIC HOSPITAL

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CARE.

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DR. BELL IS THE FOUNDER AND LONG

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TIME DIRECTOR OF THE PEDIATRIC

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RESEARCH CONSORTIUM AT CHOP, A

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PRACTICE BASED RESEARCH NETWORK

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THAT SEEKS TO IMPROVE

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AMBLATTATORY CARE OF CHILDREN

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THROUGH CLINICAL RESEARCH.

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A NETWORK TODAY THAT INCLUDES 31

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PRIMARY CARE PRACTICES WITH MORE

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THAN 200 PROVIDERS IN THE

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GREATER PHILADELPHIA AREA.

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IN ADDITION TO ALL THESE

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INCREDIBLE ACCOMPLISHMENTS, ON A

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MORE PERSONAL NOTE, I HAVE KNOWN

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DR. BELL FOR 30 YEARS, OVER 30

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YEARS.

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MY FIRST ROTATION AT CHOP AS AN

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INTERN IN JULY 1992 WAS IN THE

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EMERGENCY DEPARTMENT AND

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DR. BELL WAS 1 OF THE FIRST

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ATTENDINGS I WORKED WITH AS A

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PEDIATRIC INTERN.

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I WAS LUCKY ENOUGH TO HAVE HIM

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AS MY MENTOR, HE WAS KIND,

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PATIENT AND CALM AND PROVIDED

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THE TRAINING FOR MY TRAINING AND

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DEVELOPMENT THIS PEDIATRICS.

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I AM THRILLED DR. BELL COULD

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YOIN US TODAY.

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THE TITLE OF TODAY'S

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PRESENTATION IS LESSONS LEARNED

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IN THE PATH TOWARDS OUTCOMES IN

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CHILDREN.

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PLEASE WELCOME ME IN JOINING

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TODAY'S GRAND ROUNDS SPEAKER

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DR. LOUIS BELL EMPLOY

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[ APPLAUSE ]

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>> THANK YOU VERY MUCH FOR
THAT

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KIND INTRODUCTION.

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WE HAD A REALLY NICE DINNER LAST

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NIGHT AND I WAS REMINDED BECAUSE

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I HAVE SENT PATIENTS OVER MY

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CAREER TO THE NIH WITH

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PARTICULARLY RARE AND COMPLEXES

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DISEASES AND I WAS JUST REMINDED

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ABOUT THE UNIQUE CARE MODEL AND

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CARE YOU PROVIDED ASK WAS

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EXCITED TO LEARN ABOUT THE

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ADDITION OF THE HOSPITAL

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MEDICINE GROUP TO THAT

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PARTNERSHIP IN COLLABORATION.

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I HAVE NOTHING TO DECLARE.

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SO A BIT ABOUT MY JOURNEY BEFORE

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WE DELVE INTO THE MEAT OF THE

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TALK TODAY, I STARTED AT CHOP IN

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83, AS A FELLOW, I REALLY WAS IN

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THE LAB DOING VIROLOGY AND I

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REALLY ENJOYED TAKING CARE OF

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PATIENTS.

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I MISS THAT AND SO I STARTED

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MOONLIGHTING IN THE EMERGENCY

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DEPARTMENT AND THAT LED TO A

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CAREER IN BOTH I.D. AND E. D.

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AND THE FIRST PART OF MY CAREER

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AND THEN I HAD A LOT TO DO AND I

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WAS GETTING OLDER AND HAVING A

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HARDER TIME RECOVERING FROM MY

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SHIFTS IN THE EMERGENCY

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DEPARTMENT AND I STOPPED DOING

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THAT FOCUSED ON INFECTIOUS

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DISEASE AND HOSPITAL MEDICINE,

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TEACHING, MENTORING AND

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SPONSORSHIP AT CHOP HAS BEEN A

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JOY AND A PRIVILEGE.

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THERE'S AMAZING TALENT THERE.

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AND THEN MY RESEARCH HAS BEEN

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REALLY EPIDEMIOLOGY TO A FOCUS

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ON HEALTH SERVICES RESEARCH TO

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QUALITY IMPROVEMENT AND NOW, AS

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YOU'LL SEE, TRYING TO LEARN A

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LITTLE BIT MORE ABOUT

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IMPLEMENTATION SCIENCE.

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I WAS THE DIRECTOR OF THE

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INFECTION, PREVENTION AND

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CONTROL GROUP, THE DIVISION OF

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GEN PEDs FOR 21 YEARS AND

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ASSOCIATE CHAIR FOR CLINICAL

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ACTIVITIES AT CHOP FOR 15 YEARS.

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PERSONALLY I HAVE A BLENDED

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FAMILY OF 7 KIDS, 10 GRANDKIDS

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AND YOU CAN SEE THAT FRONT 1 IN

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THE BLUE CODE THERE, SHE'S GOT A

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LOT OF WONDERFUL ATTITUDE WHICH

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IS A LITTLE BIT OF AN INDICATION

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OF HER PERSONALITY.

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SO LET'S THINK ABOUT THIS

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TOGETHER.

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AT THE CONCLUSION OF OUR TIME

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TODAY, I HOPE YOU WILL BE ABLE

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TO UNDERSTAND THAT THE U.S.

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HEALTHCARE AT LARGE IS THE

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COSTLIEST IN THE WORLD.

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AND LET'S THINK ABOUT TOGETHER,

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WHETHER WE'RE GETTING A RETURN

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ON THAT INVESTMENT AND THEN

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THINKING ABOUT THAT IS THE

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BURNING PLATFORM FOR CHANGE AND

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IMPROVEMENT.

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I WOULD LIKE TO SUGGIEST SOME OF

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THE CORE SERVICES AND CORE

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COMPETENCIES THAT I'VE BEEN

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INVOLVED WITH DEVELOPING OVER MY

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CAREER THAT I'M -- I'M HOPING

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CAN BE SUSTAINED AND WILL

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IMPROVE HEALTHCARE OUTCOMES FOR

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KIDS AND WILL MENTION THOSE

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SERVICES AND CORE COMPETENCIES

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AND THEN WE WILL LOOK AT IT IN A

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CASE EXAMPLE, AND THIS WILL TAKE

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ABOUT 50 MINUTES I THINK TO DO.

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SO WHAT'S THE STATUS OF THE U.S.

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HEALTHCARE.

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HOW ARE WE DOING?

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WELL, WE SPEND A LOT ON

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HEALTHCARE IN THIS COUNTRY,

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ABOUT 4 HADN'T $5 TRILLION SPENT

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ANNUALLY, THAT'S 17, MORE THAN

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17% OF OUR GROSS DOMESTIC

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PRODUCT. 

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THE 13, OVER 13,000 PER AMERICAN

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PER YEAR IS A 2024 NUMBER.

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AND THEN ABOUT $1.4 TRILLION ON

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HOSPITAL CARE.

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THAT'S A LOT.

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AND WHEN WE COMPARE OURSELVES TO

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OTHER RESOURCE RICH COUNTRIES,

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LIKE AUSTRALIA, BELGIUM, CANADA,

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JAPAN, SWITZERLAND.

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YOU CAN SEE THERE'S QUITE A GAP

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BETWEEN WHAT WE SPEND AND WHAT

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THOSE COUNTRIES SPEND.

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THIS IS THE PERCENTAGE OF GROSS

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DOMESTIC PRODUCT.

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HERE IS A GRAPH THAT'S A LITTLE

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BIT OLDER, 2019.

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AGAIN, I MENTIONED THAT NOW

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CURRENTLY IN 2024, THE PER

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CAPITA SPENDING IS OVER $13,000,

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BUT THESE PROPORTIONS ARE STILL

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-- STILL HOLD IN 2024.

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YOU CAN JUST SEE THESE ARE

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COMPARING US TO RESOURCE RICH

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COUNTRIES AND HOW MUCH WE SPEND.

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NOW IF WE SPENT THIS MUCH AND WE

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HAD AN AMAZING RETURN ON OUR

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INVESTMENT, WE WOULD AS A

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SOCIETY THINK, OKAY, WE'VE

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INVESTED APPROPRIATELY AND WE'RE

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HAPPY WITH THAT RESULT. 

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BUT IF WE LOOK AND THIS -- WE

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COULD GO ON IN TERMS OF THE DATA

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AROUND THIS BUT IF WE LOOK AT

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SOME OF THESE BIG POPULATION

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HEALTH METRICS, WE CAN START TO

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SEE THAT WE ARE SPENDING A GREAT

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DEAL BUT HOW ARE WE DOING IN

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TERMS OF THESE INFANT MORTALITY

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RATES FOR EXAMPLE, BY COUNTRY.

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AND YOU CAN SEE THAT OURS IS IN

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2022 WAS 5.6 PER THOUSAND LIVE

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BIRTHS AND THAT'S ABOUT A 3%

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INCREASE IN INFANT MORTALITY

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FROM 2024 TO 2022.

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AND SO WE RANK 54th IN THE 227

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COUNTRIES AND TERRITORIES IN THE

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WORLD.

257
00:10:11,471 --> 00:10:15,074
YOU CAN ALSO FIND THE INFANT

258
00:10:15,074 --> 00:10:16,142
MORTALITY RATES BY STATE.

259
00:10:16,142 --> 00:10:17,443
THIS IS THE COMMONWEALTH FUND

260
00:10:17,443 --> 00:10:19,545
WHICH HAS A LOT OF THIS TYPE OF

261
00:10:19,545 --> 00:10:19,745
DATA.

262
00:10:19,745 --> 00:10:23,049
I HAVE A DAUGHTER WHO LIVES IN

263
00:10:23,049 --> 00:10:23,716
BIRMINGHAM ALABAMA.

264
00:10:23,716 --> 00:10:25,585
SHE'S HAD 2 KIDS.

265
00:10:25,585 --> 00:10:27,487
JUST HAD A BABY WHO'S 5 MONTHS

266
00:10:27,487 --> 00:10:29,889
OLD NOW AND YOU CAN SEE WHAT

267
00:10:29,889 --> 00:10:33,125
THAT INFANT MORTALITY RATE IS IN

268
00:10:33,125 --> 00:10:34,760
THAT STATE, 8.5 PER THOUSAND

269
00:10:34,760 --> 00:10:36,762
BIRTHS, HERE'S PENNSYLVANIA AND

270
00:10:36,762 --> 00:10:39,732
HERE'S THE NATIONAL AVERAGE SO

271
00:10:39,732 --> 00:10:44,971
IT VARIES OVER STATE BY STATE.

272
00:10:44,971 --> 00:10:47,707
WHAT ABOUT LIFE EXPECTANCY AT

273
00:10:47,707 --> 00:10:47,940
BIRTH?

274
00:10:47,940 --> 00:10:52,778
AGAIN, OUR LIFE EXPECTANCY IS

275
00:10:52,778 --> 00:10:56,983
ABOUT 81 YEARS WHICH RANKS

276
00:10:56,983 --> 00:11:00,686
49th. 

277
00:11:00,686 --> 00:11:04,557
IN ADDITION, AND SOMEWHAT

278
00:11:04,557 --> 00:11:06,526
INEXPLICABLY TO ME BUT I THINK

279
00:11:06,526 --> 00:11:07,493
WE COULD PROBABLY TOGETHER COME

280
00:11:07,493 --> 00:11:11,364
UP WITH IDEAS ABOUT WHY THIS IS

281
00:11:11,364 --> 00:11:12,431
HAPPENING, MATERNAL MORTALITY IS

282
00:11:12,431 --> 00:11:16,402
GOING UP AND IT'S UP 200% SINCE

283
00:11:16,402 --> 00:11:16,602
1993.

284
00:11:16,602 --> 00:11:23,175
NOW THIS IS A GRAPH FROM 2016

285
00:11:23,175 --> 00:11:26,445
THAT CURRENTLY IN 2024, WE'RE A

286
00:11:26,445 --> 00:11:28,147
 A

287
00:11:28,147 --> 00:11:31,050
LITTLE BIT BETTER.

288
00:11:31,050 --> 00:11:33,786
THE MATERNAL MORTALITY IS 22,

289
00:11:33,786 --> 00:11:35,821
AND THAT RANKS 25 OUT OF THE

290
00:11:35,821 --> 00:11:37,723
COUNTRIES AND TERRITORIES.

291
00:11:37,723 --> 00:11:39,859
NOW IT'S IMPORTANT TO NOTE, AND

292
00:11:39,859 --> 00:11:42,228
WE WILL TALK ABOUT DISPARITIES

293
00:11:42,228 --> 00:11:43,863
AND CARE, THAT BLACK MOTHER

294
00:11:43,863 --> 00:11:45,231
MORTALITY IS ABOUT 2 AND HALF

295
00:11:45,231 --> 00:11:48,634
TIMES THAT OF WHITE WOMEN.

296
00:11:48,634 --> 00:11:51,604
SO LET'S THINK ABOUT INIQUITIES

297
00:11:51,604 --> 00:11:52,438
IN HEALTHCARE.

298
00:11:52,438 --> 00:11:55,942
AND THAT'S ANOTHER LITTLE BIT OF

299
00:11:55,942 --> 00:11:58,110
A PROBLEM THAT WE HAVE IN U.S.

300
00:11:58,110 --> 00:12:00,413
HEALTHCARE AND WE HAVE

301
00:12:00,413 --> 00:12:01,981
DISPARITIES PARTICULARLY BY

302
00:12:01,981 --> 00:12:10,222
EDUCATION AND INCOME AND BY

303
00:12:10,222 --> 00:12:11,424
RACE.

304
00:12:11,424 --> 00:12:14,527
THIS WAS A NEW YORK TIMES SUNDAY

305
00:12:14,527 --> 00:12:15,461
MAGAZINE ARTICLE THAT

306
00:12:15,461 --> 00:12:16,596
PARTICULARLY CAUGHT MY ATTENTION

307
00:12:16,596 --> 00:12:18,664
IN TERMS OF INFANT MORTALITY BY

308
00:12:18,664 --> 00:12:28,274
RACE AND YOU CAN SEE, THAT IT'S

309
00:12:28,274 --> 00:12:30,710
AT LEAST IN THIS WAS 2.3 TIMES

310
00:12:30,710 --> 00:12:32,645
HIGHER FOR BLACK BABIES THAN

311
00:12:32,645 --> 00:12:35,948
WHITE BABIES AND THEN BLOW BIRTH

312
00:12:35,948 --> 00:12:41,954
RATES, THIS IS A 20-22 YEAR

313
00:12:41,954 --> 00:12:42,355
AVERAGE.

314
00:12:42,355 --> 00:12:45,558
BLACKS ARE BORN MORE FREQUENTLY

315
00:12:45,558 --> 00:12:49,328
LOW BIRTH WEIGHT RATE THAN WHITE

316
00:12:49,328 --> 00:12:51,130
INFANTS BY ALMOST, WELL, BY

317
00:12:51,130 --> 00:13:00,473
GREATER THAN A HUNDRED PERCENT,

318
00:13:00,473 --> 00:13:01,340
LIKE 14-TO 7%.

319
00:13:01,340 --> 00:13:02,541
IT'S A PROBLEM, IT'S A PROBLEM

320
00:13:02,541 --> 00:13:03,342
WE FEED TO ADDRESS.

321
00:13:03,342 --> 00:13:04,877
IT'S A PROBLEM THAT AFFECTS

322
00:13:04,877 --> 00:13:05,111
TRUST.

323
00:13:05,111 --> 00:13:06,178
I REFERENCE THIS ARTICLE WHICH I

324
00:13:06,178 --> 00:13:08,714
THINK IS A GOOD THOUGHT

325
00:13:08,714 --> 00:13:15,354
PROVOKING PEACE BY HOWY

326
00:13:15,354 --> 00:13:17,757
BACHENER, THE EDITOR OF JAMA,

327
00:13:17,757 --> 00:13:22,628
AND HE TALKS ABOUT COST OF CARE

328
00:13:22,628 --> 00:13:31,003
LEADING TO DISPARITIES  AND

329
00:13:31,003 --> 00:13:32,271
RATIONAL AND THE DECLINE IN

330
00:13:32,271 --> 00:13:32,471
TRUST.

331
00:13:32,471 --> 00:13:34,140
I DIDN'T THINK ABOUT THE

332
00:13:34,140 --> 00:13:35,408
RATIONING OF HEALTHCARE, AT

333
00:13:35,408 --> 00:13:36,676
LEAST THAT'S NOT MY EXPERIENCE

334
00:13:36,676 --> 00:13:39,078
AT CHOP AT THE BEDSIDE.

335
00:13:39,078 --> 00:13:40,946
BUT WE DO ACCESS IT IN THE

336
00:13:40,946 --> 00:13:44,617
COUNTRY BY ACCESS TO CARE BY

337
00:13:44,617 --> 00:13:46,052
COST AND AGAIN INCOME

338
00:13:46,052 --> 00:13:47,887
DISPARITIES, WE HAVE BIGGER GAPS

339
00:13:47,887 --> 00:13:51,524
IN OUR INCOME DISPARITIES THAN

340
00:13:51,524 --> 00:13:53,392
OTHER RESOURCE RICH COUNTRIES.

341
00:13:53,392 --> 00:13:57,897
BY RESTRICTION, SO WE WON'T

342
00:13:57,897 --> 00:14:01,734
OFFER CERTAIN SERVICES, IMAGING,

343
00:14:01,734 --> 00:14:04,670
THERAPIES AND CERTAIN PARTS OF

344
00:14:04,670 --> 00:14:06,472
THE COUNTRY AND LONG WAITS AND

345
00:14:06,472 --> 00:14:09,709
THAT LEADS TO A DECLINE THIS

346
00:14:09,709 --> 00:14:09,942
TRUST.

347
00:14:09,942 --> 00:14:11,777
SO ARE WE GETTING RETURN ON OUR

348
00:14:11,777 --> 00:14:19,385
INVESTMENT AND I WOULD SAY NO, I

349
00:14:19,385 --> 00:14:20,986
THINK THE VALUE THAT WE GET AS

350
00:14:20,986 --> 00:14:23,823
U.S. CITIZEN BY THE AMOUNT WE

351
00:14:23,823 --> 00:14:30,830
SPEND IS NOT REALIZED.

352
00:14:30,830 --> 00:14:31,630
[INDISCERNIBLE] EMANUEL WROTE

353
00:14:31,630 --> 00:14:33,833
ANOTHER SORT OF INTERESTING

354
00:14:33,833 --> 00:14:36,035
COMMENTARY IN JAMA IN 2018 AND

355
00:14:36,035 --> 00:14:38,904
HE IS IN THIS ARTICLE, TALKS

356
00:14:38,904 --> 00:14:41,173
ABOUT, WELL WHAT ARE THE DRIVERS

357
00:14:41,173 --> 00:14:44,243
OF THAT, THAT GAP IN HOW MUCH WE

358
00:14:44,243 --> 00:14:46,879
SPENT PER CAPITA AND HOW MUCH

359
00:14:46,879 --> 00:14:48,481
OUR RESOURCE RICH COUNTRIES THAT

360
00:14:48,481 --> 00:14:53,119
WE'RE COMPARED TO AND HE SAID

361
00:14:53,119 --> 00:14:54,920
DRUG PRICES IS 1 AND IN THIS

362
00:14:54,920 --> 00:14:57,790
ARTICLE, HE SAID IT'S OVER $1400

363
00:14:57,790 --> 00:14:59,725
PER CAPITA EXTRA TO OUR U.S.

364
00:14:59,725 --> 00:15:00,926
CITIZEN.

365
00:15:00,926 --> 00:15:03,696
AND THIS IS NOT, THIS IS NOT

366
00:15:03,696 --> 00:15:06,165
VOLUME, IT'S NOT INCREASED

367
00:15:06,165 --> 00:15:09,301
VOLUME OF THE PRESCRIPTIONS IN

368
00:15:09,301 --> 00:15:11,437
OUR COUNTRY, IT'S REALLY JUST

369
00:15:11,437 --> 00:15:11,670
PRICE.

370
00:15:11,670 --> 00:15:14,473
WE ALSO AS A GROUP HAVE HIGH

371
00:15:14,473 --> 00:15:16,876
MARGIN, HIGH VOLUME PROCEDURES

372
00:15:16,876 --> 00:15:18,611
IN IMAGING AND IT'S BOTH

373
00:15:18,611 --> 00:15:20,112
PRICING, HOW MUCH WE CHARGE OUR

374
00:15:20,112 --> 00:15:23,249
PATIENTS FOR THOSE BUT IT'S ALSO

375
00:15:23,249 --> 00:15:27,019
VOLUME, WE ORDER MORE MRIs AND

376
00:15:27,019 --> 00:15:27,987
CT SCANS ON OUR PATIENT

377
00:15:27,987 --> 00:15:31,323
POPULATION THAN WHEN WE COMPARE

378
00:15:31,323 --> 00:15:36,095
THEM TO OTHER RICH COUNTRIES AND

379
00:15:36,095 --> 00:15:37,797
IN HIS ANALYSIS, HE SAW A

380
00:15:37,797 --> 00:15:39,298
SEIVET% OF THE PER CAPPAIT

381
00:15:39,298 --> 00:15:40,599
DIFFERENCE IN THE GAP BETWEEN

382
00:15:40,599 --> 00:15:44,670
THOSE COUNTRIES THAT WE'VE BEEN

383
00:15:44,670 --> 00:15:44,970
COMPARED TO.

384
00:15:44,970 --> 00:15:47,406
SO THAT'S THE BURNING PLATFORM

385
00:15:47,406 --> 00:15:49,475
ABOUT HOW TO IMPROVE AND SO I

386
00:15:49,475 --> 00:15:51,977
WANT TO TALK A LITTLE BIT NOW

387
00:15:51,977 --> 00:15:54,580
ABOUT, WE WILL TALK ABOUT CORE

388
00:15:54,580 --> 00:15:56,715
SERVICES AND CORE COMPETENCIES.

389
00:15:56,715 --> 00:15:58,384
TWO CORE SERVICES AND 3 CORE

390
00:15:58,384 --> 00:16:01,954
COMPETENCIES TO TRY TO IMPROVE

391
00:16:01,954 --> 00:16:04,824
AND WE'RE TALKING ABOUT

392
00:16:04,824 --> 00:16:07,993
HEALTHCARE DELIVERY IMPROVEMENT

393
00:16:07,993 --> 00:16:09,061
IN THIS SETTINGS, IN THIS TODAY.

394
00:16:09,061 --> 00:16:12,464
WE WILL NOT TALK ABOUT HEALTH

395
00:16:12,464 --> 00:16:14,500
IMPROVEMENT AND THE WONDERFUL

396
00:16:14,500 --> 00:16:18,904
WORK IN TERMS OF HOW DO WE --

397
00:16:18,904 --> 00:16:22,408
HOW DO WE CREATE A HEALTHY

398
00:16:22,408 --> 00:16:23,576
NEIGHBORHOODS AND WHAT'S

399
00:16:23,576 --> 00:16:27,546
STUDYING THE IMPACT OF HEALTHY

400
00:16:27,546 --> 00:16:29,849
NEIGHBORHOODS, GREEN SPACE, FOOD

401
00:16:29,849 --> 00:16:32,918
SECURITY, HOW DO WE FOSTER THOSE

402
00:16:32,918 --> 00:16:36,355
THINGS TO HELP OUR PATIENTS AND

403
00:16:36,355 --> 00:16:37,056
FAMILY BE HEALTHIER.

404
00:16:37,056 --> 00:16:39,358
IN THE CLINIC NOW, IN OUR CLINIC

405
00:16:39,358 --> 00:16:41,227
SETTING, IN THE URBAN CLINICS,

406
00:16:41,227 --> 00:16:46,632
WE HAVE HIRED LAWYERS TO HELP

407
00:16:46,632 --> 00:16:48,801
THE FAMILIES WITH THEIR LEGAL

408
00:16:48,801 --> 00:16:50,736
PROBLEMS AND HOUSING MAINLY.

409
00:16:50,736 --> 00:16:52,271
WE HAVE A FOOD PANTRY WHERE WE

410
00:16:52,271 --> 00:16:53,873
CAN GIVE THE FAMILIES A

411
00:16:53,873 --> 00:16:56,308
PRESCRIPTION FOR FOOD FOR 3 DAYS

412
00:16:56,308 --> 00:17:01,146
UNTIL WE CAN SORT OF GET THEM ON

413
00:17:01,146 --> 00:17:04,817
-- GET THEM OTHER SUPPORT.

414
00:17:04,817 --> 00:17:06,619
WE HAVE TAX PREPARATION TO HELP

415
00:17:06,619 --> 00:17:09,555
THE FAMILIES GET EARNED INCOME

416
00:17:09,555 --> 00:17:13,993
TAX CREDITS WHICH ARE OFTEN LEFT

417
00:17:13,993 --> 00:17:17,596
ON THE -- JUST NOT -- THEY DON'T

418
00:17:17,596 --> 00:17:18,430
EVEN APPLY FOR THEM.

419
00:17:18,430 --> 00:17:20,399
AND ALL THESE THINGS I THINK, WE

420
00:17:20,399 --> 00:17:21,500
HAVE BEEN STUDYING THEM AND

421
00:17:21,500 --> 00:17:22,768
HOPEFULLY THEY WILL HAVE AN

422
00:17:22,768 --> 00:17:23,002
IMPACT.

423
00:17:23,002 --> 00:17:25,471
WE ARE NOT GOING TO TALK ABOUT

424
00:17:25,471 --> 00:17:26,138
THOSE THINGS TODAY.

425
00:17:26,138 --> 00:17:27,907
WE'RE GOING TO TALK ABOUT THESE

426
00:17:27,907 --> 00:17:29,208
CORE SERVICES, PRACTICE BASED

427
00:17:29,208 --> 00:17:30,542
RESEARCH NETWORK ANDS CLINICAL

428
00:17:30,542 --> 00:17:33,279
DECISION SUPPORT JUST BRIEFLY

429
00:17:33,279 --> 00:17:34,380
AND WE'RE TAKING, FOR ALL OF

430
00:17:34,380 --> 00:17:35,581
THESE THINGS WE'RE GOING TO TALK

431
00:17:35,581 --> 00:17:38,050
ABOUT, WE'RE JUST TAKING A DIP

432
00:17:38,050 --> 00:17:41,487
OF OUR TOE IN THIS PUDDLE TO

433
00:17:41,487 --> 00:17:43,122
TALK ABOUT THEM IN THE INTEREST

434
00:17:43,122 --> 00:17:44,823
OF TIME, BUT THESE ARE THINGS

435
00:17:44,823 --> 00:17:47,393
THAT I'VE BEEN INTERESTED OVER

436
00:17:47,393 --> 00:17:53,432
THE LAST 25 YEARS OR SO, SO THIS

437
00:17:53,432 --> 00:17:54,233
IS [INDISCERNIBLE] WASSERMAN WHO

438
00:17:54,233 --> 00:17:56,902
IS LEADER OF THE PEDIATRIC AND

439
00:17:56,902 --> 00:17:59,305
OFFICE RESEARCH SETTINGS, PROS

440
00:17:59,305 --> 00:18:02,007
NETWORK AT THE AAPP SPONSORS AND

441
00:18:02,007 --> 00:18:04,109
HE JUST TALKS ABOUT THE

442
00:18:04,109 --> 00:18:05,611
COLLABORATION, PARTNERSHIP OF

443
00:18:05,611 --> 00:18:10,382
PRACTITIONERS AND RESEARCHERS

444
00:18:10,382 --> 00:18:13,252
WHO OVERTIME CONDUCT STUDIES TO

445
00:18:13,252 --> 00:18:14,954
IMPROVE OVERTIME WITH THE

446
00:18:14,954 --> 00:18:16,488
ULTIMATE GOAL OF IMPROVING

447
00:18:16,488 --> 00:18:18,757
PATIENT HELP AND THE AHRQ HAS

448
00:18:18,757 --> 00:18:20,726
BEEN A NIETION CONVENER OF THESE

449
00:18:20,726 --> 00:18:23,128
PRACTICE BASED RESEARCH NETWORKS

450
00:18:23,128 --> 00:18:25,431
OF WHICH THERE ARE -- THERE'S A

451
00:18:25,431 --> 00:18:28,467
CHILD ABOWS RESEARCH NETWORK,

452
00:18:28,467 --> 00:18:30,102
THERE'S BEHAVIORIAL HEALTH

453
00:18:30,102 --> 00:18:32,805
RESEARCH NETWORKS, OF COURSE,

454
00:18:32,805 --> 00:18:34,907
THE ONCOLOGY GROUP HAS, YOU KNOW

455
00:18:34,907 --> 00:18:37,676
HISTORICALLY DONE THIS VERY WELL

456
00:18:37,676 --> 00:18:40,746
AS WELL BUT THIS -- THIS

457
00:18:40,746 --> 00:18:42,381
INVOLVES A LOT OF PATIENTS AND

458
00:18:42,381 --> 00:18:47,786
WE WERE LUCKY ENOUGH TO HAVE OUR

459
00:18:47,786 --> 00:18:48,554
OWN PEDIATRIC RESEARCH

460
00:18:48,554 --> 00:18:54,760
CONSORTIUM, IT WAS ESTABLISHED

461
00:18:54,760 --> 00:18:58,330
IN 2002 WITH A GRANT FROM THE

462
00:18:58,330 --> 00:19:01,600
AGENCY FOR AHRQ, AND THEN IF WE

463
00:19:01,600 --> 00:19:04,036
FLASH FORWARD TO TODAY, WE

464
00:19:04,036 --> 00:19:05,838
SUPPORTED OVER 300 CLINICAL

465
00:19:05,838 --> 00:19:07,139
STUDIES, 300 PEER REVIEW

466
00:19:07,139 --> 00:19:07,973
PUBLICATIONS AND IT REALLY

467
00:19:07,973 --> 00:19:14,046
SUPPORTS RESEARCH FROM ALL OF

468
00:19:14,046 --> 00:19:17,483
THE SUBSPECIALTIES AND DREXEL,

469
00:19:17,483 --> 00:19:19,318
JEFFERSON, SO SOME OF THE

470
00:19:19,318 --> 00:19:21,186
OUTSIDE INSTITUTION CANS TAKE

471
00:19:21,186 --> 00:19:22,621
ADVANTAGE OF THIS LABORATORY IF

472
00:19:22,621 --> 00:19:22,921
YOU WILL.

473
00:19:22,921 --> 00:19:27,993
THIS IS THE CHOP CARE NETWORK,

474
00:19:27,993 --> 00:19:30,095
THE STARS THERE ARE THE PRIMARY

475
00:19:30,095 --> 00:19:32,431
CARE PRACTICES OF WHICH THERE

476
00:19:32,431 --> 00:19:34,566
ARE 31 AND YOU CAN SEE THE

477
00:19:34,566 --> 00:19:38,937
VISITS, THE PATIENT COHORT THAT

478
00:19:38,937 --> 00:19:42,708
WE HAVE, IN THIS IN THE PRIMARY

479
00:19:42,708 --> 00:19:44,009
CARE NETWORK, PEDIATRICIANS AND

480
00:19:44,009 --> 00:19:54,453
NURSE PRACTITIONERS AND WE

481
00:19:54,753 --> 00:19:58,791
USUALLY HAVE BETWEEN 25 AND 40

482
00:19:58,791 --> 00:20:00,859
STUDIES GOING ON PER YEAR,

483
00:20:00,859 --> 00:20:03,062
CURRENT WE WE HAVE 40 AND

484
00:20:03,062 --> 00:20:03,862
CURRENTLY THE PRACTICES

485
00:20:03,862 --> 00:20:04,863
PARTICIPATE, SOME OF THE

486
00:20:04,863 --> 00:20:06,231
PRACTICES HAVE 5, SOME OF THEM

487
00:20:06,231 --> 00:20:12,704
HAVE 1 BUT ALL OF THEM ARE

488
00:20:12,704 --> 00:20:13,038
PARTICIPATING.

489
00:20:13,038 --> 00:20:14,540
THE STRENGTHS -- WE WERE REALLY

490
00:20:14,540 --> 00:20:19,044
LUCKY WHEN WE STARTED IN 02

491
00:20:19,044 --> 00:20:20,913
BECAUSE WE HAD A VERY -- AND

492
00:20:20,913 --> 00:20:22,414
YOU'RE THINKING ABOUT HOW YOU'RE

493
00:20:22,414 --> 00:20:23,715
DOING A STUDY, HOW YOU'RE

494
00:20:23,715 --> 00:20:26,418
ENROLLING PATIENTS AND YOU WANT

495
00:20:26,418 --> 00:20:28,120
A DIVERSE GROUP OF PATIENTS, SO

496
00:20:28,120 --> 00:20:31,323
WE HAVE URBAN, WE HAVE SUBURBAN

497
00:20:31,323 --> 00:20:33,926
POPULATIONS, WE HAVE SOME MORE

498
00:20:33,926 --> 00:20:35,661
RURAL PRACTICES AND THE CULTURE

499
00:20:35,661 --> 00:20:38,897
OF THE PRACTICES ARE ALL

500
00:20:38,897 --> 00:20:43,302
DIFFERENT, SO WE DIDN'T BUILD

501
00:20:43,302 --> 00:20:46,705
THESE CHOP DIDN'T BUILD THESE

502
00:20:46,705 --> 00:20:49,808
PRACTICES, WE ALL HAVE SLIGHTLY

503
00:20:49,808 --> 00:20:50,676
ORGANIZATIONAL DYNAMICS AND THEY

504
00:20:50,676 --> 00:20:52,144
FLOW THEIR PATIENTS THROUGH,

505
00:20:52,144 --> 00:20:54,546
THEY COMMUNICATE WITH THEIR

506
00:20:54,546 --> 00:20:55,147
PATIENTS SLIGHTLY DIFFERENTLY

507
00:20:55,147 --> 00:20:56,315
WHICH WE THINK IS A STRENGTH AS

508
00:20:56,315 --> 00:20:58,717
WE LOOK AT HOW DO THESE

509
00:20:58,717 --> 00:21:00,252
PROTOCOL, HOW CAN WE DO THOSE

510
00:21:00,252 --> 00:21:03,822
PROTOCOLS AND STUDIES IN THE

511
00:21:03,822 --> 00:21:05,390
REAL WORLD, WE WERE ALSO

512
00:21:05,390 --> 00:21:07,025
INCREDIBLY LUCKY BECAUSE WE HAD

513
00:21:07,025 --> 00:21:11,630
A SINGLE INSTITUTIONAL REVIEW

514
00:21:11,630 --> 00:21:12,431
BOARD.

515
00:21:12,431 --> 00:21:14,500
OTHER PRACTICE BASED RESEARCH

516
00:21:14,500 --> 00:21:15,134
NETWORKS PARTICULARLY PRIMARY

517
00:21:15,134 --> 00:21:17,569
CARE WOULD HAVE TO HAVE

518
00:21:17,569 --> 00:21:18,871
DIFFERENT IRBs DEPENDING ON

519
00:21:18,871 --> 00:21:21,173
WHERE THOSE PRIMARY CARE

520
00:21:21,173 --> 00:21:22,574
PRACTICES WERE FACILITATED SO WE

521
00:21:22,574 --> 00:21:23,842
WERE REALLY LUCKY IN THAT WAY

522
00:21:23,842 --> 00:21:28,514
AND THEN WE HAD 1 ELECTRONIC

523
00:21:28,514 --> 00:21:29,114
HEALTH RECORD.

524
00:21:29,114 --> 00:21:35,954
AND I WAS VERY INTENTIONAL IN

525
00:21:35,954 --> 00:21:36,922
HIRING AND SUPPORTING OUR

526
00:21:36,922 --> 00:21:40,325
FACULTY IN THE DIVISION OF

527
00:21:40,325 --> 00:21:42,427
GENERAL PEDIATRICS TO GET

528
00:21:42,427 --> 00:21:43,295
BOARDED CLINICAL INFORMATICS AND

529
00:21:43,295 --> 00:21:44,229
IT STARTED WITH, AND I DON'T

530
00:21:44,229 --> 00:21:46,899
KNOW IF YOU GUYS WORKED WITH BOB

531
00:21:46,899 --> 00:21:48,634
[INDISCERNIBLE], I'M NOT SURE.

532
00:21:48,634 --> 00:21:50,335
HE WAS LITERALLY A PROPULSION

533
00:21:50,335 --> 00:21:52,337
SCIENTIST AT M. I.T. WHO DECIDED

534
00:21:52,337 --> 00:21:55,607
HE WANTED TO BE A PEDIATRICIAN.

535
00:21:55,607 --> 00:22:00,379
AND HE CAME TO CHOP AND HE COULD

536
00:22:00,379 --> 00:22:02,447
PROGRAM EPIC IN THE EARLY DAYS.

537
00:22:02,447 --> 00:22:03,982
SOMEHOW HE GOT ACCESS TO, AND HE

538
00:22:03,982 --> 00:22:05,517
WAS ABLE TO DO SOME AMAZING

539
00:22:05,517 --> 00:22:14,860
THINGS FOR US WHICH I WILL JUST

540
00:22:14,860 --> 00:22:16,929
MENTION AS WE GO THROUGH THIS

541
00:22:16,929 --> 00:22:17,362
TALK.

542
00:22:17,362 --> 00:22:18,897
SO BOB WAS VERY IMPORTANT TO BE

543
00:22:18,897 --> 00:22:20,766
ABLE TO MINE THIS DATA.

544
00:22:20,766 --> 00:22:23,368
THE GUIDING PRINCIPLES AND THE

545
00:22:23,368 --> 00:22:26,004
LESSONS OTHER THAN LEARNED IN

546
00:22:26,004 --> 00:22:27,172
SUSTAINING OUR PRACTICE BASED

547
00:22:27,172 --> 00:22:28,373
RESEARCH NETWORK, WE HAVE TO

548
00:22:28,373 --> 00:22:30,375
PROTECT AND RESPECT THE

549
00:22:30,375 --> 00:22:30,676
LABORATORY.

550
00:22:30,676 --> 00:22:32,377
THE LABORATORY ARE THE CLINICAL

551
00:22:32,377 --> 00:22:33,879
PRACTICES, AND WE DON'T CAN THEM

552
00:22:33,879 --> 00:22:35,314
TO DO ANYTHING, AT FIRST WE DID

553
00:22:35,314 --> 00:22:38,016
STUDIES WHERE WE ASKED THEM TO

554
00:22:38,016 --> 00:22:40,485
DO CERTAIN THINGS FOR US AND IT

555
00:22:40,485 --> 00:22:41,887
JUST FAILED.

556
00:22:41,887 --> 00:22:43,655
SO WE BRING EVERYTHING INTO THE

557
00:22:43,655 --> 00:22:45,257
PRACTICES AND THAT WORKS.

558
00:22:45,257 --> 00:22:47,125
MAKE IT EASY FOR THE

559
00:22:47,125 --> 00:22:49,394
RESEARCHERS, TOO, WE HAVE A

560
00:22:49,394 --> 00:22:50,862
FAMILY COUNCIL WHICH I'LL

561
00:22:50,862 --> 00:22:54,233
MENTION AND THEN JUST MAKING

562
00:22:54,233 --> 00:22:57,269
SURE THAT OUR GROUP,

563
00:22:57,269 --> 00:22:58,503
[INDISCERNIBLE] WHICH IS A SMALL

564
00:22:58,503 --> 00:23:01,073
GROUP BUT WE JUST MANAGE THE

565
00:23:01,073 --> 00:23:03,442
COMMUNICATION, THE EXPECTATIONS

566
00:23:03,442 --> 00:23:05,544
AND THE HONESTY BETWEEN THESE

567
00:23:05,544 --> 00:23:06,511
PARTNERS, THE PRIMARY CARE

568
00:23:06,511 --> 00:23:12,651
PRACTICES AND THE RESEARCHERS.

569
00:23:12,651 --> 00:23:14,152
IN IS THE [INDISCERNIBLE]

570
00:23:14,152 --> 00:23:16,321
APPLICATION THAT WE NEED IN

571
00:23:16,321 --> 00:23:21,059
ORDER FOR THEM TO HAVE A

572
00:23:21,059 --> 00:23:22,894
[INDISCERNIBLE] STUDY, THEY

573
00:23:22,894 --> 00:23:24,263
WON'T GET APPROVAL UNTIL THEY

574
00:23:24,263 --> 00:23:26,164
APPROVE THE STUDY IF IT INVOLVES

575
00:23:26,164 --> 00:23:27,799
THE PRIMARY CARE PRACTICES.

576
00:23:27,799 --> 00:23:28,867
HERE'S OUR WEBSITE AND YOU CAN

577
00:23:28,867 --> 00:23:33,505
SEE HERE WE HAVE INFORMATION FOR

578
00:23:33,505 --> 00:23:35,774
GRANT PROPOSALS, SO WE HAVE

579
00:23:35,774 --> 00:23:37,709
BOILER PLATE LANGUAGE THAT THE

580
00:23:37,709 --> 00:23:41,480
RESEARCHERS ARE GOING TO PUT IN

581
00:23:41,480 --> 00:23:42,114
THEIR GRANTS.

582
00:23:42,114 --> 00:23:44,516
AND WE'LL HELP THEM ALSO

583
00:23:44,516 --> 00:23:46,818
POPULATE THEIR GRANTS WITH THE

584
00:23:46,818 --> 00:23:48,320
PATIENT DEMOGRAPHICS AND PROFILE

585
00:23:48,320 --> 00:23:50,789
THAT THEY MIGHT NEED TO MAKE THE

586
00:23:50,789 --> 00:23:55,861
CASE IF YOU WILL THAT WE HAVE

587
00:23:55,861 --> 00:23:59,364
THE PATIENTS THAT THEY WANT TO

588
00:23:59,364 --> 00:23:59,598
STUDY.

589
00:23:59,598 --> 00:24:03,869
SO BOB WAS ABLE TO CREATE A POP

590
00:24:03,869 --> 00:24:11,143
UP THAT WOULD MAGICALLY APPEAR

591
00:24:11,143 --> 00:24:13,011
IN AS THE PHYSICIAN IS SITTING

592
00:24:13,011 --> 00:24:14,012
WITH THE PATIENT.

593
00:24:14,012 --> 00:24:16,748
IF THAT CHILD WAS ELIGIBLE FOR

594
00:24:16,748 --> 00:24:20,352
THAT STUDY, THIS IS THE

595
00:24:20,352 --> 00:24:23,955
PARENTING WITH DEPRESSION STUDY

596
00:24:23,955 --> 00:24:24,356
THAT WAS ONGOING.

597
00:24:24,356 --> 00:24:25,590
JIM [INDISCERNIBLE] RAN THIS, 1

598
00:24:25,590 --> 00:24:29,194
OF OUR HEALTH SERVICES

599
00:24:29,194 --> 00:24:31,697
RESEARCHERS, IT GIVES SOME -- A

600
00:24:31,697 --> 00:24:33,465
BRIEF SYNOPSIS OF THE STUDY TO

601
00:24:33,465 --> 00:24:34,533
REMIND THE PROVIDER AS HE'S

602
00:24:34,533 --> 00:24:36,635
SITTING IN FRONT OF THE PATIENT

603
00:24:36,635 --> 00:24:39,938
AND THEN HE ASKS, WOULD YOU LIKE

604
00:24:39,938 --> 00:24:48,747
TO TALK TO SOMEONE FROM THE

605
00:24:48,747 --> 00:24:49,548
STUDY TEAM?

606
00:24:49,548 --> 00:24:53,418
SO IF THE PATIENT SAYS YES, TO

607
00:24:53,418 --> 00:24:55,020
CLICK THE PROVIDER FOR CONTACT

608
00:24:55,020 --> 00:24:56,355
AND IT WILL BE SENT TO THE WERE

609
00:24:56,355 --> 00:24:58,090
TEAM AND THEN THEY CAN --

610
00:24:58,090 --> 00:25:01,360
RESEARCH TEAM AND THEN THEY CAN

611
00:25:01,360 --> 00:25:02,461
REQUEST THE ELIGIBLE FAMILIES

612
00:25:02,461 --> 00:25:04,262
AND CHILDREN WHO SAID THEY WERE

613
00:25:04,262 --> 00:25:08,533
INTERESTED AND THEY CAN BE GIVEN

614
00:25:08,533 --> 00:25:10,535
REPORTS, AND WE CAN SEND THEM

615
00:25:10,535 --> 00:25:14,039
WEEKLY, DAILY, WHATEVER THE

616
00:25:14,039 --> 00:25:14,873
STUDY TEAM WOULD LIKE.

617
00:25:14,873 --> 00:25:17,809
SO THAT'S BEEN A REAL BOONE TO

618
00:25:17,809 --> 00:25:26,051
HELPING US ENROLL PATIENTS.

619
00:25:26,051 --> 00:25:28,520
SO WE HAD A PATIENTS ADVISORY

620
00:25:28,520 --> 00:25:29,755
BOARD SINCE 2016 AND THE SAME

621
00:25:29,755 --> 00:25:35,327
PARENTS ARE STILL DOING THIS AT

622
00:25:35,327 --> 00:25:37,129
THIS TIME AND THEY'VE REVIEWED

623
00:25:37,129 --> 00:25:39,164
OVER 250 STUDIES AND THE -- I

624
00:25:39,164 --> 00:25:42,701
WOULD SAY OF THOSE 250, MAYBE

625
00:25:42,701 --> 00:25:47,105
20% OF THE TIME THEY HAVE

626
00:25:47,105 --> 00:25:50,575
QUESTIONS AND MAYBE 5% OF THE

627
00:25:50,575 --> 00:25:52,844
TIME THE RESEARCHERS WILL CHANGE

628
00:25:52,844 --> 00:25:57,282
THEIR PROTOCOLS BASED ON WHAT

629
00:25:57,282 --> 00:25:57,916
THE FAMILIES SAY.

630
00:25:57,916 --> 00:26:03,955
AND IN SOME STUDIES IT'S QUITE

631
00:26:03,955 --> 00:26:04,423
HELPFUL.

632
00:26:04,423 --> 00:26:05,857
ALL RIGHT, THAT'S PRACTICE BASED

633
00:26:05,857 --> 00:26:12,531
RESEARCH, A SERVICE FOR YOUR

634
00:26:12,531 --> 00:26:14,266
RESEARCH COMMUNITY AND THEN

635
00:26:14,266 --> 00:26:15,367
CLINICAL DECISION SUPPORT IS

636
00:26:15,367 --> 00:26:16,334
REALLY IMPORTANT.

637
00:26:16,334 --> 00:26:18,603
NOW CLINICAL DECISION SUPPORT

638
00:26:18,603 --> 00:26:21,873
WHEN IT WAS FIRST BEING TOUTED

639
00:26:21,873 --> 00:26:25,911
AND BEING SUPPORTED TO IMPROVE

640
00:26:25,911 --> 00:26:28,880
CARE HAD SOME DISCUSSIONS,

641
00:26:28,880 --> 00:26:30,282
LIMITS AUTONOMY A BIT, A

642
00:26:30,282 --> 00:26:31,683
CLINICAL PATHWAY OR A PROTOCOL

643
00:26:31,683 --> 00:26:36,755
THAT WE WANT PHYSICIANS TO AND

644
00:26:36,755 --> 00:26:37,489
PRACTITIONERS TO FOLLOW BUT WE

645
00:26:37,489 --> 00:26:39,558
WANT TO MAKE IT EASIER TO DO

646
00:26:39,558 --> 00:26:45,397
THINGS RIGHT AND DRIVE DOWN

647
00:26:45,397 --> 00:26:45,730
VARIATION.

648
00:26:45,730 --> 00:26:48,567
IN 2014 THE NATIONAL LIBRARY OF

649
00:26:48,567 --> 00:26:50,235
MEDICINE BEGAN EXPORTING

650
00:26:50,235 --> 00:26:56,107
CITATIONS 7 DAYS A WEEK SO THEIR

651
00:26:56,107 --> 00:26:57,943
-- THEIR EXPORTING MORE THAN

652
00:26:57,943 --> 00:26:59,478
15,000 ARTICLES PER WEEK AND A

653
00:26:59,478 --> 00:27:03,114
LOT -- MANY OF THOSE ARE

654
00:27:03,114 --> 00:27:05,317
RANDOMIZED CLINICAL TRIALS, BUT

655
00:27:05,317 --> 00:27:06,251
REALLY, IT'S COMPLICATED AND WE

656
00:27:06,251 --> 00:27:07,886
NEED TO GET THAT INFORMATION IF

657
00:27:07,886 --> 00:27:09,721
WE'RE GOING TO IMPROVE CARE AND

658
00:27:09,721 --> 00:27:11,223
THAT'S WHERE CLINICAL DECISION

659
00:27:11,223 --> 00:27:15,060
SUPPORT COMES IN, NOW THIS WAS

660
00:27:15,060 --> 00:27:15,894
MY CLINICAL DECISION SUPPORT AND

661
00:27:15,894 --> 00:27:20,198
WHEN I WAS DOING THE RESIDENT

662
00:27:20,198 --> 00:27:22,968
CLINIC, ALL SORTS OF PAPERS TO

663
00:27:22,968 --> 00:27:24,636
TELL ME, DON'T FORGET TO DO

664
00:27:24,636 --> 00:27:26,771
THIS, DON'T FORGET TO DO THAT

665
00:27:26,771 --> 00:27:32,310
AND IT REALLY WASN'T PROBABLY

666
00:27:32,310 --> 00:27:32,978
VERY EFFECTIVE.

667
00:27:32,978 --> 00:27:34,746
SO WITH WE DEVELOP CLINICAL

668
00:27:34,746 --> 00:27:36,748
DECISION SUPPORT, WE WANT TO

669
00:27:36,748 --> 00:27:38,950
HAVE -- THESE ARE THE SO CALLED

670
00:27:38,950 --> 00:27:40,585
5 RIGHTS OF CLINICAL DECISION

671
00:27:40,585 --> 00:27:41,653
SUPPORT, THE FRAMEWORK THAT YOU

672
00:27:41,653 --> 00:27:45,524
SHOULD THINK ABOUT AS YOU CREATE

673
00:27:45,524 --> 00:27:46,191
CLINICAL DECISION SUPPORT.

674
00:27:46,191 --> 00:27:47,359
SO IT'S THE RIGHT INFORMATION IT

675
00:27:47,359 --> 00:27:50,629
HAS TO BE ACCURATE.

676
00:27:50,629 --> 00:27:52,664
I REMEMBER GOING UP AND TALKING

677
00:27:52,664 --> 00:27:53,965
TO MY FRIENDS AT BOSTON

678
00:27:53,965 --> 00:27:57,569
CHILDREN'S EARLY IN THE DAY THEY

679
00:27:57,569 --> 00:27:58,803
HAD A DECISION SUPPORT TOOL THAT

680
00:27:58,803 --> 00:28:04,476
WAS GOING TO TELL THE PRIMARY

681
00:28:04,476 --> 00:28:05,777
CARE PEDIATRICIANS WHAT VACCINES

682
00:28:05,777 --> 00:28:09,614
THE CHILD NEEDED ON THE VISIT.

683
00:28:09,614 --> 00:28:11,082
SO THE CHILD WOULD SIT IN THE

684
00:28:11,082 --> 00:28:13,051
CHAIR, THE PRIMARY CARE PROVIDER

685
00:28:13,051 --> 00:28:14,319
WOULD BE THERE, THEY PULL UP THE

686
00:28:14,319 --> 00:28:15,854
CHART AND THEN THIS DECISION

687
00:28:15,854 --> 00:28:19,457
SUPPORT SAID WHAT VACCINES IN

688
00:28:19,457 --> 00:28:21,893
AND WITHIN 2 WEEKS, THE PRIMARY

689
00:28:21,893 --> 00:28:24,296
CARE PEDIATRICIANS DISCOVERED

690
00:28:24,296 --> 00:28:25,230
THIS WASN'T ACCURATE.

691
00:28:25,230 --> 00:28:26,965
IT WASN'T GIVING THEM THE RIGHT

692
00:28:26,965 --> 00:28:28,233
INFORMATION AND THEY ABANDONED

693
00:28:28,233 --> 00:28:32,404
IT AND IT HAD TAKEN LIKE 2 YEARS

694
00:28:32,404 --> 00:28:33,271
TO CREATE THIS PROGRAM.

695
00:28:33,271 --> 00:28:38,343
SO IT HAS TO BE REALLY, REALLY

696
00:28:38,343 --> 00:28:41,680
GOOD INFORMATION. 

697
00:28:41,680 --> 00:28:43,748
IT NEEDS TO BE THE RIGHT PERSON

698
00:28:43,748 --> 00:28:46,117
WHO NEEDS THE INFORMATION.

699
00:28:46,117 --> 00:28:47,886
IS IT THE PHYSICIAN?

700
00:28:47,886 --> 00:28:50,188
IS IT THE NURSE PRACTITIONER?

701
00:28:50,188 --> 00:28:52,090
IS IT THE PHYSICAL THERAPIST?

702
00:28:52,090 --> 00:28:53,725
AND IT NEEDS TO BE THE RIGHT

703
00:28:53,725 --> 00:28:58,129
FORMAT, IS IT BEST AS A ORDER

704
00:28:58,129 --> 00:29:00,231
SET, IS IT BEST AS A POP UP ON

705
00:29:00,231 --> 00:29:04,769
EPIC AS A BEST PRACTICED ALERT?

706
00:29:04,769 --> 00:29:07,405
AND THESE, YOU KNOW, THESE, IT

707
00:29:07,405 --> 00:29:08,673
TAKES SOME STUDYING TO FIGURE

708
00:29:08,673 --> 00:29:11,142
OUT HOW TO DELIVER THIS

709
00:29:11,142 --> 00:29:15,280
INFORMATION BECAUSE YOU CAN

710
00:29:15,280 --> 00:29:16,247
OVERWHELM PHYSICIANS AS THEY SIT

711
00:29:16,247 --> 00:29:17,749
IN FRONT OF THEIR MEDICAL RECORD

712
00:29:17,749 --> 00:29:20,785
JUST LIKE WE SAW THE PAPERS.

713
00:29:20,785 --> 00:29:22,887
SO YOU CAN HAVE TOO MANY

714
00:29:22,887 --> 00:29:24,522
PRACTICE ALERTS, YOU CAN HAVE

715
00:29:24,522 --> 00:29:25,690
TOO MANY THINGS GOING ON.

716
00:29:25,690 --> 00:29:27,692
IT NEEDS TO BE THE RIGHT TIME IN

717
00:29:27,692 --> 00:29:29,761
THE FLOW AND THE RIGHT CHANNEL.

718
00:29:29,761 --> 00:29:31,930
SOMETIMES IT'S BEST DELIVERED AT

719
00:29:31,930 --> 00:29:33,398
EPIC, SOMETIMES IT'S BEST

720
00:29:33,398 --> 00:29:35,233
DELIVERED ON YOUR SMART PHONE,

721
00:29:35,233 --> 00:29:45,777
YOU HAVE TO -- YOU HAVE TO MAKE

722
00:29:46,945 --> 00:29:47,278
THESE DECISIONS.

723
00:29:47,278 --> 00:29:49,447
SO THIS IS A STUDY WE DID EARLY

724
00:29:49,447 --> 00:29:52,183
ON IN 2009 THAT I DID AND I WAS

725
00:29:52,183 --> 00:29:55,020
THINKING WELL, LET'S USE THIS

726
00:29:55,020 --> 00:29:56,521
CLINICAL DECISION SUPPORT, AND

727
00:29:56,521 --> 00:30:00,058
AGAIN, I HAVE TO GIVE CREDIT TO

728
00:30:00,058 --> 00:30:07,232
BOB AND ALEX FIX AND OTHER WHO

729
00:30:07,232 --> 00:30:16,708
IS HELPED ME WITH -- BECAUSE I

730
00:30:16,708 --> 00:30:19,077
NEVER PRACTICED PRIMARY CARE BUT

731
00:30:19,077 --> 00:30:21,913
AS A HOSPITAL BASED PEDIATRICIAN

732
00:30:21,913 --> 00:30:27,018
I WAS ALWAYS FRUSTRATED WITH THE

733
00:30:27,018 --> 00:30:28,219
RETURN VISITS WITH OUR ASTHMA

734
00:30:28,219 --> 00:30:29,921
PATIENTS AND IT WAS SOMEWHAT OF

735
00:30:29,921 --> 00:30:31,790
A BLACK BOX WHEN I SENT THEM OUT

736
00:30:31,790 --> 00:30:35,527
IN TERMS OF DID THEY GET THEIR

737
00:30:35,527 --> 00:30:35,994
PRESCRIPTIONS FILLED?

738
00:30:35,994 --> 00:30:37,295
HOW OFTEN WERE THEY REALLY

739
00:30:37,295 --> 00:30:38,797
COMPLYING WITH THEIR CONTROLLER

740
00:30:38,797 --> 00:30:39,130
MEDICINE?

741
00:30:39,130 --> 00:30:41,800
HOW WERE THEY DOING?

742
00:30:41,800 --> 00:30:44,202
AND I THOUGHT PERHAPS THIS COULD

743
00:30:44,202 --> 00:30:46,171
HELP US DO THE RIGHT THING.

744
00:30:46,171 --> 00:30:48,106
WE CREATED A CLINICAL DECISION

745
00:30:48,106 --> 00:30:52,911
SUPPORT TOOL, IT WAS INTEGRATED

746
00:30:52,911 --> 00:30:57,215
INTO THE EHR AND WE FOUND WE

747
00:30:57,215 --> 00:30:58,416
COULD SIGNIFICANTLY INCREASE

748
00:30:58,416 --> 00:30:59,551
PRESCRIPTIONS FOR CONTROLLER

749
00:30:59,551 --> 00:31:00,985
MEDS BASED ON HOW SEVERE THE

750
00:31:00,985 --> 00:31:02,420
ASTHMA WAS, WE COULD

751
00:31:02,420 --> 00:31:03,188
SIGNIFICANTLY INCREASE THE

752
00:31:03,188 --> 00:31:08,693
FILING OF UP TO DATE ACTION

753
00:31:08,693 --> 00:31:11,529
PLANS AND WE COULD SIGNIFICANTLY

754
00:31:11,529 --> 00:31:12,931
INCREASE THE USE OF SPIRITUAL

755
00:31:12,931 --> 00:31:14,032
STRUGGLES ORDER OF MICRONSETRY

756
00:31:14,032 --> 00:31:16,167
IN RELATED TO CARE.

757
00:31:16,167 --> 00:31:17,635
AGAIN, ALL RELATED TO FIGURING

758
00:31:17,635 --> 00:31:18,737
OUT HOW SEVERE THESE PATIENTS

759
00:31:18,737 --> 00:31:20,338
ARE AND THEN GIVING THEM THE

760
00:31:20,338 --> 00:31:23,274
RIGHT THERAPY.

761
00:31:23,274 --> 00:31:27,779
THIS IS OUR -- THE NURSE OR

762
00:31:27,779 --> 00:31:28,513
WHOMEVER WOULD TRIAGE THE

763
00:31:28,513 --> 00:31:30,115
PATIENT WOULD DO THE ASTHMA

764
00:31:30,115 --> 00:31:31,416
CONTROL TOOL IN TRIAGE.

765
00:31:31,416 --> 00:31:33,485
NOW IN THOSE DAYS, THE NURSE DID

766
00:31:33,485 --> 00:31:36,554
IT BUT NOW THE PARENTS DO THIS

767
00:31:36,554 --> 00:31:40,925
IN THE WAITING ROOM.

768
00:31:40,925 --> 00:31:43,328
AND THEN THAT AUTOMATICALLY

769
00:31:43,328 --> 00:31:44,429
POPULATED THIS CARE ASSISTANT,

770
00:31:44,429 --> 00:31:45,497
IT'S CALL EXCLUDE THAT WOULD

771
00:31:45,497 --> 00:31:48,500
COME DOWN INTO THE EPIC CHART AS

772
00:31:48,500 --> 00:31:50,401
YOU WERE -- AS YOU WERE SEEING

773
00:31:50,401 --> 00:31:51,336
THE PATIENT AND IT WOULD TELL

774
00:31:51,336 --> 00:31:53,538
YOU WHAT TO DO AND IF IT WAS

775
00:31:53,538 --> 00:31:57,308
RED, MAKE IT GREEN, THAT WAS THE

776
00:31:57,308 --> 00:31:58,510
MANTRA FOR THE PROVIDERS WHO ARE

777
00:31:58,510 --> 00:32:05,917
CARING FOR THE PATIENTS.

778
00:32:05,917 --> 00:32:07,285
ANOTHER KIND OF CLINICAL

779
00:32:07,285 --> 00:32:08,453
DECISION SUPPORT WHICH I THINK

780
00:32:08,453 --> 00:32:10,121
HAS BEEN QUITE IMPORTANT ARE THE

781
00:32:10,121 --> 00:32:12,190
CHOPPED CLINICAL PATHWAYS, WE

782
00:32:12,190 --> 00:32:14,459
HAVE OVER 200 NOW AND THEY'RE

783
00:32:14,459 --> 00:32:17,762
ONLINE, SO ANYBODY CAN HAVE

784
00:32:17,762 --> 00:32:19,097
ACCESS TO THEM.

785
00:32:19,097 --> 00:32:20,665
IF YOU GOOGLE CHOP CLINICAL

786
00:32:20,665 --> 00:32:22,233
PATHWAYS, YOU WILL GET ALL OF

787
00:32:22,233 --> 00:32:25,370
THEM AND THEY'RE DIVIDED UP BY

788
00:32:25,370 --> 00:32:26,671
ED, HOSPITAL, INTENSIVE CARE,

789
00:32:26,671 --> 00:32:29,140
BEHAVIORIAL HEALTH AND YOU CAN

790
00:32:29,140 --> 00:32:33,444
-- YOU CAN LOOK AT THOSE, THE

791
00:32:33,444 --> 00:32:35,814
CLINICAL PATHWAYS.

792
00:32:35,814 --> 00:32:38,349
ALL OF THEM ARE DECISION

793
00:32:38,349 --> 00:32:40,418
SUPPORT, IT PROVIDES A COMMON

794
00:32:40,418 --> 00:32:42,487
MENTAL MODEL FOR HOW WE WILL

795
00:32:42,487 --> 00:32:43,154
CARE FOR PATIENTS.

796
00:32:43,154 --> 00:32:44,689
IT'S EVIDENCE BASED IN TERMS OF

797
00:32:44,689 --> 00:32:48,560
WHAT THE BEST PRACTICE IS, IT

798
00:32:48,560 --> 00:32:50,395
EDUCATES US AND IT CAN BE

799
00:32:50,395 --> 00:32:53,264
UPDATED AND USUALLY IT MANAGING

800
00:32:53,264 --> 00:32:53,865
QUALITY AND COST.

801
00:32:53,865 --> 00:33:00,738
THERE IS A DOWN SIDE TO PATHWAYS

802
00:33:00,738 --> 00:33:03,041
AND WHEN I'M ON SERVICE, THE

803
00:33:03,041 --> 00:33:05,610
PATIENTS WILL COME UP ON ED ON A

804
00:33:05,610 --> 00:33:07,045
PATHWAY AND I ALSO HAVE A LITTLE

805
00:33:07,045 --> 00:33:10,448
TALK WITH MY TEAM BEFORE WE

806
00:33:10,448 --> 00:33:12,050
START THE WEEK TOGETHER AND I

807
00:33:12,050 --> 00:33:14,219
SAY, YOU WILL EARN YOUR MONEY IF

808
00:33:14,219 --> 00:33:18,256
YOU TAKE YOUR PATIENT OFF THE

809
00:33:18,256 --> 00:33:18,790
PATHWAY.

810
00:33:18,790 --> 00:33:20,124
BECAUSE THESE PATHWAYS ARE

811
00:33:20,124 --> 00:33:22,527
DESIGNED FOR 75% OF PEOPLE WITH

812
00:33:22,527 --> 00:33:29,601
THOSE TYPES OF SYMPTOMS AND IT'S

813
00:33:29,601 --> 00:33:31,870
IMPORTANT IN EACH TRANSITION OF

814
00:33:31,870 --> 00:33:33,504
CARE, WE REEXAMINE WHAT OUR

815
00:33:33,504 --> 00:33:35,874
ASSUMPTIONS ARE AND WHAT THE

816
00:33:35,874 --> 00:33:39,844
APPROPRIATE PATHWAY OR NOT BE.

817
00:33:39,844 --> 00:33:46,317
FOR EXAMPLE, I HAVE HAD  2 PAIBS

818
00:33:46,317 --> 00:33:49,621
WHO CAME UP WHO HAD VASCULAR

819
00:33:49,621 --> 00:33:51,456
[INDISCERNIBLE] AND WHO WERE

820
00:33:51,456 --> 00:33:54,025
WHEEZING, SO THAT'S AN IMPORTANT

821
00:33:54,025 --> 00:33:54,259
CAVEAT.

822
00:33:54,259 --> 00:34:00,164
THEY'RE WONDERFUL, 75% OF THE

823
00:34:00,164 --> 00:34:02,200
TIME THEY'RE TERRIFIC BUT WE

824
00:34:02,200 --> 00:34:04,969
DON'T WANT THAT TO BIAS US.

825
00:34:04,969 --> 00:34:07,839
ALL OF THE PATHWAYS HAVE

826
00:34:07,839 --> 00:34:08,806
CLINICAL STANDARDS, THE GOALS

827
00:34:08,806 --> 00:34:10,375
AND METRICS, YOU CAN SEE WHO

828
00:34:10,375 --> 00:34:11,442
WROTE THEM AND WHEN THEY WERE

829
00:34:11,442 --> 00:34:12,844
POSTED AND WHEN THEY WERE

830
00:34:12,844 --> 00:34:14,946
REVIEWED AND WE HAVE A PROGRAM

831
00:34:14,946 --> 00:34:17,081
WHERE THEY'RE CONTINUALLY

832
00:34:17,081 --> 00:34:18,583
UPGRADED, ALL OF THE REFERENCE

833
00:34:18,583 --> 00:34:22,854
MATERIAL HERE CAN BE ACCESSED

834
00:34:22,854 --> 00:34:24,455
AND THEY ALL LOOK THE SAME SO

835
00:34:24,455 --> 00:34:27,058
FOLKS CAN SORT OF SEE.

836
00:34:27,058 --> 00:34:31,496
SO THOSE WERE THE CORE SERVICES.

837
00:34:31,496 --> 00:34:32,664
PRACTICE BASED RESEARCH,

838
00:34:32,664 --> 00:34:33,564
CLINICAL DECISION SUPPORT,

839
00:34:33,564 --> 00:34:38,169
TRYING TO DEVELOP THOSE AND NOW

840
00:34:38,169 --> 00:34:39,804
LET'S JUST SORT OF EXPLAIN WHAT

841
00:34:39,804 --> 00:34:41,239
I'M MEANING ABOUT THESE CORE

842
00:34:41,239 --> 00:34:42,607
COMPETENCIES AND THEN WE WILL GO

843
00:34:42,607 --> 00:34:47,211
INTO THIS CASE STUDY TOGETHER.

844
00:34:47,211 --> 00:34:52,650
SO THE HEALTH SERVICES RESEARCH

845
00:34:52,650 --> 00:34:54,619
DISCOVERS NEW KNOWLEDGE.

846
00:34:54,619 --> 00:34:55,787
THE QUALITY IMPROVEMENT TAKES

847
00:34:55,787 --> 00:34:57,889
THAT AND THEN TWEAKS IT WITH A

848
00:34:57,889 --> 00:35:01,459
PROJECT TO REDUCE THE VARIATION

849
00:35:01,459 --> 00:35:08,466
AND DELIVERING THAT CARE AND

850
00:35:08,466 --> 00:35:10,501
IMPLEMENTATION EVIDENCE AND

851
00:35:10,501 --> 00:35:14,238
DISCOVER KNOWLEDGES ABOUT,

852
00:35:14,238 --> 00:35:15,406
REDUCES VARIATIONS OF AND

853
00:35:15,406 --> 00:35:16,908
EVIDENCE PRACTICE INTO THE

854
00:35:16,908 --> 00:35:19,277
STRUCTURE, PROCESSES AND EFFECTS

855
00:35:19,277 --> 00:35:20,144
OF HEALTH SERVICES FOR

856
00:35:20,144 --> 00:35:26,351
INDIVIDUALS AND POPULATIONS AND

857
00:35:26,351 --> 00:35:31,422
LEADS TO CHANGE AND SO IT'S A

858
00:35:31,422 --> 00:35:31,956
CONTINUUM.

859
00:35:31,956 --> 00:35:36,661
LET'S LOOK AT PRESCRIBING

860
00:35:36,661 --> 00:35:37,328
PRIMARY CARE?

861
00:35:37,328 --> 00:35:42,967
YOU WILL ALSO NOTICE THIS IS

862
00:35:42,967 --> 00:35:44,936
THESE ARE YEARS OF BABY STEPS.

863
00:35:44,936 --> 00:35:47,505
THIS ISN'T LIKE A BREAK THROUGH,

864
00:35:47,505 --> 00:35:49,040
AND EVERYTHING'S   PERFEC, SO

865
00:35:49,040 --> 00:35:52,443
IT'S KIND OF SLOGGING ALONG, AND

866
00:35:52,443 --> 00:35:57,515
USING THESE TOOLS TO TRY TO MAKE

867
00:35:57,515 --> 00:35:59,717
A CHANGE SO THIS IS RESEARCH TO

868
00:35:59,717 --> 00:36:02,987
DISCOVERING NEW KNOWLEDGE TO

869
00:36:02,987 --> 00:36:07,091
QUALITY IMPROVEMENT AND

870
00:36:07,091 --> 00:36:08,126
IMPLEMENTATION SO OBVIOUSLY WE

871
00:36:08,126 --> 00:36:09,193
ALWAYS HAVE TO REDEFINE THE

872
00:36:09,193 --> 00:36:11,963
PROBLEM, SO WE CONTINUE TO HAVE

873
00:36:11,963 --> 00:36:14,899
OVERUSE OF ANTIBI BIOTICS IN

874
00:36:14,899 --> 00:36:15,700
CHILDREN.

875
00:36:15,700 --> 00:36:18,469
AT LEAST 30% OF ASPECT BIOTICS

876
00:36:18,469 --> 00:36:25,176
IN OUT PATIENT SETTINGS ARE

877
00:36:25,176 --> 00:36:26,210
PROBABLY UNNECESSARY AND IT'S

878
00:36:26,210 --> 00:36:27,545
EVEN MORE APPARENT TO ME THAT

879
00:36:27,545 --> 00:36:30,815
THE USE OF ANTIBIOTICS HAS SOME

880
00:36:30,815 --> 00:36:34,685
DOWN STREAM EFFECTS NOW, WHEN I

881
00:36:34,685 --> 00:36:35,386
FIRST STARTED WORRYING ABOUT

882
00:36:35,386 --> 00:36:40,825
THIS IN THE LATE 80S, EARLY 90S.

883
00:36:40,825 --> 00:36:42,460
ANTIBIOTIC RESISTANCE, WE WERE

884
00:36:42,460 --> 00:36:43,628
ALWAYS WORRIED ABOUT ADVERSE

885
00:36:43,628 --> 00:36:45,063
DRUG EFFECTS, WE WERE ALWAYS

886
00:36:45,063 --> 00:36:46,664
WORRIED ABOUT, BUT WHAT ARE THE

887
00:36:46,664 --> 00:36:48,499
LONG-TERM IMPACTS ON THE

888
00:36:48,499 --> 00:36:48,833
MICROBIOME.

889
00:36:48,833 --> 00:36:51,636
THERE ARE SOME CONFLICTING DATA,

890
00:36:51,636 --> 00:36:54,839
I ADMIT ABOUT ANTIBIOTIC USE,

891
00:36:54,839 --> 00:36:56,808
MULTIPLE COURSES OF ANTIBIOTICS

892
00:36:56,808 --> 00:36:59,310
IN THE FIRST 2 YEARS OF LIFE AND

893
00:36:59,310 --> 00:36:59,677
OBESITY.

894
00:36:59,677 --> 00:37:02,146
THERE'S A PARTNERSHIP I JUST

895
00:37:02,146 --> 00:37:05,183
READ 2 DAYS AGO ABOUT MULTIPLE

896
00:37:05,183 --> 00:37:06,651
ANTIBIOTICKINGS IN ADULTS AND

897
00:37:06,651 --> 00:37:08,653
THE DEVELOPMENT OF IBD.

898
00:37:08,653 --> 00:37:16,861
THERE'S A RISK FACTOR FOR THAT.

899
00:37:16,861 --> 00:37:19,530
SO I THINK WE NEED TO BE MORE

900
00:37:19,530 --> 00:37:24,936
PRECISE ABOUT HOW WE PRESCRIBE

901
00:37:24,936 --> 00:37:26,204
ANTIBIOTICS, I WAS WORRY BODY

902
00:37:26,204 --> 00:37:27,705
THIS FOR A LONG TIME.

903
00:37:27,705 --> 00:37:29,841
THIS A BOOK FOR PARENTS CALLED

904
00:37:29,841 --> 00:37:30,775
BREAKING THE ANTIBIOTIC HABIT

905
00:37:30,775 --> 00:37:40,051
AND I'M NOT SURE, AGAIN, BABY

906
00:37:40,051 --> 00:37:40,418
STEPS.

907
00:37:40,418 --> 00:37:43,354
SO WE STARTED LOOKING AT THIS

908
00:37:43,354 --> 00:37:48,025
AND I GIVE JEFF [INDISCERNIBLE]

909
00:37:48,025 --> 00:37:49,127
THE PROPS FOR THIS BECAUSE WE

910
00:37:49,127 --> 00:37:50,928
CONTINUE TO DO IT EMPLOY WE HAVE

911
00:37:50,928 --> 00:37:52,330
WITH THIS LARGE PRACTICE BASED

912
00:37:52,330 --> 00:37:54,999
RESEARCH NETWORK WE CAN LOOK AT

913
00:37:54,999 --> 00:37:57,235
PRESCRIBING RATES IN THESE 31

914
00:37:57,235 --> 00:37:57,969
DIFFERENT PRACTICES.

915
00:37:57,969 --> 00:38:00,204
SO THERE WERE -- THERE WERE

916
00:38:00,204 --> 00:38:02,607
VARIED RATES OF DIAGNOSIS ACROSS

917
00:38:02,607 --> 00:38:05,776
THE NETWORK, SO, SOME PRACTICES,

918
00:38:05,776 --> 00:38:09,914
THE DIAGNOSTIC RATE WAS 8% OF

919
00:38:09,914 --> 00:38:11,983
OTITIS MEDIA, SOME 20, SIGNUE

920
00:38:11,983 --> 00:38:18,222
SIGHT ISOTOPE, STREP AND

921
00:38:18,222 --> 00:38:19,357
PNEUMONIA, SO THERE'S A

922
00:38:19,357 --> 00:38:21,092
VARIATION OF HOW OFTEN THESE

923
00:38:21,092 --> 00:38:23,995
DIAGNOSIS ARE BEING MADE ACROSS

924
00:38:23,995 --> 00:38:25,830
THE NETWORK.

925
00:38:25,830 --> 00:38:27,832
SO WE DECIDED TO LOOK AT THIS

926
00:38:27,832 --> 00:38:34,205
CAREFULLY AND OUR GOAL FOR THIS

927
00:38:34,205 --> 00:38:36,174
STUDY WAS TO HELP PROVIDERS USE

928
00:38:36,174 --> 00:38:38,276
THE MOST NARROW SPECTRUM

929
00:38:38,276 --> 00:38:40,945
ANTIBIOTICS FOR THE ACUTE

930
00:38:40,945 --> 00:38:42,480
RESPIRATORY TRACT INFECS THAT

931
00:38:42,480 --> 00:38:43,681
ARE THE MOST COMMON REASONS THEY

932
00:38:43,681 --> 00:38:45,249
COME TO EITHER THE EMERGENCY

933
00:38:45,249 --> 00:38:49,253
DEPARTMENT OR PRIMARY CARE.

934
00:38:49,253 --> 00:38:51,322
WE USED A CLUSTER RANDOMIZED

935
00:38:51,322 --> 00:38:54,892
TRIAL WITH OUR PRACTICES AND WE

936
00:38:54,892 --> 00:38:59,030
GAVE AUDIT AND FEEDBACK REPORTS

937
00:38:59,030 --> 00:39:00,798
TO THE INTERVENTION PRACTICES

938
00:39:00,798 --> 00:39:01,899
COMPARED TO THE CONTROLS WHO

939
00:39:01,899 --> 00:39:03,234
DIDN'T GET ANYTHING.

940
00:39:03,234 --> 00:39:05,536
AND I LOVE AUDIT AND FEEDBACK, I

941
00:39:05,536 --> 00:39:06,804
THINK IT'S 1 OF THE MOST

942
00:39:06,804 --> 00:39:11,542
POWERFUL TOOLS WE CAN USE IN

943
00:39:11,542 --> 00:39:13,044
QUALITY IMPROVEMENT AND WE

944
00:39:13,044 --> 00:39:15,880
WANTED THE APPROPRIATE

945
00:39:15,880 --> 00:39:20,851
ANTIBIOTIC FOR PNEUMONIA,

946
00:39:20,851 --> 00:39:28,192
SIGNUEICITIS, AND STREP, USUALLY

947
00:39:28,192 --> 00:39:29,160
AMOXACILLIN, THIS IS THE REPORT

948
00:39:29,160 --> 00:39:33,164
WE WOULD GIVE TO THE

949
00:39:33,164 --> 00:39:36,000
PEDIATRICIANS; YOU, THE

950
00:39:36,000 --> 00:39:42,139
ANTIBIOTICS FOR ACUTE SINEW

951
00:39:42,139 --> 00:39:44,141
SITIS THAT YOU PRESCRIBED, TO

952
00:39:44,141 --> 00:39:45,109
BASE LINE, QUARTER 1, THIS IS

953
00:39:45,109 --> 00:39:47,945
YOUR PRACTICE AND THIS IS THE

954
00:39:47,945 --> 00:39:48,179
NETWORK.

955
00:39:48,179 --> 00:39:54,652
SO EVERYBODY GOT THESE REPORTS

956
00:39:54,652 --> 00:39:57,288
IN A STANDARD WAY, PUSHED OUT TO

957
00:39:57,288 --> 00:40:02,093
THEM AND WE SAW A NICE -- WHEN

958
00:40:02,093 --> 00:40:04,495
WE STARTED GIVING THE REPORTS WE

959
00:40:04,495 --> 00:40:05,696
SAW A REALLY NICE EFFECT.

960
00:40:05,696 --> 00:40:07,999
THE PHYSICIANS WHO WERE GETTING

961
00:40:07,999 --> 00:40:11,168
THE REPORTS STOPPED PRESCRIBING

962
00:40:11,168 --> 00:40:13,237
BROAD SPECTRUM ANTIBIOTICS AND

963
00:40:13,237 --> 00:40:13,971
BECAME MORE APPROPRIATE.

964
00:40:13,971 --> 00:40:15,106
SO THAT WAS WONDERFUL.

965
00:40:15,106 --> 00:40:17,008
WE WERE SO HAPPY, WE PUBLISHED

966
00:40:17,008 --> 00:40:17,475
IT.

967
00:40:17,475 --> 00:40:19,410
IT WAS MY FIRST ARTICLE THAT I

968
00:40:19,410 --> 00:40:21,312
HAD EVER GOTTEN PUBLISHED IN

969
00:40:21,312 --> 00:40:22,513
JAMA, I WAS REALLY HAPPY ABOUT

970
00:40:22,513 --> 00:40:24,582
THAT AND THEN LOOK WHAT

971
00:40:24,582 --> 00:40:33,758
HAPPENED, WE STOPPED THE STUDY

972
00:40:33,758 --> 00:40:35,226
AND WHAT HAPPENED?

973
00:40:35,226 --> 00:40:37,495
THEY TARTED PRESCRIBING BROAD

974
00:40:37,495 --> 00:40:38,062
SPECTRUM ANTIBIOTICS AGAIN.

975
00:40:38,062 --> 00:40:44,335
SO IT WAS GREAT BECAUSE WE GOT

976
00:40:44,335 --> 00:40:46,370
THAT PUBLISHED TOO.

977
00:40:46,370 --> 00:40:46,771
[LAUGHTER]

978
00:40:46,771 --> 00:40:47,905
SO THERE'S A PROBLEM THERE,

979
00:40:47,905 --> 00:40:48,139
RIGHT?

980
00:40:48,139 --> 00:40:49,473
SO WE DECIDED THIS IS HELT

981
00:40:49,473 --> 00:40:50,141
SERVICES RESEARCH.

982
00:40:50,141 --> 00:40:52,009
THIS IS DISCOVERING NEW

983
00:40:52,009 --> 00:40:58,182
KNOWLEDGE, NOW LET'S BRING IT

984
00:40:58,182 --> 00:40:59,884
INTO QUALITY IMPROVEMENT.

985
00:40:59,884 --> 00:41:02,820
OH, ALSO, ALSO ALWAYS LOOK FOR

986
00:41:02,820 --> 00:41:06,257
WHEN YOU'RE DOING THESE DATA

987
00:41:06,257 --> 00:41:07,725
ANALYSIS FOR DISPARITIES BY

988
00:41:07,725 --> 00:41:10,461
INCOME, RACE AND GENDER.

989
00:41:10,461 --> 00:41:11,896
THAT'S 1 TENET THAT I THINK WE

990
00:41:11,896 --> 00:41:14,298
REALLY NEED TO MAKE SURE WE DO

991
00:41:14,298 --> 00:41:17,935
AND WE DID FIND RACIAL

992
00:41:17,935 --> 00:41:20,104
DIFFERENCES IN ANTIBIOTIC

993
00:41:20,104 --> 00:41:21,706
PRESCRIBING BY PRIMARY CARE

994
00:41:21,706 --> 00:41:22,873
PHYSICIANS, SAME DATA SET THIS,

995
00:41:22,873 --> 00:41:25,142
IS A WHOLE OTHER THING THAT WE

996
00:41:25,142 --> 00:41:26,677
POPPED UP THAT WE'RE SURPRISED

997
00:41:26,677 --> 00:41:28,612
ABOUT AND RUSS WASAUR

998
00:41:28,612 --> 00:41:29,680
BIOSTATISTICIAN AND WAS JUST

999
00:41:29,680 --> 00:41:31,048
TEARING HIS HAIR OUT TO MAKE

1000
00:41:31,048 --> 00:41:33,050
SURE THAT THIS ANALYSIS WAS DONE

1001
00:41:33,050 --> 00:41:35,753
PROPERLY AND THAT WE WEREN'T

1002
00:41:35,753 --> 00:41:38,856
MISSING SOME BIAS HE THAT WAS

1003
00:41:38,856 --> 00:41:40,024
SKEWING THE DATA AND HE'S

1004
00:41:40,024 --> 00:41:43,294
FANTASTIC AND I THINK HE, HE DID

1005
00:41:43,294 --> 00:41:45,262
THAT, AND WE FOUND THAT BLACK

1006
00:41:45,262 --> 00:41:49,333
CHILDREN IN OUR PRIMARY CARE

1007
00:41:49,333 --> 00:41:52,636
NETWORK RECEIVED FEWER

1008
00:41:52,636 --> 00:41:56,540
ANTIBIOTIC PRESCRIPTIONS THAN

1009
00:41:56,540 --> 00:42:03,147
WHITES, WERE DIAGNOSED WITH

1010
00:42:03,147 --> 00:42:04,448
FEWER ACUTE RESPIRATORY ATTACK

1011
00:42:04,448 --> 00:42:06,617
INFECTIONS AND HAD A LOWER

1012
00:42:06,617 --> 00:42:09,587
PROPORTION OF BROAD SPECTRUM

1013
00:42:09,587 --> 00:42:09,920
ANTIBIOTICS.

1014
00:42:09,920 --> 00:42:13,023
SO IT'S SORT OF THE REVERSE

1015
00:42:13,023 --> 00:42:14,992
DISPARITY, THEY GOT BETTER CARE

1016
00:42:14,992 --> 00:42:18,429
BECAUSE THEY WERE BLACK, THE

1017
00:42:18,429 --> 00:42:20,598
WHITE FOLKS GOT BROAD SPECTRUM

1018
00:42:20,598 --> 00:42:22,366
ANTIBIOTICS THEY GOT MORE X-RAYS

1019
00:42:22,366 --> 00:42:26,871
TOO, WE FOUND OUT AND THIS WAS

1020
00:42:26,871 --> 00:42:28,506
AT THE LEVEL OF SAME CLINICIAN,

1021
00:42:28,506 --> 00:42:30,374
IT WASN'T THE LEVEL OF THE

1022
00:42:30,374 --> 00:42:31,776
PRACTICE, IT WAS THE SAME

1023
00:42:31,776 --> 00:42:35,346
PROVIDER THAT THIS ANALYSIS WAS

1024
00:42:35,346 --> 00:42:38,215
DONE. 

1025
00:42:38,215 --> 00:42:39,150
SO VARYY, VARY INTERESTING.

1026
00:42:39,150 --> 00:42:42,453
SO WE'RE GOING TO MOVE FROM THAT

1027
00:42:42,453 --> 00:42:45,089
STUDY WHICH WAS DISCOVERING NEW

1028
00:42:45,089 --> 00:42:45,856
KNOWLEDGE ABOUT [INDISCERNIBLE]

1029
00:42:45,856 --> 00:42:48,058
FEEDBACK AND HOW WE CAN IMPACT

1030
00:42:48,058 --> 00:42:49,827
THE PREKRIPGZ AND BROAD SPECTRUM

1031
00:42:49,827 --> 00:42:51,962
-- NOW WE'RE GOING DO QUALITY

1032
00:42:51,962 --> 00:42:53,464
IMPROVEMENT TO REALLY TRY TO

1033
00:42:53,464 --> 00:42:55,599
REDUCE THE VARIATION OF

1034
00:42:55,599 --> 00:43:01,672
PRESCRIPTION IN THOSE 31

1035
00:43:01,672 --> 00:43:02,773
DIFFERENT PRACTICES.

1036
00:43:02,773 --> 00:43:05,709
EDWARD DEMMINGS WAS A VERY

1037
00:43:05,709 --> 00:43:06,844
FAMOUS INDUSTRIAL QUALITY

1038
00:43:06,844 --> 00:43:11,549
IMPROVEMENT PHYSICIAN -- NOT

1039
00:43:11,549 --> 00:43:12,616
PHYSICIAN, ENGINEER WHO DID A

1040
00:43:12,616 --> 00:43:14,318
LOT OF QUALITY IMPROVEMENT FOR

1041
00:43:14,318 --> 00:43:17,721
THE WEAPONRY THAT WE WERE

1042
00:43:17,721 --> 00:43:18,989
PRODUCING IN WORLD WAR II BUT HE

1043
00:43:18,989 --> 00:43:21,325
ALSO WENT OVER TO JAPAN, AFTER

1044
00:43:21,325 --> 00:43:25,362
WORLD WAR II AND REALLY

1045
00:43:25,362 --> 00:43:27,731
REDESIGNED ALL THEIR

1046
00:43:27,731 --> 00:43:30,367
MANUFACTURING, IN TERMS OF THE

1047
00:43:30,367 --> 00:43:30,601
QUALITY.

1048
00:43:30,601 --> 00:43:32,136
YOU CAN'T MANAGE WHAT YOU DON'T

1049
00:43:32,136 --> 00:43:33,704
MEASURE, SO MEASUREMENT IS A

1050
00:43:33,704 --> 00:43:36,106
VERY IMPORTANT PART OF QUALITY

1051
00:43:36,106 --> 00:43:38,242
IMPROVEMENT AND A BAD SYSTEM

1052
00:43:38,242 --> 00:43:43,147
WILL GET A GOOD  -- BEAT A GOODN

1053
00:43:43,147 --> 00:43:43,547
EVERY TIME.

1054
00:43:43,547 --> 00:43:46,750
SO THIS IS A SYSTEM ANALYSIS.

1055
00:43:46,750 --> 00:43:47,952
PAUL [INDISCERNIBLE] IS A FAMILY

1056
00:43:47,952 --> 00:43:54,725
DOCTOR AND HE LIKES TO LINK THE

1057
00:43:54,725 --> 00:43:57,027
OUTCOMES, PATIENT OUTCOMES TO

1058
00:43:57,027 --> 00:43:58,529
SYSTEMS TO WELLNESS FOR

1059
00:43:58,529 --> 00:43:59,263
PROVIDERS.

1060
00:43:59,263 --> 00:44:01,065
HE THINKS THAT'S THE LENGTH THAT

1061
00:44:01,065 --> 00:44:02,233
WE SHOULD REALLY START BECAUSE

1062
00:44:02,233 --> 00:44:03,734
THE MORE EFFICIENT THE SYSTEM,

1063
00:44:03,734 --> 00:44:05,503
THE BETTER OFF WE'RE FEELING

1064
00:44:05,503 --> 00:44:09,673
ABOUT THE OUTCOMES FOR OUR

1065
00:44:09,673 --> 00:44:09,940
PATIENTS.

1066
00:44:09,940 --> 00:44:11,108
EVERY SYSTEM IS DESIGNED TO GET

1067
00:44:11,108 --> 00:44:13,377
THE RESULTS IT GETS, SO IF YOU

1068
00:44:13,377 --> 00:44:14,411
WANT DIFFERENT RESULTS, YOU HAVE

1069
00:44:14,411 --> 00:44:16,380
TO CHANGE THE SYSTEM, SO THIS IS

1070
00:44:16,380 --> 00:44:18,749
A SYSTEMS APPROACH TO EVERYTHING

1071
00:44:18,749 --> 00:44:19,550
WE DO.

1072
00:44:19,550 --> 00:44:22,953
SO I DID TAKE A SEBATICLE IN

1073
00:44:22,953 --> 00:44:26,991
2012 AND SPENT TIME AT

1074
00:44:26,991 --> 00:44:28,626
INTERMOUNTAIN HEALTH AT A COURSE

1075
00:44:28,626 --> 00:44:31,762
AND IT WAS 160 HOURS OF TEACHING

1076
00:44:31,762 --> 00:44:32,630
ABOUT QUALITY IMPROVEMENT AND

1077
00:44:32,630 --> 00:44:35,666
THESE ARE THE 5 THINGS THAT THAT

1078
00:44:35,666 --> 00:44:37,735
IF YOU COULD REALLY DISTILL

1079
00:44:37,735 --> 00:44:39,270
EVERYTHING DOWN FROM THAT 160

1080
00:44:39,270 --> 00:44:44,008
HOURS, THIS IS WHAT I LEARNED.

1081
00:44:44,008 --> 00:44:47,278
VARIATION IN HEALTHCARE IS BAD.

1082
00:44:47,278 --> 00:44:49,813
AND THEN THERE'S THIS

1083
00:44:49,813 --> 00:44:50,948
PROVOCATIVE SENTENCE IN RED,

1084
00:44:50,948 --> 00:44:53,584
IT'S MORE IMPORTANT TO DO IT THE

1085
00:44:53,584 --> 00:44:55,653
SAME THAN TO DO IT THE RIGHT

1086
00:44:55,653 --> 00:44:57,087
WAY.

1087
00:44:57,087 --> 00:44:58,722
SO THAT MEANS YOU'RE IN A ROOM

1088
00:44:58,722 --> 00:45:01,559
AND YOU'VE GOT A PROBLEM WITH

1089
00:45:01,559 --> 00:45:05,262
SOME ASPECT OF THE CARE AND YOU

1090
00:45:05,262 --> 00:45:07,798
HAVE 5 PEOPLE WHO HAVE

1091
00:45:07,798 --> 00:45:09,833
FUNDAMENTAL KNOWLEDGE OF THE

1092
00:45:09,833 --> 00:45:10,568
PROCEDURE OR FUNDAMENTAL

1093
00:45:10,568 --> 00:45:11,669
KNOWLEDGE OF THE PROTOCOL AND

1094
00:45:11,669 --> 00:45:12,770
THEY ALL HAVE A DIFFERENT VIEW

1095
00:45:12,770 --> 00:45:15,940
OF HOW TO DO IT THE RIGHT WAY.

1096
00:45:15,940 --> 00:45:17,808
AND WHAT YOU NEED TO DO AS THE

1097
00:45:17,808 --> 00:45:23,380
LEADER OF THIS PROJECT IS TO

1098
00:45:23,380 --> 00:45:24,915
CONVINCE THEM, ABANDON WHAT YOU

1099
00:45:24,915 --> 00:45:27,551
THINK IS RIGHT AND ALL AGREE ON

1100
00:45:27,551 --> 00:45:30,988
DOING IT THE SAME WAY AND I WILL

1101
00:45:30,988 --> 00:45:33,290
AND NUMBER 2, I WILL MEASURE IT

1102
00:45:33,290 --> 00:45:34,425
AND I WILL MEASURE THE OUTCOMES

1103
00:45:34,425 --> 00:45:37,661
AND I WILL GIVE YOU -- I WILL

1104
00:45:37,661 --> 00:45:39,630
GIVE YOU FEEDBACK ABOUT

1105
00:45:39,630 --> 00:45:40,230
EVERYTHING THAT'S HAPPENING.

1106
00:45:40,230 --> 00:45:43,267
IT'S HARD TO DO THIS SOMETIMES

1107
00:45:43,267 --> 00:45:44,768
AND I DON'T KNOW IF THERE ARE

1108
00:45:44,768 --> 00:45:46,437
ANY SURGEONS IN THE ROOM BUT

1109
00:45:46,437 --> 00:45:50,441
IT'S PARTICULARLY HARD TO DO IT

1110
00:45:50,441 --> 00:45:52,743
WITH SURGEONS BUT I DON'T WANT

1111
00:45:52,743 --> 00:45:53,777
TO OFFEND ANYBODY.

1112
00:45:53,777 --> 00:45:55,179
AS QUALITY IMPROVE, SAFETY AND

1113
00:45:55,179 --> 00:45:56,013
EQUITY IMPROVE AND COST GOES

1114
00:45:56,013 --> 00:45:58,649
DOWN AND THEN THIS IS A REALLY

1115
00:45:58,649 --> 00:46:01,418
IMPORTANT 1, THE SUCCESS OF THIS

1116
00:46:01,418 --> 00:46:03,153
PROJECT DEPENDS ON THOSE WITH

1117
00:46:03,153 --> 00:46:04,755
THE FUNDAMENTAL KNOWLEDGE OF

1118
00:46:04,755 --> 00:46:05,422
WHAT YOU'RE DOING.

1119
00:46:05,422 --> 00:46:07,157
YOU DON'T WANT THE SECTION

1120
00:46:07,157 --> 00:46:08,792
CHIEFS, YOU DON'T WANT THE

1121
00:46:08,792 --> 00:46:13,731
DIVISION CHIEFS, YOU WANT THE

1122
00:46:13,731 --> 00:46:16,166
NURSE PRACTITIONERS, YOU WANT

1123
00:46:16,166 --> 00:46:18,135
THE RESPIRATORY TECHNICIANS, YOU

1124
00:46:18,135 --> 00:46:19,637
WANT FOLKS IN THE ROOM WHO KNOW

1125
00:46:19,637 --> 00:46:22,339
WHAT THE PROCESS AT THE BEDSIDE

1126
00:46:22,339 --> 00:46:24,341
IS, AND IT'S INNOVATIVE.

1127
00:46:24,341 --> 00:46:25,743
IT'S AN INNOVATIVE PROCESS, SO

1128
00:46:25,743 --> 00:46:28,345
HERE'S MY FAVORITE CLASSIC

1129
00:46:28,345 --> 00:46:31,615
ARTICLE, AND AGAIN, I'M A FAN OF

1130
00:46:31,615 --> 00:46:32,282
AUDIT AND FEEDBACK.

1131
00:46:32,282 --> 00:46:39,123
SO THIS IS FROM 1977.

1132
00:46:39,123 --> 00:46:44,928
THESE AUTHORS ARE PRETTY FAMOUS

1133
00:46:44,928 --> 00:46:48,332
AND THEY DID A AUDIT AND

1134
00:46:48,332 --> 00:46:53,170
FEEDBACK IN CHANGES IN

1135
00:46:53,170 --> 00:46:54,238
TONSILLECTOMY RATES IN REVIEW,

1136
00:46:54,238 --> 00:46:57,641
THIS IS WHAT THEY FOUND IN 1969

1137
00:46:57,641 --> 00:47:00,577
THIS, IS THE RATE PER 10,000

1138
00:47:00,577 --> 00:47:05,849
KIDS OF TONSILLECTOMY AND THESE

1139
00:47:05,849 --> 00:47:07,685
AT THE AMONG 13 VERMONT

1140
00:47:07,685 --> 00:47:09,987
HOSPITAL, AND YOU CAN SEE

1141
00:47:09,987 --> 00:47:13,190
THEY'RE DOING A WHOLE LOT OF

1142
00:47:13,190 --> 00:47:13,924
TONSILLECTOMYS SO THEY DID

1143
00:47:13,924 --> 00:47:15,192
FEEDBACK, SO WHEN YOU START A

1144
00:47:15,192 --> 00:47:16,860
PROJECT AND YOU DO AUDIT AND

1145
00:47:16,860 --> 00:47:19,029
FEEDBACK, THESE ARE THE STAGES

1146
00:47:19,029 --> 00:47:20,330
OF GRIEVE OF WHAT THE COMMITTEE

1147
00:47:20,330 --> 00:47:22,866
AND WHAT THE GROUP IS GOING TO

1148
00:47:22,866 --> 00:47:26,136
SAY TO YOU WHEN YOU PRESENT THEM

1149
00:47:26,136 --> 00:47:27,371
WITH THE AUDIT AND FEEDBACK.

1150
00:47:27,371 --> 00:47:29,540
THEY WILL SAY THE DATA IS WRONG,

1151
00:47:29,540 --> 00:47:32,609
YOU HAVE THE WRONG DATA AND SO

1152
00:47:32,609 --> 00:47:33,911
THEN YOU WILL HAVE TO MAKE SURE

1153
00:47:33,911 --> 00:47:35,879
THE DATA IS RIGHT AND THEN

1154
00:47:35,879 --> 00:47:37,281
THEY'LL SAY THE DATA IS RIGHT

1155
00:47:37,281 --> 00:47:38,182
BUT ASTERISKS NOT A PROBLEM

1156
00:47:38,182 --> 00:47:40,284
BECAUSE WE'RE THE CHILDREN'S

1157
00:47:40,284 --> 00:47:41,185
HOSPITAL OF PHILADELPHIA.

1158
00:47:41,185 --> 00:47:43,120
AND OUR PATIENTS ARE MUCH SICKER

1159
00:47:43,120 --> 00:47:44,955
THAN EVERYBODY ELSE, SO WE'RE AT

1160
00:47:44,955 --> 00:47:49,259
A DIFFERENT STANDARD WHICH IS

1161
00:47:49,259 --> 00:47:50,394
NEVER THE CASE.

1162
00:47:50,394 --> 00:47:52,029
AND THEN STAGE 3 IS THE DATA'S

1163
00:47:52,029 --> 00:47:53,964
RIGHT, IT'S A PROBLEM BUT I'M

1164
00:47:53,964 --> 00:47:54,531
PRETTY GOOD.

1165
00:47:54,531 --> 00:47:58,001
IT'S NOT PRY PROBLEM.

1166
00:47:58,001 --> 00:48:00,270
AND THEN THE FOURTH STAGE IS I

1167
00:48:00,270 --> 00:48:02,005
ACCEPT AND I WILL CHANGE.

1168
00:48:02,005 --> 00:48:04,608
AND THIS IS REALLY CONSISTENT

1169
00:48:04,608 --> 00:48:06,910
WITH YOUR DISCUSSIONS IN THESE

1170
00:48:06,910 --> 00:48:08,979
PROGECS AND YOU CAN SEE IN THIS

1171
00:48:08,979 --> 00:48:12,816
CLASSIC PAPER, YOU CAN SEE, WHAT

1172
00:48:12,816 --> 00:48:14,952
HAPPENS AND WE IN MEDICINE ARE

1173
00:48:14,952 --> 00:48:16,887
TYPE A.

1174
00:48:16,887 --> 00:48:18,856
THIS IS NO MONEY EXCHANGED HERE,

1175
00:48:18,856 --> 00:48:20,491
THIS WAS NOT TRANSACTIONAL AT

1176
00:48:20,491 --> 00:48:22,126
ALL, THIS IS JUST GIVING THEM

1177
00:48:22,126 --> 00:48:29,666
THE REPORT AND EVERYTHING

1178
00:48:29,666 --> 00:48:29,933
IMPROVED.

1179
00:48:29,933 --> 00:48:31,168
SO, WE HAVE THIS IDEA THAT WE

1180
00:48:31,168 --> 00:48:32,803
ARE GOING TO GIVE AUDIT AND

1181
00:48:32,803 --> 00:48:37,007
FEEDBACK AND WE'RE GOING TO

1182
00:48:37,007 --> 00:48:38,475
IMPROVE THE PRESCRIBING AND

1183
00:48:38,475 --> 00:48:45,415
DRIVE DOWN BROAD SPECTRUM

1184
00:48:45,415 --> 00:48:48,519
ANTIBIOTIC USE FOR THESE ACUTE

1185
00:48:48,519 --> 00:48:50,354
RESPIRATORY INFECTIONS IN KIDS,

1186
00:48:50,354 --> 00:48:53,323
YOU CAN SEE THE PNEUMONIA

1187
00:48:53,323 --> 00:48:54,758
PATHWAY, JEFF GERBER AND SOME OF

1188
00:48:54,758 --> 00:48:56,293
US WERE INVOLVED IN AUTHORING IN

1189
00:48:56,293 --> 00:49:00,264
PATHWAY AND IT'S A PROCESS TO

1190
00:49:00,264 --> 00:49:05,335
COME UP WITH THIS AND IT'S -- WE

1191
00:49:05,335 --> 00:49:06,637
STARTED GIVING AUDIT AND

1192
00:49:06,637 --> 00:49:12,109
FEEDBACK, SO ALONG THE X-AXIS OR

1193
00:49:12,109 --> 00:49:14,511
ALL THE PRACTICES, AND THIS IS

1194
00:49:14,511 --> 00:49:17,981
THE PERCENT PRESCRIBING

1195
00:49:17,981 --> 00:49:19,316
APPROPRIATE ANTIBIOTICS.

1196
00:49:19,316 --> 00:49:25,722
AND WE HAD A BAR AND YOU CAN SEE

1197
00:49:25,722 --> 00:49:27,491
GREEN, THESE PRACTICES ARE DOING

1198
00:49:27,491 --> 00:49:37,901
PRETTY WELL AND WE HAVE

1199
00:49:39,303 --> 00:49:41,672
SIGNUEICITIS, OTITIS MEDIA,

1200
00:49:41,672 --> 00:49:43,240
PHARYNGITIS AND PNEUMONIA, THEY

1201
00:49:43,240 --> 00:49:50,681
CAN CLICK ON THIS DATA AND OVER

1202
00:49:50,681 --> 00:49:52,182
TIME IN 2013, 2012 AND IT'S

1203
00:49:52,182 --> 00:49:53,684
CONTINUING AND THE APPROPRIATE

1204
00:49:53,684 --> 00:50:04,161
ANTIBIOTICS ARE IN THE 98-100%

1205
00:50:04,161 --> 00:50:04,528
NOW.

1206
00:50:04,528 --> 00:50:11,134
SO, BUT WHAT ABOUT LENGTH OF

1207
00:50:11,134 --> 00:50:12,970
THERAPY SO WE KNOW THAT

1208
00:50:12,970 --> 00:50:14,605
PNEUMONIA IS 5 DAYS RIGHT?

1209
00:50:14,605 --> 00:50:18,709
SO WE NEED TO LOOK AT THAT PIECE

1210
00:50:18,709 --> 00:50:19,209
WHICH WE ARE.

1211
00:50:19,209 --> 00:50:21,445
WE ALSO NEED TO LOOK AT, I WAS

1212
00:50:21,445 --> 00:50:24,214
JUST ON SERVICE AND PATIENTS WHO

1213
00:50:24,214 --> 00:50:27,050
ARE IN THE FIRST -- WHO ARE

1214
00:50:27,050 --> 00:50:30,087
PRESCHOOL AGED WHO HAVE

1215
00:50:30,087 --> 00:50:31,755
PNEUMONIA HAVE AN INFILTRATE,

1216
00:50:31,755 --> 00:50:34,625
85% OF THE TIME THAT'S A VIRUS,

1217
00:50:34,625 --> 00:50:36,627
AND THEY DON'T NEED AN

1218
00:50:36,627 --> 00:50:39,096
ANTIBIOTIC, BUT IT'S REALLY HARD

1219
00:50:39,096 --> 00:50:41,265
TO WITHHOLD ANTIBIOTICS FOR

1220
00:50:41,265 --> 00:50:44,101
PNEUMONIA BECAUSE THERE'S

1221
00:50:44,101 --> 00:50:44,935
DIAGNOSTIC UNCERTAINTY, THE

1222
00:50:44,935 --> 00:50:50,941
PARENTS HAVE A CERTAIN

1223
00:50:50,941 --> 00:50:52,809
EXPECTATION, PNEUMONIA IS A

1224
00:50:52,809 --> 00:50:54,645
SCARY WORD AND IF YOU'RE

1225
00:50:54,645 --> 00:50:55,512
PRACTICING IN THE EMERGENCY

1226
00:50:55,512 --> 00:50:56,680
DEPARTMENT THERE'S GOING TO BE A

1227
00:50:56,680 --> 00:50:57,614
FOLLOW UP ISSUE, SO WE'RE

1228
00:50:57,614 --> 00:51:06,757
LOOKING AT HOW WE CAN CHANGE AND

1229
00:51:06,757 --> 00:51:11,962
THERE'S A LARGE STUDY AT

1230
00:51:11,962 --> 00:51:12,996
[INDISCERNIBLE] THAT'S LOOKING

1231
00:51:12,996 --> 00:51:14,398
AT THIS AND GOING FORWARD AND

1232
00:51:14,398 --> 00:51:15,332
WE'RE ALREADY STARTING TO DO

1233
00:51:15,332 --> 00:51:18,835
THIS IS THAT IN THE APPROPRIATE

1234
00:51:18,835 --> 00:51:20,337
SETTINGS, PRESCHOOL AGE CHILD,

1235
00:51:20,337 --> 00:51:23,307
NOT THAT SICK, LOW GRADE FEVER,

1236
00:51:23,307 --> 00:51:25,575
MAYBE HAS AN INFILTRATE, GIVE

1237
00:51:25,575 --> 00:51:26,643
THEM A PRESCRIPTION AND TELL

1238
00:51:26,643 --> 00:51:28,946
THEM NOT TO FILL IT UNLESS THEY

1239
00:51:28,946 --> 00:51:32,215
GET SICKER OR ON FOLLOW-UP WITH

1240
00:51:32,215 --> 00:51:32,749
THEIR PEDIATRICIAN.

1241
00:51:32,749 --> 00:51:36,119
WE'RE WORKING OUT THAT PROTOCOL,

1242
00:51:36,119 --> 00:51:38,889
BUT I THINK THAT MAY BE THE NEXT

1243
00:51:38,889 --> 00:51:41,959
ITERATION OF TRYING TO DRIVE

1244
00:51:41,959 --> 00:51:44,494
DOWN AND IMPLEMENTATION SCIENCE,

1245
00:51:44,494 --> 00:51:46,596
WE'RE LUCKY, I WAS LUCKY ENOUGH

1246
00:51:46,596 --> 00:51:52,235
TO BE COINVESTIGATOR ON THIS PC

1247
00:51:52,235 --> 00:51:54,438
ORI GRANLT WITH ALEX FIX, AND

1248
00:51:54,438 --> 00:51:57,674
THIS IS CALLED THE HEALTH

1249
00:51:57,674 --> 00:52:00,277
SYSTEMS IMPLEMENTATION

1250
00:52:00,277 --> 00:52:01,478
INITIATIVE, THE

1251
00:52:01,478 --> 00:52:03,513
HHS II INITIATIVE AND IF YOU

1252
00:52:03,513 --> 00:52:05,716
WERE SELECTED AS AN ACADEMIC

1253
00:52:05,716 --> 00:52:06,316
INSTITUTION, WITH THE RIGHT

1254
00:52:06,316 --> 00:52:09,186
BONES IF YOU WILL, WITH THE

1255
00:52:09,186 --> 00:52:11,989
RIGHT INFRASTRUCTURE TO DO PC

1256
00:52:11,989 --> 00:52:13,357
ORI IMPLEMENTATION PROJECTS AND

1257
00:52:13,357 --> 00:52:14,624
MEASURE THEIR IMPACT AND PROVE

1258
00:52:14,624 --> 00:52:17,127
THAT THEY'VE BEEN SUSTAINED THEN

1259
00:52:17,127 --> 00:52:19,529
YOU CAN BE PART OF THIS GROUP

1260
00:52:19,529 --> 00:52:23,400
AND THEN YOU ARE ALLOWED TO

1261
00:52:23,400 --> 00:52:26,503
RAISE YOUR HAND FOR A REQUEST

1262
00:52:26,503 --> 00:52:27,537
FOR PROPOSALS.

1263
00:52:27,537 --> 00:52:30,607
THAT PC ORI HANDS DOWN THEY TELL

1264
00:52:30,607 --> 00:52:31,675
YOU WHAT THEY'RE INTERESTED IN

1265
00:52:31,675 --> 00:52:33,410
AND THESE ARE PROGEBS THAT HAVE

1266
00:52:33,410 --> 00:52:35,712
BEEN PROVEN TO WORK IN THE HEGHT

1267
00:52:35,712 --> 00:52:37,547
HEALTH SERVICES RESEARCH AND THE

1268
00:52:37,547 --> 00:52:38,715
QUALITY IMPROVEMENT REALM AND

1269
00:52:38,715 --> 00:52:41,585
NOW THEY WANT TO BE -- THEY WANT

1270
00:52:41,585 --> 00:52:43,120
PC ORI TO SPREAD THEM AND

1271
00:52:43,120 --> 00:52:46,289
IMPLEMENT THEM ACROSS THE

1272
00:52:46,289 --> 00:52:46,523
COUNTRY.

1273
00:52:46,523 --> 00:52:48,258
WE'RE CURRENTLY IN OUR CAPACITY

1274
00:52:48,258 --> 00:52:52,295
BUILDING PART AND WE JUST WERE

1275
00:52:52,295 --> 00:52:56,033
TOLD, LAST MONTH THAT WE HAD

1276
00:52:56,033 --> 00:52:59,936
BEEN SUCCESSFUL IN GETTING

1277
00:52:59,936 --> 00:53:01,004
SELECTED FOR THEIR FIRST

1278
00:53:01,004 --> 00:53:01,972
IMPLEMENTATION PROJECT WHICH WE

1279
00:53:01,972 --> 00:53:04,775
WERE LUCKY BECAUSE IT WAS ABOUT

1280
00:53:04,775 --> 00:53:08,178
THE USE OF ANTIBIOTICS IN

1281
00:53:08,178 --> 00:53:09,613
PRIMARY CARE SETTINGS, SO IT WAS

1282
00:53:09,613 --> 00:53:10,680
-- WE'VE BEEN WORKING ON THIS

1283
00:53:10,680 --> 00:53:13,850
FOR A WHILE SO WE WERE ABLE TO

1284
00:53:13,850 --> 00:53:16,053
DO THAT AND ON OUR CAPACITY

1285
00:53:16,053 --> 00:53:18,488
BUILDING, IT DOESN'T -- PC ORI

1286
00:53:18,488 --> 00:53:20,624
DOESN'T TELL YOU WHAT TO FOCUS

1287
00:53:20,624 --> 00:53:25,495
ON BUT WE'RE DOING AN ORGANIZAL

1288
00:53:25,495 --> 00:53:27,564
ASSESSMENT BUT WE ARE GOING TO

1289
00:53:27,564 --> 00:53:29,933
FOCUS ON OUR CLINICAL PATHWAYS,

1290
00:53:29,933 --> 00:53:30,467
WHO'S USING THEM?

1291
00:53:30,467 --> 00:53:35,372
HOW DO WE GET TO THE OUTCOMES

1292
00:53:35,372 --> 00:53:35,839
PIECE?

1293
00:53:35,839 --> 00:53:38,041
WE HAVE A LOT OF OUTCOMES, BUT

1294
00:53:38,041 --> 00:53:41,244
HOW DO WE GET TO THE DATA.

1295
00:53:41,244 --> 00:53:42,746
NOW THEN PATIENT REPORTED

1296
00:53:42,746 --> 00:53:46,016
OUTCOMES AND IMPORTANT BUT

1297
00:53:46,016 --> 00:53:48,151
NONSTANDARD APPROACH BY

1298
00:53:48,151 --> 00:53:50,921
DIFFERENT SERVICES, WE HAVE 11

1299
00:53:50,921 --> 00:53:52,389
REMOTE PATIENT MONITORING

1300
00:53:52,389 --> 00:53:53,824
PROGRAMS AT CHOP AND THEY'RE ALL

1301
00:53:53,824 --> 00:53:55,559
THIS DIFFERENT DIVISIONS AND ALL

1302
00:53:55,559 --> 00:53:57,260
DONE DIFFERENTLY AND WE REALLY

1303
00:53:57,260 --> 00:53:58,495
NEED TO STANDARDIZE THAT

1304
00:53:58,495 --> 00:54:01,264
APPROACH, SO THAT'S PART OF THIS

1305
00:54:01,264 --> 00:54:05,635
GRANT TO TRY TO MAKE IT EASIER

1306
00:54:05,635 --> 00:54:10,040
AND MORE STANDARD AND THEN

1307
00:54:10,040 --> 00:54:11,108
MEASURE THE OUTCOMES.

1308
00:54:11,108 --> 00:54:12,876
SO LESSONS LEARNED ABOUT THIS

1309
00:54:12,876 --> 00:54:14,978
SORT OF BABY STEP SLOW CAMPAIGN

1310
00:54:14,978 --> 00:54:17,714
OVER THE LAST 25 YEARS IS U.S.

1311
00:54:17,714 --> 00:54:19,783
HEALTHCARE COSTS A LOT AND IT

1312
00:54:19,783 --> 00:54:21,551
CONTINUES TO GO UP, WE NEED TO

1313
00:54:21,551 --> 00:54:26,256
IMPROVE AND I DO THINK PRACTICE

1314
00:54:26,256 --> 00:54:29,960
BASED RESEARCH DOES ALLOW YOU TO

1315
00:54:29,960 --> 00:54:31,361
DO HEALTH SERVICES RESEARCH AND

1316
00:54:31,361 --> 00:54:34,664
IT CREATES A PLATFORM FOR

1317
00:54:34,664 --> 00:54:38,935
INTRODUCING QUALITY IMPROVEMENT

1318
00:54:38,935 --> 00:54:41,238
PROJECTS AND HOPEFULLY

1319
00:54:41,238 --> 00:54:42,005
IMPLEMENTATION WHICH WE'RE

1320
00:54:42,005 --> 00:54:45,842
TRYING TO LEARN MORE ABOUT.

1321
00:54:45,842 --> 00:54:47,744
THE CLINICAL DECISION SUPPORT IS

1322
00:54:47,744 --> 00:54:49,579
ALSO REALLY IMPORTANT TO DO THE

1323
00:54:49,579 --> 00:54:53,216
RIGHT THING AND THEN THIS

1324
00:54:53,216 --> 00:54:55,819
CONTINUUM OF COMPETENCIES OF

1325
00:54:55,819 --> 00:54:57,787
HEALTH SERVICES RESEARCH, TO

1326
00:54:57,787 --> 00:55:02,259
QUALITY IMPROVEMENT, TO

1327
00:55:02,259 --> 00:55:03,360
IMPLEMENTATION, IS IMPORTANT AND

1328
00:55:03,360 --> 00:55:04,628
YOU KNOW I SUBMIT THAT

1329
00:55:04,628 --> 00:55:09,232
INVESTMENT IN THESE SERVICES

1330
00:55:09,232 --> 00:55:12,335
PARTICULARLY IN A FREE STANDING

1331
00:55:12,335 --> 00:55:14,337
CHILDREN'S HOSPITAL LIKE OURS AS

1332
00:55:14,337 --> 00:55:15,872
WELL WILL IMPROVE THE CARE FOR

1333
00:55:15,872 --> 00:55:17,507
KIDS OVER TIME BUT IT'S A WORK

1334
00:55:17,507 --> 00:55:18,708
IN PROGRESS AND CONTINUES TO BE.

1335
00:55:18,708 --> 00:55:21,178
SO I WILL STOP THERE.

1336
00:55:21,178 --> 00:55:25,549
THANK YOU  GUYS VERY MUCH.

1337
00:55:25,549 --> 00:55:28,451
THESE ARE CRITICAL PEOPLE IN MY

1338
00:55:28,451 --> 00:55:29,886
WORK LIFE THAT ARE LISTED ON THE

1339
00:55:29,886 --> 00:55:31,188
SIDE THERE AND THEN THERE'S JUST

1340
00:55:31,188 --> 00:55:36,026
A PICTURE OF SOME OF MY FAMILY.

1341
00:55:36,026 --> 00:55:37,360
SO I WILL STOP THERE AND I WILL

1342
00:55:37,360 --> 00:55:42,699
TAKE ANY QUESTIONS YOU WOULD

1343
00:55:42,699 --> 00:55:42,899
LIKE.

1344
00:55:42,899 --> 00:55:53,143
[ APPLAUSE ] 

1345
00:55:55,812 --> 00:55:58,248
HI, LOU, THAT WAS 8 GREAT TALK.

1346
00:55:58,248 --> 00:55:59,783
I HAVE A QUICK QUESTION, THESE

1347
00:55:59,783 --> 00:56:00,884
ARE ALL GREAT PROCESSES TO

1348
00:56:00,884 --> 00:56:02,285
INSURE WE HAVE BETTER CARE FOR

1349
00:56:02,285 --> 00:56:03,353
THE PATIENTS BUT I'M CURIOUS

1350
00:56:03,353 --> 00:56:05,855
WHAT YOU THINK THE EFFECTS OF

1351
00:56:05,855 --> 00:56:09,593
ALL OF THESE PATHWAYS HAVE ON

1352
00:56:09,593 --> 00:56:11,761
MEDICAL EDUCATION WHERE PEOPLE,

1353
00:56:11,761 --> 00:56:13,296
YOU KNOW STUDENTS AND RESIDENTS

1354
00:56:13,296 --> 00:56:15,932
SORT OF TURN TO THE PATHWAYS SO

1355
00:56:15,932 --> 00:56:17,667
THEY DON'T REALLY MAYBE LEARN

1356
00:56:17,667 --> 00:56:18,835
THE PATHOPHYSIOLOGY AND THE

1357
00:56:18,835 --> 00:56:21,238
REASONING BEHIND THOSE THINGS AS

1358
00:56:21,238 --> 00:56:21,605
WELL.

1359
00:56:21,605 --> 00:56:26,209
HAVE YOU MEASURED ANY OF THAT.

1360
00:56:26,209 --> 00:56:28,645
NYEAH, I HAVE A LOVE-HATE

1361
00:56:28,645 --> 00:56:30,146
RELATIONSHIP WITH PATHWAYS BUT

1362
00:56:30,146 --> 00:56:33,950
I'M THINKING PERHAPS IT'S

1363
00:56:33,950 --> 00:56:37,220
BECAUSE I WAS TRAINED IN A

1364
00:56:37,220 --> 00:56:39,623
LITTLE BIT OF A DIFFERENT ERA

1365
00:56:39,623 --> 00:56:45,295
BUT I DO THINK IF AS EDUCATORS

1366
00:56:45,295 --> 00:56:50,200
AND PROGRAM DIRECTORS IN

1367
00:56:50,200 --> 00:56:51,001
RESIDENCY TRAINING THAT WE

1368
00:56:51,001 --> 00:56:52,636
ATTEND TO THAT EDUCATIONAL

1369
00:56:52,636 --> 00:56:54,271
COMPONENT AND I THINK

1370
00:56:54,271 --> 00:56:55,905
PATHOPHYSIOLOGY AND THE

1371
00:56:55,905 --> 00:56:57,173
UNDERSTANDING OF PATHOPHYSIOLOGY

1372
00:56:57,173 --> 00:57:01,111
AND THE KEY TO MAKING GOOD

1373
00:57:01,111 --> 00:57:02,145
DECISIONS ABOUT PATIENT CARE

1374
00:57:02,145 --> 00:57:05,048
THAT'S WHY WE HAVE BEEN REALLY

1375
00:57:05,048 --> 00:57:08,251
DILIGENT ABOUT THE RESOURCES.

1376
00:57:08,251 --> 00:57:10,620
BUT I WORRY ABOUT THAT, TOO, AND

1377
00:57:10,620 --> 00:57:13,290
I WORRY ABOUT THE ANCHORING BIAS

1378
00:57:13,290 --> 00:57:14,891
OF HAVING PATIENTS ON PATHWAYS

1379
00:57:14,891 --> 00:57:18,194
AND THAT'S WHY I THINK FOR ALL

1380
00:57:18,194 --> 00:57:19,362
THE TRANSITIONS OF CARE BUT I

1381
00:57:19,362 --> 00:57:21,631
THINK WE NEED TO ADAPT TO THEM

1382
00:57:21,631 --> 00:57:24,701
AND USE THEM IN THE WAY THAT

1383
00:57:24,701 --> 00:57:26,336
WORKS AND ALSO MITIGATE THE

1384
00:57:26,336 --> 00:57:29,572
RISKS OF THE PATHWAYS BUT I HAVE

1385
00:57:29,572 --> 00:57:32,442
TO -- MEDICINE'S JUST TOO

1386
00:57:32,442 --> 00:57:32,976
COMPLICATED.

1387
00:57:32,976 --> 00:57:35,178
WE REALLY NEED HELP IN TERMS OF

1388
00:57:35,178 --> 00:57:39,649
THE WAY WE NAVIGATE THIS IF

1389
00:57:39,649 --> 00:57:42,352
WE'RE GOING TO USE -- I MEAN, I

1390
00:57:42,352 --> 00:57:43,553
THINK -- YOU GUYS PROBABLY KNOW

1391
00:57:43,553 --> 00:57:45,055
THIS BETTER THAN I DO BUT THE

1392
00:57:45,055 --> 00:57:48,658
AMOUNT OF TIME IT TAKES FOR A

1393
00:57:48,658 --> 00:57:49,259
REALLY IMPACTFUL RANDOMIZED

1394
00:57:49,259 --> 00:57:56,966
CLINICAL TRIAL TO GET INTO

1395
00:57:56,966 --> 00:57:57,567
PRACTICE IS DECADES.

1396
00:57:57,567 --> 00:58:00,737
YEAH, SO I -- I THINK WE NEED TO

1397
00:58:00,737 --> 00:58:02,372
THINK ABOUT IT AS EDUCATORS.

1398
00:58:02,372 --> 00:58:05,108
>> SO I WAS PICKING UP, --
I'M

1399
00:58:05,108 --> 00:58:06,609
DAVID HARRY AND I WAS PICKING UP

1400
00:58:06,609 --> 00:58:08,345
ON YOUR COMMENT ABOUT

1401
00:58:08,345 --> 00:58:11,381
SPECIFICALLY SEEKING OUT

1402
00:58:11,381 --> 00:58:13,049
PHYSICIANS, BOARD CERTIFIED IN

1403
00:58:13,049 --> 00:58:14,317
CLINICAL INFORMATICS AND I'M

1404
00:58:14,317 --> 00:58:15,919
TRYING TO UNDERSTAND, DID YOU

1405
00:58:15,919 --> 00:58:19,556
SORT OF MAP THAT INTO THOSE

1406
00:58:19,556 --> 00:58:21,157
COMPETENCIES OR WHAT ROLE IN

1407
00:58:21,157 --> 00:58:24,894
YOUR PROGRAM WOULD -- WHY

1408
00:58:24,894 --> 00:58:25,829
SPECIFICALLY THAT ROLE?

1409
00:58:25,829 --> 00:58:27,297
FOR THAT?

1410
00:58:27,297 --> 00:58:32,635
>> YEAH, THAT'S A GOOD
QUESTION 

1411
00:58:32,635 --> 00:58:34,938
WHAT WE FOUND WAS WE FOUND THAT

1412
00:58:34,938 --> 00:58:39,342
WHEN WE AS CLINICIANS AND

1413
00:58:39,342 --> 00:58:41,945
CLINICAL RESEARCHERS ASK FOR

1414
00:58:41,945 --> 00:58:51,020
DATA TO BE PULLED FROM EPIC THAT

1415
00:58:51,020 --> 00:58:53,423
IT WAS OFTEN SUCH A CLUNKY

1416
00:58:53,423 --> 00:58:55,058
PROCESS AND IT WAS WHAT WE

1417
00:58:55,058 --> 00:58:56,226
WANTED AND WHAT WE NEEDED AND

1418
00:58:56,226 --> 00:58:57,660
HOW WE NEEDED TO SEE THE DATA

1419
00:58:57,660 --> 00:59:03,066
WAS OFTEN LOST IN TRANSLATION.

1420
00:59:03,066 --> 00:59:04,200
SO THE CLINICAL INFORMATICS

1421
00:59:04,200 --> 00:59:09,739
GROUP WHO ARE PHYSICIANS,

1422
00:59:09,739 --> 00:59:11,007
DEVELOPED A VANDERBILT HAD SOME

1423
00:59:11,007 --> 00:59:15,779
OF THE EARLY DEVELOPMENT OF THIS

1424
00:59:15,779 --> 00:59:17,414
AND ALSO OREGON.

1425
00:59:17,414 --> 00:59:18,915
FELT LIKE ESPECIALLY WITH

1426
00:59:18,915 --> 00:59:23,787
ELECTRONIC HEALTH RECORDS HOW

1427
00:59:23,787 --> 00:59:25,588
ARE THEY DESIGNED, HOW ARE THEY

1428
00:59:25,588 --> 00:59:29,092
USED, HOW CAN THEY BE

1429
00:59:29,092 --> 00:59:29,893
MANIPULATED FOR CLINICAL

1430
00:59:29,893 --> 00:59:30,393
DECISION SUPPORT.

1431
00:59:30,393 --> 00:59:35,899
THIS WOULD ALL BE IN THE REALM

1432
00:59:35,899 --> 00:59:37,434
OF A PHYSICIAN, OF BEING ABLE TO

1433
00:59:37,434 --> 00:59:38,835
UNDERSTAND THAT AND IN THE FLOW,

1434
00:59:38,835 --> 00:59:40,937
IN THE WORK ON THE IN-PATIENT

1435
00:59:40,937 --> 00:59:42,672
SERVICE OR THE PRIMARY CARE

1436
00:59:42,672 --> 00:59:45,809
SETTING, IN THE WORK FLOW, WHERE

1437
00:59:45,809 --> 00:59:48,311
WOULD THAT DECISION SUPPORT BE

1438
00:59:48,311 --> 00:59:48,678
BEST PLACED.

1439
00:59:48,678 --> 00:59:52,415
HOW COULD IT BE AND THEN, THEN

1440
00:59:52,415 --> 00:59:54,751
HAVE ACADEMICS AROUND THAT AND

1441
00:59:54,751 --> 00:59:55,185
STUDY IT.

1442
00:59:55,185 --> 01:00:03,560
SO WE HAVE, I THINK WE HAVE

1443
01:00:03,560 --> 01:00:07,697
MAYBE 8 OR 9, BUT WE HAVE 1 IN

1444
01:00:07,697 --> 01:00:08,698
NEOINATOLOGY AND 2 IN CRITICAL

1445
01:00:08,698 --> 01:00:10,567
CARE AND SO I THINK THERE ARE

1446
01:00:10,567 --> 01:00:15,071
ALMOST A LIAISON IF YOU WILL,

1447
01:00:15,071 --> 01:00:16,139
NOT ONLY FOR RESEARCH BUT ALSO

1448
01:00:16,139 --> 01:00:18,174
FOR JUST THE WAY WE WERE CARING

1449
01:00:18,174 --> 01:00:18,608
FOR PATIENTS.

1450
01:00:18,608 --> 01:00:20,243
ONE OF OUR GENERAL PEDIATRICIANS

1451
01:00:20,243 --> 01:00:24,881
FOR EXAMPLE, DID A REALLY NICE

1452
01:00:24,881 --> 01:00:29,586
JOB IN CREATING A ROUNDING

1453
01:00:29,586 --> 01:00:36,826
SHEET, ROUNDING AN EPIC PROGRAM

1454
01:00:36,826 --> 01:00:39,496
AND EPIC HAS SUCH AN AMAZING

1455
01:00:39,496 --> 01:00:42,131
BUSINESS MODEL, THEY TOOK THAT

1456
01:00:42,131 --> 01:00:46,069
INNOVATION AND THEY ADD IT TO

1457
01:00:46,069 --> 01:00:48,104
THE NEXT -- THE NEXT ITERATION

1458
01:00:48,104 --> 01:00:55,378
OF EPIC.

1459
01:00:55,378 --> 01:00:56,679
SO, YOU KNOW, BUT I THINK THAT'S

1460
01:00:56,679 --> 01:01:00,083
THE WAY WE USE THE CLINIC ASK

1461
01:01:00,083 --> 01:01:00,984
INFORMATICS FOLKS.

1462
01:01:00,984 --> 01:01:01,417
>> LAST QUESTION.

1463
01:01:01,417 --> 01:01:04,053
>> THAT WAS A GREAT TALK.

1464
01:01:04,053 --> 01:01:05,088
VERY THOUGHT-PROVOKING.

1465
01:01:05,088 --> 01:01:07,056
SO 1 THING THAT YOU'VE LEARNED,

1466
01:01:07,056 --> 01:01:08,191
I THINK SINCE YOU'VE BEEN HERE

1467
01:01:08,191 --> 01:01:09,626
IS THAT WE'RE VERY GOOD AT

1468
01:01:09,626 --> 01:01:12,362
STUDYING RARE DECS AND I WAS

1469
01:01:12,362 --> 01:01:14,898
WONDERING WHAT THE PRACTICE

1470
01:01:14,898 --> 01:01:16,833
BASED RESEARCH, IF THAT'S BEING

1471
01:01:16,833 --> 01:01:19,235
USED AT ALL TO STUDY THE CARE OF

1472
01:01:19,235 --> 01:01:24,040
KIDS WITH RARE DISEASES?

1473
01:01:24,040 --> 01:01:26,075
>> WELL, YOU'RE PROBABLY
AWARE,

1474
01:01:26,075 --> 01:01:29,479
KATE SULLIVAN WHO'S OUR

1475
01:01:29,479 --> 01:01:31,748
IMMUNOLOGIST AT CHOP WAS 1 OF

1476
01:01:31,748 --> 01:01:37,153
THE LEADERS OF A FEDERALLY

1477
01:01:37,153 --> 01:01:38,221
FUNDED GRANT ON RARE DISEASES

1478
01:01:38,221 --> 01:01:41,958
AND IT WAS A MULTISITE GROUP AND

1479
01:01:41,958 --> 01:01:44,494
THEY -- I MEAN THE IDEA WAS THAT

1480
01:01:44,494 --> 01:01:46,329
THESE -- THESE DIFFERENT

1481
01:01:46,329 --> 01:01:47,564
ACADEMIC MEDICAL CENTERS WOULD

1482
01:01:47,564 --> 01:01:49,832
CARE FOR PATIENTS WITH RARE

1483
01:01:49,832 --> 01:01:53,436
DISEASES ASK THEN THEY WOULD ALL

1484
01:01:53,436 --> 01:01:54,938
JOIN THE DATA TOGETHER AND I

1485
01:01:54,938 --> 01:01:56,906
THINK THE IDEA IS GENO TYPE AND

1486
01:01:56,906 --> 01:02:01,110
PHENOTYPE AND JUST TRYING TO

1487
01:02:01,110 --> 01:02:03,580
CONNECK THE DOTS AND FIND AS

1488
01:02:03,580 --> 01:02:04,981
MANY PATIENTS AS POSSIBLE.

1489
01:02:04,981 --> 01:02:10,053
SO THAT -- THAT'S CONTINUING.

1490
01:02:10,053 --> 01:02:11,354
>> YEAH AND IS IT THE SAME
MODEL

1491
01:02:11,354 --> 01:02:13,189
THAT CHOP IS USING WHERE IT'S

1492
01:02:13,189 --> 01:02:16,159
KIND OF REAL WORLD DATA

1493
01:02:16,159 --> 01:02:16,459
COLLECTION?

1494
01:02:16,459 --> 01:02:18,561
>> I BELIEVE IT IS.

1495
01:02:18,561 --> 01:02:21,497
I WASN'T INVOLVED WITH KATE'S

1496
01:02:21,497 --> 01:02:26,135
WORK, I DO KNOW THAT OUR RARE

1497
01:02:26,135 --> 01:02:28,304
DISEASES, THE FOCUS AT CHOP NOW

1498
01:02:28,304 --> 01:02:29,572
IS ON PRECISION MEDICINE, I WAS

1499
01:02:29,572 --> 01:02:32,875
PART OF THE TASK FORCE AND THE

1500
01:02:32,875 --> 01:02:35,278
CLINICAL VOICE TOWARDS HOW DO WE

1501
01:02:35,278 --> 01:02:39,515
FLOW PATIENTS THROUGH OUR

1502
01:02:39,515 --> 01:02:46,656
INSTITUTION FOR WHAT WE CALL

1503
01:02:46,656 --> 01:02:49,692
KITCHEN SINK-OMICs, SO

1504
01:02:49,692 --> 01:02:50,560
GENOMICS, METABOLOMICS, RNA,

1505
01:02:50,560 --> 01:02:54,764
MIKE ROY BIOME, YOU KNOW, HOW DO

1506
01:02:54,764 --> 01:02:56,532
WE BRING PATIENTS IN WHO HAVE

1507
01:02:56,532 --> 01:03:00,336
UNDIAGNOSED DISEASES AND HELP

1508
01:03:00,336 --> 01:03:02,205
THEM DISCOVER WHAT THAT IS AS

1509
01:03:02,205 --> 01:03:03,539
WELL AS CARE FOR THEM.

1510
01:03:03,539 --> 01:03:05,575
SO WE'RE EXPANDING THAT PROGRAM

1511
01:03:05,575 --> 01:03:07,310
AND THAT'S A FOCUS.

1512
01:03:07,310 --> 01:03:09,479
IN TERMS OF COLLABORATIONS

1513
01:03:09,479 --> 01:03:10,880
BETWEEN DIFFERENT ACADEMIC

1514
01:03:10,880 --> 01:03:13,149
MEDICAL CENTERS AND RARE

1515
01:03:13,149 --> 01:03:14,484
DISEASES, WE SHOULD FIND OUT

1516
01:03:14,484 --> 01:03:15,018
MORE ABOUT THAT.

1517
01:03:15,018 --> 01:03:17,754
I THINK THERE IS SOME, SOME

1518
01:03:17,754 --> 01:03:19,255
COLLABORATION THOUGH AND I THINK

1519
01:03:19,255 --> 01:03:21,524
IT'S IMPORTANT.

1520
01:03:21,524 --> 01:03:27,730
>> THANK YOU. 

1521
01:03:27,730 --> 01:03:28,798
[ APPLAUSE ]

1522
01:03:28,798 --> 01:03:30,266
>> THANKS, EVERYONE THANKS
FOR

1523
01:03:30,266 --> 01:03:40,476
YOUR TIME.