>>WELCOME TO THE 2021 NATIONAL NURSING RESEARCH ROUNDTABLE. WE WELCOME BACK THOSE OF YOU WHO WERE ABLE TO JOIN US YESTERDAY FOR DR. ELISEO PEREZ-STABLE'S REMARKS AND DR. SANDRO GALEO'S KEYNOTE. WE'RE WELCOMING THOSE JOINING US FOR THE FIRST TIME. TODAY PROMISES TO BE REWARDING AND INFORMATION PACKED. I'M DR. JANE HANSON LASSETTER, PRESIDENT OF THE WESTERN INSTITUTE OF NURSING. OUR VISION IS THAT ONE DAY ALL PEOPLE WILL HAVE THE OPPORTUNITY TO ACHIEVE THEIR BEST HEALTH AND WELL BEING, WHICH CLOSELY ALIGNS WITH TODAY'S MEETING FOCUSED ON NURSING RESEARCH OF THE FUTURE, USING CLINICAL BIG DATA TO EXPLORE HEALTH INEQUITIES AND SOCIAL DETERMINANTS OF HEALTH. PLEASE JOIN ME YOU ME NOW IN WELCOMING THE DIRECTOR OF NINR, DR. SHANNON ZENK. >> THANK YOU, AND WELCOME, EVERYONE. SO, AGAIN, IT'S GREAT TO HAVE YOU BACK FOR THOSE JOINING AGAIN TODAY AND WELCOME THOSE NEW. IT'S A PLEASURE TO BE WITH YOU VIRTUALLY FOR MY FIRST NURSING ROUNDTABLE AS DIRECTOR OF NINR. SO THIS MORNING I WANT TO GIVE YOU A BRIEF UPDATE ON SOME OF THE ACTIVITIES HERE AT NIH AND NINR INCLUDING AN UPDATE ON MY ACTIVITIES AS NEW DIRECTOR AND A BIT ABOUT MY VISION FOR THE FUTURE AND OUR NEW STRATEGIC PLAN THAT'S IN THE WORKS. I WILL ALSO BRIEFLY INTRODUCE OUR MEETING TOPIC TO SET THE STAGE FOR SPEAKERS AND ROUNDTABLE DISCUSSION. I'LL START WITH A FEW NIH UPDATES. EARLIER THIS WEEK NIH DIRECTOR DR. FRANCIS COLLINS ANNOUNCED AN IMPORTANT NEW NIH INITIATIVE TO END STRUCTURAL RACISM IN BIOMEDICAL RESEARCH. HE REMINDEDS SYSTEMIC RACISM PLAGUED OUR SOCIETY FOR FAR TOO LONG. SADLY THE RESEARCH COMMUNITY IS NOT IMMUNE FROM THESE ISSUES. UNITE WAS ESTABLISHED TO IDENTIFY AND ADDRESS STRUCTURAL RACISM WITHIN THE NIH-SUPPORTED AND GREATER SCIENTIFIC COMMUNITY. DR. COLLINS SAID THAT, AND I QUOTE, AS A SCIENCE AGENCY WE KNOW THAT BRINGING DIVERSE PERSPECTIVES, BACKGROUNDS AND SKILL SETS TO COMPLEX SCIENTIFIC PROBLEMS ENHANCES SCIENTIFIC PRODUCTIVITY, END QUOTE. I COULDN'T AGREE MORE. A NINR WE UNEQUIVOCALLY SUPPORT THIS EFFORT. I ENCOURAGING THE NURSING SCIENCE COMMUNITY TO READ DR. COLLINS' MESSAGE TO LEARN HOW YOU CAN CONTRIBUTE TO THIS EFFORT. UNITE IS COMPRISED OF FIVE COMMITTEES WITH EXPERTS ACROSS ALL 27 INSTITUTES AND CENTERS WHO WITH PASSIONATE ABOUT RACIAL DIVERSITY, EQUITY, AND INCLUSION. I'M GLAD TO REPRESENT NINR ON THE N COMMITTEE, AND COLLEAGUE SEAN LEWIS REPRESENTS NINR ON THE I COMMITTEE, INSTITUTE TO DISMANTLE POLICIES AND PRACTICES THAT CONTRIBUTE TO STRUCTURAL RACISM AND SUPPORT INNOVATIVE RESEARCH TO ELIMINATE HEALTH DISPARITIES AND ADVANCE HEALTH EQUITIES. YOU CAN LEARN MORE ABOUT ALL THESE EFFORTS AT THE WEBSITE SHOWN HERE, AND I ENCOURAGE YOU TO DO SO. AS PART OF UNITE AN NIH COMMON FUND INITIATIVE TRANSFORMATIVE HEALTH DISPARITIES RESEARCH INITIATIVE HAS BEEN ANNOUNCED TO BOLSTER INNOVATION, SOLVE CHALLENGES, ADDRESS EMERGENT OPPORTUNITIES IN HEALTH DISPARITIES RESEARCH. ONE INITIATIVE THAT'S BEEN ANNOUNCED WILL SUPPORT RESEARCH TO DEVELOP, DISSEMINATE AND IMPLEMENT INNOVATIVE INTERVENTIONS THAT PREVENT, REDUCE, ELIMINATE HEALTH DISPARITIS AND HEALTH INEQUITIES. IN ADDITION, THE DIRECTOR OF NIMHD, NATIONAL INSTITUTE OF MINORITY HEALTH AND DR. HEALTH DISPARITIES, DR. ELISEO PEREZ-STABLE MENTIONED YESTERDAY A FUNDING OPPORTUNITY THAT WILL BE PUBLISHED SOON ON STRUCTURAL RACISM AND DISCRIMINATION. NINR IS ENTHUSIASTICALLY SUPPORTING THIS FUNDING INITIATIVE. MORE INFORMATION CAN BE FOUND ON BOTH OF THESE FUNDING OPPORTUNITIES ON THE PROVIDED WEBSITE, AND WE AT NINR WILL SHARE MORE DETAILS AS SOON AS THEY BECOME AVAILABLE. THE NIH COMMON FUND HAS LAUNCHED THE FACULTY INSTITUTIONAL RECRUITMENT FOR SUSTAINABLE TRANSFORMATION, FIRST PROGRAM. NIH FIRST SEEKS TO BUILD DIVERSE TEAMS OF EARLY CAREER SCIENTISTS AND SET THEM UP FOR LONG-TERM SUCCESS BY FOSTERING A CULTURE OF INCLUSIVE EXCELLENCE. THE FIRST COHORT AWARDS ENABLE INSTITUTIONS TO HIRE A DIVERSE COHORT OF EARLY STAGE RESEARCH FACULTY COMMITTED TO INCLUSIVE EXCELLENCE AND DIVERSITY. IT WILL SUPPORT THE DEVELOPMENT AND STRENGTHENING OF INSTITUTION-WIDE APPROACHES FACILITATING THE SUCCESS OF COHORT MEMBERS AND FUTURE FACULTY, FROM A DIVERSITY OF BACKGROUNDS. THERE WILL BE A COORDINATION AND EVALUATION CENTER, WHICH WILL DEVELOP AND USE COMMON DATA ELEMENTS TO RIGOROUSLY ASSESS AND THEN SHARE LESSONS LEARNED ABOUT THE EFFECTS OF NEW FACULTY COHORTS ON INSTITUTIONAL CULTURE. IN NOVEMBER NIH ANNOUNCED THE PUBLICATION OF A FUNDING OPPORTUNITY ANNOUNCEMENT FOR THE STEPHEN I KATZ EARLY STAGE INVESTIGATOR RESEARCH PROJECT GRANT PROGRAM. THIS NEW RESEARCH GRANT PROGRAM IS NAMED IN HONOR OF DR. KATZ WHO DIRECTED THE NATIONAL INSTITUTE OF ARTHRITIS AND MUSCULOSKELETAL AND SKIN DISEASES FROM 1995 UNTIL HIS DEATH IN 2008. HE'S REMEMBERED AS AN OUTSTANDING SCIENTIST, ADMINISTRATOR, AND CIVIL SERVANT. THIS GRANT PROGRAM SUPPORTS INNOVATIVE PROJECTS IN AN AREA OF SCIENCE THAT REPRESENTS A CHANGE IN THE RESEARCH DIRECTION OF AN EARLY STAGE INVESTIGATOR FOR WHICH NO PRELIMINARY DATA EXISTS. SO, AGAIN, I ENCOURAGE YOU ALL IN NURSING COMMUNITY TO VISIT THE WEBSITE FOR DETAILS ABOUT THESE EARLY STAGE FUNDING OPPORTUNITIES. IT GOES WITHOUT SAYING THAT MUCH OF OUR ATTENTION AT NIH AND NINR CONTINUES TO BE GIVEN TO COVID-19. AS YOU KNOW NIH HAS BEEN INVOLVED IN EVERY ASPECT OF ADDRESSING COVID-19 INCLUDING THE DEVELOPMENT OF TESTING AND DIAGNOSTICS, TO TREATMENT THERAPEUTICS AS WELL AS CLINICAL STUDIES AND DEVELOPMENT OF VACCINES. NIH HAS NOW LAUNCHED A WEBSITE THAT PROVIDES TRUSTED INFORMATION ABOUT COVID-19 RESEARCH AT NIH AND THE AGENCY'S ROLE IN THE PANDEMIC. USERS CAN FIND MORE INFORMATION ABOUT FUNDED PROJECTS BY STATE AND CONGRESSIONAL DISTRICT, HOW TO JOIN CLINICAL TRIALS OR DONATE PLASMA, AND OTHER RESOURCES AVAILABLE THROUGH THE CEAL INITIATIVE, CENTERS FOR DISEASE CONTROL AND PREVENTION AND OTHER FEDERAL AGENCIES. NOW SOME NEWS OF NOTE FROM NINR. IN THE AREA OF COVID-RELATED EFFORTS, NINR IS SUPPORTING TWO PROJECTS UNDER THE RADX-up INITIATIVE WHICH SEEKS TO UNDERSTAND THE FACTORS ASSOCIATED WITH DISPARITIES IN COVID-19 AND DEVELOP STRATEGIES TO REDUCE THESE DISPARITIES IN GROUPS DISPROPORTIONATELY AFFECTED BY AND MOST AT RISK FOR COVID-19. NINR IS SUPPORTING ONE PROJECT UNDER THE RADx RAD INITIATIVE WHICH SUPPORTS INNOVATIVE APPROACHES AND REIMAGINED USES OF EXISTING TOOLS TO ADDRESS GAPS IN COVID-19 TESTING AND SURVEILLANCE. AS WELL AS DEVELOP PLATFORMS THAT CAN BE DEPLOYED QUICKLY DURING AN EMERGING OUTBREAK OF COVID-19 OR OTHER INFECTIOUS DISEASES. MANY OF YOU MAY BE FAMILIAR WITH NIH'S HEAL INITIATIVE, STANDS FOR HELPING TO END ADDICTION LONG TERM INITIATIVE. THIS IS A TRANSAGENCY EFFORT TO SUPPORT RESEARCH, DEVELOP LONG-TERM SOLUTIONS TO THE CURRENT OPIOID EPIDEMIC. BECAUSE OF INTEREST IN PAIN RESEARCH I WAS INVITED TO JOIN THE HEAL EXECUTIVE COMMITTEE WHEN I ARRIVED AT NIHENED -- AND WAS DELIGHTED TO ACCEPT. IF YOU'RE RESEARCH ARE COVERED BY "HEAL" EXPLORE THE FUNDING OPPORTUNITIES OFFERED BY THIS INITIATIVE. A COUPLE OF NINR ACTIVITIES TO TELL YOU ABOUT OVER THE LAST SEVERAL MONTHS. IN SEPTEMBER NINR CONVENED WITH SEVERAL OTHER INSTITUTES AND OFFICES, A WORKSHOP ON INNOVATIVE MODELS OF CARE FOR REDUCING INEQUITIES IN MATERNAL HEALTH, A SUMMARY NOW AVAILABLE ON OUR WEBSITE. THIS VIRTUAL WORKSHOP FOCUSED ON MODELS OF CARE AND EXPLORED HOW NURSES, MIDWIVES AND BIRTH COMPANIONS CAN IMPROVE MATERNAL AND INFANT HEALTH FOR WOMEN IN U.S. COMMUNITIES AFFECTED BY RACIAL DISCRIMINATION, SOCIOECONOMIC INTHE QUESTIONS, OTHER SYSTEM LEVEL FACTORS THAT CONTRIBUTE TO MATERNAL HEALTH DISPARITIES. IN DECEMBER IN COLLABORATION WITH THE NATIONAL INSTITUTE OF MINORITY HEALTH AND HEALTH DISPARITIES, NINR HOSTED A JOINT DIRECTOR SEMINAR THAT FEATURED DR. DAVID WILLIAMS WHO PRESENTED A TALK ENTITLED "THE SCIENCE OF STRUCTURAL RACISM." JOINED LIVE BY 650 STAFF, DR. WILLIAMS SUMMARIZED SCIENCE ON A MECHANISMS BY WHICH MULTIPLE FORMS OF DISCRIMINATION AFFECT HEALTH AND CONTRIBUTE TO DISPARITIES AS WELL AS DIRECTIONS FOR FUTURE RESEARCH. DR. WILLIAMS IS A PROFESSOR OF PUBLIC HEALTH, CHAIR OF DEPARTMENT OF SOCIAL AND BEHAVIOR SCIENCE, PROFESSOR OF AFRICAN AMERICAN STUDIES AT HARVARD UNIVERSITY. AT ANOTHER NINR NEWS, ON OCTOBER 14, 2020, I WAS SWORN IN AS DIRECTOR OF NINR. OUT OF ABUNDANCE OF CAUTION DURING THE PANDEMIC MY SWEARING IN CEREMONY WAS HELD VIRTUALLY. BUT IT DID INCLUDE LIGHTHEARTED MOMENTS WITH DR. COLLINS AND ALSO DEPUTY DIRECTOR LARRY TABAK AND ASSOCIATE DEPUTY DIRECTOR TARA SCHWETZ WHO SERVED IN ACTIVE LEADERSHIP ROLES AT NINR LAST YEAR. TO SAY THE LEAST THESE LAST FEW MONTHS HAVE BEEN VERY BUSY. I'VE HAD THE OPPORTUNITY TO MEET WITH SO MANY AMAZING PEOPLE AND GROUPS AND I'VE LISTED A FEW OF THEM HERE. MY FIRST ORDER OF BUSINESS WAS MEETING EVERYONE AT NINR WHICH WAS CERTAINLY AN INTERESTING THING TO DO REMOTELY BUT WE'VE MADE IT HAPPEN AND MADE DO. I'VE HAD SO MANY GREAT DISCUSSIONS WITH EVERYONE AT NINR ABOUT THE FUTURE AND WE DO HAVE A FANTASTIC TEAM AT NINR AND I LOOK FORWARD TO MEETING THEM ALL IN PERSON SOMEDAY. I'VE ALSO BEEN MEETING AND GETTING TO KNOW ALL OF MY NIH COLLEAGUES WHO HAVE BEEN REALLY GRACIOUS AND WELCOMING ME TO THE TEAM AND HELPING ME LEARN THE ROPES. WE'VE HAD GREAT DISCUSSIONS ABOUT WEARS WHERE WE CAN COLLABORATE, I LOOK FORWARD TO THOSE OPPORTUNITIES. I'VE BEEN MEETING WITH MANY OF THE GROUPS THAT HAVE INTEREST IN NINR RESEARCH SUCH AS SCHOOLS OF NURSING, AND MANY OTHERS AND HAD A CHANCE TO MEET MANY OF YOU, IF I HAVEN'T HAD THE CHANCE TO MEET WITH YOU YET I HOPE TO VERY SOON. THERE'S A LOT OF OPTIMISM ABOUT THE FUTURE IN THE COMMUNITY, AROUND NURSING SCIENCE, THAT'S REALLY ENCOURAGING TO ALL OF US. FINALLY I'VE HAD THE OPPORTUNITY TO SPEAK WITH SEVERAL GROUPS ABOUT MY BACKGROUND, RESEARCH INTERESTS, AND THE FUTURE OF NINR RESEARCH AND TRAINING. AGAIN, I'VE LISTED SOME OF THOSE GROUPS HERE. MANY MORE ARE SCHEDULED IN THE MONTHS TO COME. THIS BRINGS US TO WHAT WE'RE DOING AT NINR TO ADVANCE SCIENCE AND IMPROVE HEALTH. SO I'D LIKE TO TELL YOU A LITTLE BIT ABOUT WHERE I SEE NINR-SUPPORTED SCIENCE GOING IN THE FUTURE AND HOW WE'RE PLANNING FOR THAT. WHAT I STARTED THINKING ABOUT A VISION FOR NINR SOME OF THE QUESTIONS I CONSIDERED WERE WHAT ARE NINR'S AND NURSING SCIENCE'S BIGGEST CONTRIBUTIONS TO RESEARCH AND TO HEALTH? AND WHAT ARE THE AREAS OF EXPERTISE THAT NINR BRINGS TO THE TABLE? I BELIEVE THAT IT'S NURSING'S HOLISTIC PERSPECTIVE ON RESEARCH AND ON HEALTH THAT IS NURSING SCIENCE'S MOST IMPORTANT CONTRIBUTION TO RESEARCH. SO WHAT DO I MEAN BY HOLISTIC PERSPECTIVE? IT'S NURSING'S RECOGNITION IT'S IMPORTANT TO ADDRESS HEALTH NEEDS AT MULTIPLE LEVELS. PHYSICAL, EMOTIONAL, SOCIAL, AND ECONOMIC. AND CREATE SUPPORTIVE ENVIRONMENTS, SYSTEMS, POLICIES AND PRACTICE. MY VISION FOR NINR IS TO USE NURSING'S HOLISTIC TO IMPROVE INDIVIDUAL AND POPULATION HEALTH AND ADVANCE HEALTH EQUITY BY BRIDGING BIOMEDICAL SCIENCE AND HEALTH CARE DELIVERY WITH THE REALITIES OF PEOPLE'S LIVES AND THEIR LIVING CONDITIONS. THE ULTIMATE GOAL IS TO IDENTIFY PRACTICE AND POLICY SOLUTIONS TO OUR MOST PRESSING HEALTH PROBLEMS AND OUR MOST STUBBORN HEALTH INEQUITIES, ACROSS THE WIDE VARIETY OF COMMUNITY AND CLINICAL SETTINGS WHERE NURSES PRACTICE. TO DO THIS WE'RE GOING TO NEED TO COLLABORATIVELY TAKE NURSING SCIENCE TO NEW LEVELS. WE CAN PUSH THE SCIENTIFIC BOUNDARIES OF INTEGRATIVE UNDERSTANDING OF HEALTH DETERMINANTS, FROM THE MOLECULAR TO MACRO, AND INTEGRATIVE SOLUTIONS INCLUDING HEALTH CARE AND COMMUNITY APPROACHES. COVID-19 ILLUSTRATES THAT IMPROVING THE PUBLIC'S HEALTH AND ADVANCING HEALTH EQUITY AND JUSTICE WILL REQUIRE PRIORITIZING SOCIAL DETERMINANTS OF HEALTH TO ACHIEVE LASTING AND UPSTREAM CHANGE. TO MAXIMIZE IMPACT OF OUR SCIENTIFIC BREAKTHROUGHS IT'S IMPORTANT FOR US TO FOCUS ON IDENTIFYING EFFECTIVE STRATEGIES FOR INTGRATING NURSING PRACTICE AND POLICY SOLUTIONS INTO CLINICAL AND COMMUNITY SETTINGS. NINR'S CURRENT FIVE-YEAR STRATEGIC PLAN WILL EXPIRE AT THE END OF THIS YEAR, DEVELOPING THE NEXT STRATEGIC PLAN IS A MAJOR FOCUS OF OUR ACTIVITIES THIS YEAR. AND WE'RE REALLY EXCITED TO SEE WHERE THE PLANNING PROCESS TAKES US. THERE ARE SEVERAL KEY PRINCIPLES THAT ARE GUIDING OUR PROCESS. THINK BOLDLY, DIFFERENTLY. THINK ABOUT THE END OF THE BEGINNING, PLAN FOR TRANSLATION. DEMONSTRATE IMPACT. EMBRACE CHANGE AND OPPORTUNITY. AND MENTOR THE NEXT GENERATION. WE CERTAINLY EVERYONE WILL BE INTERESTED IN CONTRIBUTING TO THE NEW STRATEGIC PLAN. WE ENCOURAGE ALL OF YOU WHO ARE INTERESTED IN PROVIDING FEEDBACK FOR BOLD NEW AGENDA FOR NURSING RESEARCH TO VISIT OUR WEBSITE AND SEND US AN E-MAIL AT THE ADDRESS SHOWN HERE. AND NOW LET'S TURN OUR ATTENTION TO TODAY'S ACTIVITY, THE NATIONAL NURSING RESEARCH ROUNDTABLE. SINCE 1987, LEADERS OF NURSING ORGANIZATIONS WITH RESEARCH FOCUS HAVE PARTICIPATED IN THE ANNUAL MEETING OF THE ROUNDTABLE. TOGETHER, THIS GROUP SHARES ADVANCES IN SCIENCE AND PRACTICE, AS THEY WORK TO IDENTIFY, ENHANCE AND LEVERAGE RESEARCH RESOURCES. THIS ASSESS CHALLENGES, GAPS, REDUNDANCIES, AND OPPORTUNITIES, AND PINPOINT AND SUPPORT STRATEGIES, INNOVATION, POLICY INITIATIVES THAT FUEL NEW DISCOVERIES IN SCIENCE, DRIVE TRANSLATION OF THESE DISCOVERIES INTO IMPROVEMENT OF OUR NATION'S HEALTH. THE ANNUAL MEETING OF THE ROUNDTABLE FOSTERS COMMUNICATION, PROMOTES COLLABORATION, DISSEMINATES KNOWLEDGE AND INFORMS RESEARCH EFFORTS ON A NATIONAL SCALE. AS YOU KNOW, THE TOPIC OF THIS YEAR'S ROUNDTABLE IS NURSING RESEARCH OF THE FUTURE, USING CLINICAL BIG DATA TO EXPLORE HEALTH INEQUITIES AND SOCIAL DETERMINANTS OF HEALTH. AND IT'S CO-HOSTED BY NINR AND THE WESTERN INSTITUTE OF NURSING. TODAY WE'LL FOCUS ON HOW BIG DATA CAN BE USED TO DOCUMENT HEALTH CARE INEQUITIES, AND LEARN HOW BIG DATA, INCLUDING ELECTRONIC HEALTH RECORDS, CAN BE MINED TO INFORM INTERVENTIONS, REDUCE HEALTH INEQUITIES. SO I NOW WOULD LIKE TO PROVIDE SOME BACKGROUND ON THE TOPIC. AS WE SCAN THE CURRENT HEALTH AND HEALTH CARE LANDSCAPE IT'S CLEAR THAT THERE IS MUCH WORK TO DO. MORE THAN EVER, WE SEE THE NEED FOR MORE AND BETTER KNOWLEDGE, TECHNOLOGY, HEALTH CARE AND PUBLIC HEALTH SERVICES TO IMPROVE OUR NATION'S HEALTH. WE FACE PRESSING CHALLENGES AFFECTING THE PUBLIC'S HEALTH AND PERSISTENT HEALTH INEQUALITIES FOR WHICH WE HAVE INCOMPLETE UNDERSTANDING AND INSUFFICIENT SOLUTIONS. IN THE CURRENT LANDSCAPE, RACIAL AND SOCIAL INJUSTICES HAVE GAINED BROADER RECOGNITION, INCLUDING THEIR WIDE-REACHING HEALTH EFFECTS. PUBLIC DEMAND IS HIGH, FOR DEEP AND ENDURING CHANGE, SO THAT EVERYONE HAS A CHANCE TO LIVE A LONG AND HEALTHY LIFE. NURSING PRACTICE AND POLICY SOLUTIONS IN THIS LANDSCAPE ARE URGENTLY NEEDED. FOR EXAMPLE, COMPARED WITH NON-HISPANIC WHITE WOMEN, MATERNAL MORTALITY RATES ARE ABOUT 3.2 TIMES HIGHER IN BLACK WOMEN AND 2.3 TIMES HIGHER IN AMERICAN INDIAN/ALASKA NATIVE WOMEN, AND PRE-TERM BIRTH RATES ARE HIGHER AMONG BLACK WOMEN TOO, ABOUT 1.5 TIMES HIGHER. HYPERTENSION-RELATED MORTALITY IS ANOTHER OUTCOME FOR WHICH PERSISTENT INEQUITIES ARE OBSERVED. COVID IS THE LATEST ON THE LANDSCAPE. AS OF TUESDAY, MARCH 2, CDC REPORTS 28.4 MILLION CASES, IN THE UNITED STATES, 510,000 DEATHS. SOBERING DIFFERENCE BY RACE AND ETHNICITY AND RISK OF INFECTION, SERIOUS ILLNESS AND DEATH, COMPARED TO NON-HISPANIC WHITE INDIVIDUALS, AMERICAN INDIAN OR ALASKA NATIVE TWICE AS LIKELY TO BE INFECTED. LATINX 3.2 TIMES MORE LIKELY TO BE HOSPITALIZED, BLACK INDIVIDUALS 1.9 TIMES MORE LIKELY TO DIE. THESE ARE ONLY A FEW EXAMPLES OF THE INEQUITIES WE FACE. GIVEN THE PRESSING NEED, THIS IS THE RIGHT TIME FOR US TO RENEW OUR FOCUS ON OVERCOMING THESE CHALLENGES AND THAT'S WHY I'M GLAD WE'RE HAVING THIS DISCUSSION TODAY. THAT BRINGS ME TO TODAY'S AGENDA. THE FIRST SESSION WILL FOCUS ON PRESENTATIONS THAT WILL ADDRESS CAPTURING AND EXPLORING DATA ON SOCIAL DETERMINANTS OF HEALTH TO IMPROVE CARE AND REDUCE HEALTH DISPARITIES. THE SECOND SESSION WILL EXPLORE THE AREA OF MINING DATA TO INFORM CLINICAL INTERVENTIONS. THAT WILL BE FOLLOWED BY A PANEL DISCUSSION BETWEEN OUR PRESENTERS AND PARTICIPANTS. SO WE CERTAINLY LOOK FORWARD TO TODAY'S DISCUSSION. THANKS FOR JOINING US. >> THANK YOU, DR. ZENK. NOW I WOULD LIKE TO INTRODUCE OUR NINR COLLEAGUE AND CO-CHAIR DR. REBECCA RIZULI, WHO WILL INTRODUCE THE NEXT SESSION AND SPEAKERS. SHE IS THE ACTING DIRECTOR OF THE DIVISION OF EXTRAMURAL SCIENCE PROGRAMS, IN THIS ROLE SHE IS RESPONSIBLE FOR SCIENTIFIC LEADERSHIP AND OVERSEEING POLICY AND MANAGEMENT FOR GRANTS AND CONTRACTS TO SUPPORT NINR RESEARCH AND TRAINING. SHE IS ALSO BRANCH CHIEF FOR WELLNESS AND TECHNOLOGY AND TRAINING. DR. RASOOLY. >> THANK YOU VERY MUCH, ESPECIALLY TO OUR COLLEAGUES AT WIN. IT'S REALLY BEEN A WONDERFUL EXPERIENCE, TO MY COLLEAGUES AT NINR WORKING WITH WIN TO PLAN THIS EVENT. IT'S A TOPIC THAT I THINK IS EXTREMELY TIMELY AND INTERESTING AND VALUABLE TO ALL OF US AND HOW TO MAKE ALL THESE DATA WORK FOR US TO ADDRESS THESE IMPORTANT QUESTIONS THAT ARE RESEARCH QUESTIONS BUT IMPACT ON HEALTH CARE. SO, OUR FIRST SESSION IS ON CAPTURING AND EXPLORING DATA ON SOCIAL DETERMINANTS OF HEALTH TO IMPROVE CARE AND REDUCE HEALTH DISPARITIES. WE HAVE THREE SPEAKERS. I'M GOING TO INTRODUCE ALL THREE OF THEM RIGHT NOW AND THEY ARE GOING TO SPEAK FOR ABOUT 20 MINUTES EACH. OUR FIRST SPEAKER IS DR. LAURA GOTTLIEB, PROFESSOR OF FAMILY AND COMMUNITY MEDICINE, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO. HER RESEARCH EXPLORES HEALTH CARE SECTOR PROGRAMS AND POLICIES RELATED TO IDENTIFYING AND ADDRESSING SOCIAL RISK FACTORS IN THE CONTEXT OF CARE DELIVERY. SHE'S A FOUNDING DIRECTOR OF SIREN, SOCIAL INTERVENTIONS RESEARCH AD EVALUATION NETWORK, THAT'S A NETWORK -- NATIONAL RESEARCH NETWORK, ADVANCES RESEARCH ON HEALTH CARE STRATEGIES TO IMPROVE SOCIAL CONDITIONS. DR. GOTTLIEB IN SPARE TIME IS ALSO ASSOCIATE DIRECTOR OF THE ROBERT WOOD JOHNSON FOUNDATION EVIDENCE FOR ACTION NATIONAL OFFICE. FOLLOWED BY RACHEL GOLD, RESEARCHER AT KAISER PERMANENTE CENTER FOR HEALTH RESEARCH. HER WORK FOCUSES ON HOW HEALTH INFORMATION TECHNOLOGY CAN BE HARNESSED TO ADDRESS HEALTH DISPARITIES EXPERIENCED BY PATIENTS WHO ARE SERVED IN SAFETY NET CLINICS, THE IMPLEMENTATION METHODS NEEDED TO SUPPORT CLINICS ADOPTING THOSE TECHNOLOGIES. SHE'S REALLY A PIONEER AND EXPERT ON PRACTICE IMPROVEMENT-RELATED IMPLEMENTATION, IN PRIMARY CARE SAFETY NET SETTINGS. DR. GOLD IS CURRENTLY STUDYING IMPACT OF INNOVATIVE POINT OF CARE RISK ASSESSMENT TOOL ON CARDIOVASCULAR DISEASE OUTCOMES IN COMMUNITY CLINICIAN AND HAS DEVELOPED AND PILOT TESTED ELECTRONIC HEALTH RECORD TOOLS FOR DOCUMENTING AND ADDRESSING PATIENT-REPORTED SOCIAL DETERMINANTS OF HEALTH. STUDYING HOW TO ADOPT AND SUSTAIN THESE SYSTEMATIC SOCIAL DETERMINANTS SCREENING AND REFERRAL-MAKING ACTIVITIES. AND FINALLY YOU'LL HEAR FROM DR. CHANITA HUGHES-HALBERT, WHO IS ASSOCIATE DEAN FOR ASSESSMENT AND EVALUATION, COLLEGE OF MEDICINE, AND PROFESSOR IN DEPARTMENT OF PSYCHIATRY AND BEHAVIORAL SCIENCES, AND SHE'S ALSO ATT AND T DISTINGUISHED ENDOWED CHAIR, MEDICAL UNIVERSITY OF SOUTH CAROLINA. DR. HUGHES-HALBERT IS RECOGNIZED FOR CANCER DISPARITIES RESEARCH, INCLUDING THREE CONVERGING LINES OF INVESTIGATION ALL OF WHICH HAVE HIGH POLICY IMPORTANCE, ONE ENHANCING PARTICIPATION OF MINORITIES IN RESEARCH IN COMMUNITY AND CLINICAL SETTINGS, TWO IS DEVELOPING CULTURALLY TAILORED ASSESSMENTS AND INTERVENTIONS TO IMPROVE OUTCOMES IN MINORITIES AND MEDICALLY UNDERSERVED POPULATIONS, AND FINALLY HER THIRD AREA IS DEVELOPING SUSTAINABLE INFRASTRUCTURE FOR HEALTH PROMOTION AND DISEASE PREVENTION AND CONTROL THROUGH COMMUNITY-BASED PARTICIPATORY RESEARCH METHODS. SO PLEASE JOIN ME IN WELCOMING THESE THREE DISTINGUISHED SPEAKERS, EACH OF WHOM WILL SPEAK FOR ABOUT 20 MINUTES, AND GENERALLY WE WOULD LIKE YOU TO HOLD YOUR QUESTIONS FOR THE PANEL DISCUSSION BUT YOU MAY BEGIN SUBMITTING QUESTIONS DURING THE PRESENTATION USING THE CHAT FUNCTION, AND DURING THE BREAK WE'LL CURATE THE QUESTIONS FOR THE PANEL MODERATOR. SO WITHOUT FURTHER ADO DR. GOTTLIEB. >> REBEKAH, THANK YOU SO MUCH. I'M DELIGHTED TO JOIN YOU. BECAUSE WE'RE STARTING EARLY I THINK THAT MEANS I GET TEN EXTRA MINUTES. JUST KIDDING. I STRUCK FEAR IN THE HEART OF THE ORGANIZERS. I'M SO HAPPY TO JOIN YOU TODAY. I'M A FAMILY PHYSICIAN IN THE COUNTY HOSPITAL AT SAN FRANCISCO GENERAL HOSPITAL, MOSTLY I WORK WITH A TERRIFIC TEAM OF RESEARCHERS WHO REALLY ARE STUDYING THE REMARKABLE SEA CHANGE AROUND INTEREST AND ENGAGED FOR INTERVENING AND IDENTIFYING SOCIAL RISK FACTORS AND ASSETS TO IMPROVE HEALTH IN CLINICAL RESEARCH AND HEALTH POLICY RESEARCH. I'LL SHARE SOME OF OUR WORK TODAY. I'M GOING TO SHOW SOME SLIDES. LET ME JUST SCREEN SHARE. HERE WE GO. I AM VERY CONFIDENT THAT PEOPLE IN THE ROOM IN PART BECAUSE OF THE INTRODUCTION AND YOUR OWN EXPERIENCES BOTH PROFESSIONAL AND PERSONALLY ARE VERY AWARE THAT THE TERM SOCIAL DETERMINANTS OF HEALTH HAS BECOME QUITE POPULAR IN THE HEALTH CARE DELIVERY SECTOR. QUESTIONS ABOUT THE SECTOR SOCIAL CARE RULES AND RESPONSIBILITY IS A CENTRAL FOCUS OF CONVERSATIONS LIKE THIS, ALSO MANY REPORTS, PAYMENT MODELS, AND CLINICAL INNOVATIONS TOO OF LATE. AND IN LIGHT OF THAT SURGE IN ENTHUSIASM, I'VE BEEN THINKING A LOT THAT YOU NEED TO RECOGNIZE THAT WE ARE SORT OF AT THE PEAK OF INFLATED EXPECTATIONS ON HEALTH CARE INNOVATION WHERE EARLY PUBLICITY PRODUCES MANY SUCCESS STORIES. BUT UNFORTUNATELY THAT PEAK OF INFLATED EXPECTATIONS CERTAINLY IN HEALTH CARE INNOVATION IS OFTEN FOLLOWED BY A TROUGH OF DISILLUSIONMENT WHERE EARLY INNOVATIONS DON'T CONSISTENTLY DELIVER. AND SO I LIKE TO THINK OF THE WORK WE DO AT SIREN AND MANY OF THE PANELISTS ARE TALKING ABOUT, AND I KNOW THAT THE INSTITUTE HAS BEEN REALLY THINKING ABOUT IS INCREASE SLOPE OF ENLIGHTEN. , SLOPE OF THE SLOPE OF ENLIGHTMENT TO FIND INNOVATION WITH STAYING POWER A LITTLE BIT MORE QUICKLY. I'M GOING TO LEAVE MY CURVE AT THAT, BUT THE GOAL TO GO FROM PEEK OF INFLATED EXPECTATIONS TO FIND OUT WHAT WORKS AND WHAT CAN BE SUSTAINED IN THE HEALTH CARE SECTOR. OF COURSE, THE IMPORTANCE OF FINDING THAT PLATEAU OF PRODUCTIVITY HAS ACCELERATED IN THE CONTEXT OF COVID, WHICH AS YOU ALL KNOW REALLY UNDERSCORED THE POWERFUL AND DEVASTATING INTERSECTION OF HEALTH AND SOCIAL CONTEXT. AND COVID ALSO EXPOSED IMPACT OF THE COUNTRY'S RACIST PAST AND PRESENT WHICH LED TO AND PERPETUATE SOCIAL INEQUITIES ACROSS THE UNITED STATES. SO -- AND WORLDWIDE. SO ALL THAT TO SAY THAT THE CONTEXT THAT WE ARE IN HAS REALLY MAGNIFIED THE NEED FOR MORE INTENTIONAL TARGETED AND INFORMED EVIDENCE-BASED PRACTICES, FOR DIRECTING SOCIAL ADVERSITY AS ONE PART OF A COMPREHENSIVE STRATEGY FOR IMPROVING HEALTH AND REDUCING INEQUITY. SO, MY PLAN IS TO REALLY USE THE BULK OF MY TIME WITH YOU TODAY TO SHARE WITH YOU WORK THAT I DID WITH MY CO-PANELIST, RACHEL GOLD, WITH THE NATIONAL ACADEMIES OF MEDICINE. WE WERE PART OF A COMMITTEE ON INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE TO IMPROVE THE NATION'S HEALTH. THE REPORT WAS PUBLISHED IN SEPTEMBER 2019, EASY TO DOWNLOAD ON THE INTERNET. I LIKE TO PRESENT FROM THIS REPORT BECAUSE I THINK IT OFFERS A VERY USEFUL ORGANIZING FRAMEWORK, A COMMON LANGUAGE FOR US TO THINK ABOUT THE DIFFERENT TYPES OF RANGE OF ACTIVITIES THAT THE HEALTH CARE SECTOR COULD BE INVOLVED IN TO ADDRESS SOCIAL ADVERSITY BUT THE GOAL WAS TO EXPLORE HOW HEALTH CARE COULD BOTH IDENTIFY AND INTERVENE AROUND SOCIAL CONDITIONS, AS A STRATEGY TO IMPROVE HEALTH. SO, THE CORE OF OUR WORK REALLY CAME OUT AS THIS FRAMEWORK. DIDN'T LOOK LIKE THIS IN THE ACTUAL REPORT. THIS IS MY VERSION OF IT. BUT THIS IS THE FRAMEWORK, WHERE WE ARTICULATED CATEGORIES OF ACTIVITIES. SO EACH OF THESE IS A BUCKET THAT ACTUALLY HOLDS MANY DIFFERENT AND DIVERSE ACTIVITIES RELATED TO THE TOPIC LISTED. AND I'M GOING TO SPEND THE TALK WALKING THROUGH THIS BUT I WANT TO GIVE YOU ORIENTATION. ON THE FAR LEFT, FIRST CATEGORY IS REALLY ABOUT RECOGNIZING PATIENTS SOCIAL CONDITIONS. THE LEFT OF THE FRAMEWORK IS REALLY ABOUT WHAT YOU DO AFTER YOU KNOW ABOUT THEM. HOW DO YOU INTERVENE? WHAT'S OUR ROLE, OUR RESPONSIBILITY FROM WITHIN THE HEALTH CARE SECTOR? AS I MENTIONED, THE FIRST OF THESE TYPES OF SOCIAL ACTIVITIES WAS A GROUP THING WE HAVE STRATEGIES ABOUT IDENTIFYING PATIENT SOCIAL RISKS AND ASSETS. AND THIS INCLUDES A VERY DIVERSE SET OF INITIATIVES, INCLUDING THOSE WHERE PATIENTS ARE ASKED AT THE POINT OF CARE OR HEALTH INSURER ASSESSMENTS ABOUT THEIR SOCIAL CONDITIONS, ABOUT THEIR FOOD AND HOUSING CONDITIONS, ET CETERA. BUT THERE ALSO ARE SYSTEMS THAT ARE TRYING TO IDENTIFY OR SURFACE, RECOGNIZE PATIENTS' SOCIAL CONDITIONS BY LINKING IT TO ADDRESS DATA OR BUYING BIG CONSUMER DATA ABOUT THEIR PATIENT POPULATIONS. SO THAT THERE ARE MANY DIFFERENT AWARENESS STRATEGIES. BUT AT THE INDIVIDUAL PATIENT LEVEL, MUCH OF THE RESEARCH HAPPENING AROUND SOCIAL RISK HAS REVOLVED AROUND THESE NEW SOCIAL RISK SCREENING TOOLS THAT HAVE BEEN ENDORSED BY CENTER FOR MEDICARE AND MEDICAID SERVICES, EVEN THE NATIONAL ACADEMY, AND WHAT YOU'RE SEEING HERE IS JUST A LIST OF SOME DOMAINS COVERED IN EACH OF THOSE VERY POPULAR SOCIAL RISK ASSESSMENT TOOLS. WHAT HAS BEEN TROUBLESOME OR DIFFICULT AS A RESEARCHER I CAN SAY IS A THAT THERE'S A VEXING LACK OF CONSISTENCY ACROSS THE DIFFERENT TOOLS THAT HAS SPRUNG UP IN THIS CASE. EVEN TOOLS COVERING SIMILAR DOMAINS WILL ASK THEIR QUESTIONS IN DIFFERENT WAYS, MAKING IT MORE DIFFICULT TO COMBINE INFORMATION ACROSS DIFFERENT INSTITUTIONS. AND IN ADDITION TO THAT, OUR COLLEAGUES IN SEATTLE AND PORTLAND, WE WORK WITH OUR FRIENDS THERE TO LOOK AT DEVELOPMENT OF THESE TOOLS, MANY DEVELOPED WITHOUT REAL FOCUS ON THE PRAGMATIC OR PSYCHOMETRIC VALIDITY OF THE QUESTIONS THAT WERE BEING ASKED. NONETHELESS, THEY ARE INCREASINGLY BEING USED IN CLINICAL SETTINGS, AND WE'LL TALK ABOUT HOW MUCH AND HOW PREVALENT WE'RE SEEING THEIR RUSE IN A -- USE IN A MINUTE. I WANT TO FIRST SAY THIS IS WORK THAT WE DID AS A TEAM IN OVER TEN SITES AROUND THE COUNTRY, TRYING TO JUST LOOK AT, WELL, DO PATIENTS AND CAREGIVERS FIND IT ACCEPTABLE TO BE ASKED ABOUT SOCIAL RISKS AT THE POINT OF CARE? SO WE TALKED WITH A THOUSAND DIFFERENT PEOPLE, IN PEDIATRIC SETTINGS, E.D. SETTINGS, PATRIOTIC, ADULT AND E.D. PRIMARY CARE SETTINGS. DOES IT FEEL APPROPRIATE TO BE ASKED ABOUT SOCIAL RISKS AND MOREOVER IN THE RIGHT-HAND PIECHART YOU CAN SEE RESULTS, WHEN PATIENTS OR CAREGIVERS WERE ASKED ABOUT WOULD YOU FEEL COMFORTABLE HAVING THAT KIND OF INFORMATION INCLUDED IN YOUR ELECTRONIC HEALTH RECORD AS WELL. YOU CAN SEE FROM BOTH OF THE PIECHARTS THAT THE MAJORITY OF PEOPLE ARE EITHER VERY OR SOMEWHAT COMFORTABLE WITH BOTH. SO, WE ARE LEARNING A LITTLE BIT ABOUT THE FACILITATORS OF AWARENESS ACTIVITIES, SO TECHNOLOGY IS ONE OF THEM, AS MANY OF YOU MAY BE AWARE EHR VENDORS ARE INCREASINGLY INCORPORATING SOME TOOLS I SHOWED YOU, AND OTHERS, THAT I'VE BEEN ADAPTED BY INDIVIDUAL SYSTEMS, INTO THEIR EHR, SO THAT INFORMATION IS AVAILABLE MORE READILY AVAILABLE, AND AGGREGATABLE, WITHIN CLINICAL SETTINGS. RACHEL WILL TALK A LITTLE BIT ABOUT HER WORK AND OUR SHARED WORK ABOUT IMPLEMENTATION SCIENCE ON THE TECHNOLOGY INNOVATIONS. WE ALSO KNOW PAYMENT IS FACILITATING AWARENESS ACTIVITIES, SO THINGS LIKE THIS IS A SLIDE FROM AN INSURE, THEY ARE ACTUALLY PAYING HEALTH CARE DELIVERY ORGANIZATIONS TO CONDUCT SOCIAL DETERMINANTS OF HEALTH SCREENING. KIND OF ON PAR WITH WHAT WE DID TO INCREASE ADOPTION OR UPTAKE OF DEPRESSION SCREENINGS YEARS AGO AND CONTINUE TO DO. SO GIVEN THAT MEASURES HAVE BEEN DEVELOPED, QUESTIONS ARE ACCEPTABLE, THERE'S FACILITATORS, YOU MIGHT WONDER THE EXTENT THIS IS HAPPENING. IN ONE STUDY DONE BY MY COLLEAGUE FRAZE ANALYZED DATA FROM NATIONAL HEALTH CARE ORGANIZATIONS INCLUDING HOSPITALS AND PRACTICES ANDS MANY HOSPITALS SAID OF COURSE WE'RE SCREENING FOR AT LEAST ONE BIG SOCIAL RISK LIKE FOOD, HOUSING, UTILITY, TRANSPORTATION. 92% ARE DOING THIS. IF YOU ASK PATIENTS MANY FEWER PATIENTS ARE SAYING THEY ARE BEING SCREENED FOR ANY SOCIAL RISK SO IT REALLY DEPENDS ON HOW AND WHOM YOU ASK. IT'S NOT CLEAR HOW FREQUENTLY THIS IS HAPPENING AT LEAST AS OF A FEW YEARS AGO. I THINK IT ACTUALL HAS INCREASED OVER THE LAST PROBABLY TWO YEARS. WHAT DO YOU DO ABOUT THE INFORMATION ONCE YOU ARE MORE AWARE OF IT? AND HERE THE COMMITTEE BROKE UP THE FRAMEWORK INTO TWO DIFFERENT CATEGORIES, TWO DIFFERENT SETS OF CATEGORIES. SO THE FIRST TWO OF THE INTERVENTION CATEGORIES ARE ADDRESS. AND ASSIST. ASSISTANCE AND ADVOCACY AND ALIGNMENT. I WILL MENTION ALIGNMENT AND ADVOCACY AS WELL. SO THE FIRST OF THE HEALTH CARE DELIVERY PATIENT-FOCUSED STRATEGIES WE CALLED ADJUSTMENT. THIS REFERS TO SITUATIONS IN WHICH SOCIAL RISK DATA ARE BEING USED TO INFORM CLINICAL CARE DECISIONS AT THE POINT OF CARE. THESE ADJUSTMENT STRATEGIES MIGHT BE CHOOSING A LESS EXPENSIVE MEDICATION OR ADJUSTING A QUALITY MEASURE BASED ON SOCIAL RISK FACTORS, AS YOU KNOW THERE'S A LOT OF DISCUSSION ABOUT THAT AT THE PAYMENT AND POLICY LEVEL RIGHT NOW. SO, I PERSONALLY AS A SAFETY NET PHYSICIAN THINK OF THIS WORK AS STUFF WE AS PROVIDERS DO EVERY SINGLE DAY, PARTICULARLY IN THE SAFETY NET. WE JUST DON'T DO IT WELL OR SYSTEMATICALLY AND ACCOMMODATE SOCIAL RISK FACTORS THAT CAN INTERFERE WITH TREATMENT. WE TRY TO IMPROVE ACCESS, MOBILE VANS, INTERPRETERS, WEEKENDS AND EVENINGS, MINI MENTAL STATUS EXAMINE IS SUPPOSED TO BE ADJUSTED FOR LITERACY, NOT ALWAYS AVAILABLE AT OUR FINGERS TIPS. WE ADJUST CARE TO SOCIAL CONTEXT IN THE CASE OF TREATMENT. SO WE TRY AND FIND THE LESS EXPENSIVE MED, WE DO ONCE DAILY DOSING INSTEAD OF FOUR TIMES DAILY DOSING. SO AS AN EXAMPLE IN ONE PRESENTATION I WAS DOING, A PULMONOLOGIST WOULD NEVER GIVE A CPAP MACHINE TO SOMEONE IN A SHELTER UNLESS I HAD SPOKEN WITH THE SHELTER DIRECTLY. ANOTHER EXAMPLE, I SAW A PRESENTATION ABOUT SOMEBODY DOING DIALYSIS APPOINTMENTS, OFFERING DIALYSIS APPOINTMENTS OVERNIGHT TO IMPROVE ADHERENCE FOR HOMELESS POPULATIONS. THIS IS WORK FROM OUR COLLEAGUES IN MICHIGAN, WHERE THEY TALKED WITH PROVIDERS ABOUT THE ADJUSTMENT DECISIONS EVERY DAY IN THE CASE OF DIABETES, AND YOU CAN SEE OH, I'M NOT TITRATING INSULIN AS CAREFULLY TO GET MY HEMOGLOBIN A1c CONTROLLED IF A PATIENT HAS LIMITED FOOD RESOURCE, OR MAYBE I'LL CHANGE THE TYPE OF INSULIN TO REDUCE MEDICATION TIMES. I WOULD ENCOURAGE YOU PRACTICING OR HAVE PRACTICED TO JUST THINK ABOUT WHAT ARE THE WAYS WHICH I GET ADJUSTMENTS IN MY OWN CARE IN ORDER TO ACCOMMODATE PATIENTS' SOCIAL RISK. JUST AS BEFORE I WOULD HIGHLIGHT TECHNOLOGY CAN FACILITATE ADJUSTMENT ACTIVITY. THIS IS A SCREEN SHOT OF A REALTIME PHARMACY BENEFIT TOOL INCREASINGLY BEING REQUIRE TO USE BY THE FEDS IN ALL THE HEALTH CARE SETTINGS. THE PROBLEM WITH OUR REALTIME PHARMACY BENEFITS TOOLS IS THEY HAVEN'T YET BEEN -- THEY ARE NOT YET ALWAYS HOLDING HIGH ENOUGH QUALITY INFORMATION THAT CLINICIANS ARE WANTING TO USE THEM REGULARLY SO MAY BE RELEVANT FOR SOME POPULATIONS BUT NOT ALL IN TERMS OF OUT OF POCKET COST TO PATIENTS. SO JUST TO MAKE SURE WE'RE ON THE SAME PAGE, THE REALTIME TOOLS PROVIDE INFORMATION ABOUT THE COST OF MEDICINE AT THE POINT OF CARE, COST USUALLY BOTH TO THE PATIENT AND TO THE SYSTEM. IDEALLY THEY ARE EQUIVALENT MEDS, OR HAVE SIMILAR EFFECTIVENESS OR EFFICACY. YOU CAN IMAGINE THAT IF YOU HAVE THIS INFORMATION AND YOU BELIEVED IN THIS INFORMATION IT WOULD AFFECT YOUR COMFORT ASKING THE PATIENT ABOUT FINANCIAL ABILITY TO AFFORD MEDICATION BECAUSE YOU WOULD HAVE OPTIONS. O MORE COMMON, ADJUSTMENT STRATEGIES IN RESEARCH COMMUNITY, EVEN IN THE MEDIA, ARE POINT OF CARE INTERVENTIONS TO MORE DIRECTLY INTERVENE ON PATIENTS' SOCIAL NEEDS. NATIONAL ACADEMY REPORT WE REFERRED TO THESE AS ASSISTANCE INTERVENTIONS. THESE ARE INTERVENTIONS WHERE WE LEVERAGE HEALTH CARE SYSTEM RESOURCES IN SOME WAY TO IMPROVE PATIENT SOCIAL CONDITIONS OR SOCIAL CONTACTS. INSTEAD OF GIVING NON-REFRIGERATED MEDICATION MAYBE WE HELP THE PATIENT GET A REFRIGERATOR, IN LOTS OF PLACES INCLUDING PRO MEDICA IN MICHIGAN AND OHIO GIVING EVERY HOSPITALIZED PATIENT A CONNECTION TO FOOD PROGRAMS, HERE IN OAKLAND HELPING PATIENTS GET A LIVING WAGE JOB, UNDER OUR CALIFORNIA 1115 WAIVER WE'RE CONNECTED HOMELESS PATIENTS WITH HOUSING SUPPORT SPECIALISTS USING HEALTH CARE DOLLARS TO DO SO. IN ADJUSTMENT STRATEGIES, THESE ARE SOMETIMES PART OF CARE, RARELY ROUTINE ALREADY OR SYSTEMATICALLY BUILT INTO PRACTICE. I DO WANT TO EMPHASIZE THERE ARE BIG EVIDENCE GAPS ACROSS THESE PATIENT-FOCUSED INTERVENTIONS, AND I THINK IT'S MY JOB IN THIS PRESENTATION TO HIGHLIGHT THOSE. RESEARCH IS REALLY -- OOPS. RESEARCH IS REALLY RACING TO CATCH UP WITH INNOVATION. I CAN'T MARCH THROUGH ALL OF THE LITERATURE IN THE FIELD BUT I'M GOING TO TELL YOU THAT WHAT IS MOST RELEVANT I THINK IS THAT IN STUDIES IN THIS SPACE ONLY A FEW HAVE INCLUDED VERY STRONG DESIGNS THAT MOVE US CLOSER TO CAUSAL INFERENCE. SO WORK ON COMMUNITY HEALTH WORKERS, WE'RE SEEING RESEARCH TEAMS USING CONTROL GROUPS OR SOME OTHER RESEARCH DESIGN THAT CAN HELP REDUCE STUDY BIAS AND INCREASE CONFIDENCE THAT THE FINDINGS ARE THE RESULT OF THE INTERVENTION AS OPPOSED TO REFLECTION OF REGRESSION TO THE MEAN. WE HAVE A LOT LEFT TO LEARN ABOUT THE HEALTH, UTILIZATION AND COST IMPACT AS AWARENESS ADJUSTMENT AND STRATEGIES. I WILL SAY AT THE SAME TIME WE'RE LOOKING AT THE HEALTH COST AND UTILIZATION OUTCOMES WE HAVE REALLY IMPORTANT ETHICS QUESTIONS TO LOOK AT. WHAT ARE THE POSSIBLE UNINTENDED CONSEQUENCES OF INTEGRATION, FOR INSTANCE CAN SOCIAL RISK SCREENING EXACERBATE MISTRUST AND OF COURSE QUESTIONS MAKING SURE WE'RE NOT JUST RATIONALIZING POOR CARE FOR POOR PEOPLE. I WANT TO HIGHLIGHT THE TWO COMMUNITIES-TARGETED STRATEGIES OUTLINED IN THE REPORT INCLUDING ALIGNMENT AND ADVOCACY, ACTIVITIES WHERE HEALTH CARE SYSTEMS INCREASE ACTIVITIES TO UNDERSTAND THE SOCIAL RISK ASSETS IN THE COMMUNITY AND HELP TO BEGIN TO FILL THEM USING THEIR OWN RESOURCES AND ADVOCACY USING EXTERNAL RESOURCES. AND ALL OF THESE, AGAIN, ARE MORE THOROUGHLY DESCRIBED IN THE FINAL REPORT. I'LL SKIP AN EXAMPLE. I APPRECIATE RACHEL'S YOU CAN'T -- CALLOUT BUT I WANT TO OFFER A RESOURCE TO MAKE SURE IT'S AVAILABLE TO EVERYBODY AND FREE AND EASILY SEARCHED. WE HAVE THIS EVIDENCE AND RESOURCE ON THE SIREN WEBSITE THAT'S DESIGNED TO MAKE SURE THAT RESEARCH GETS INTO THE HANDS OF PEOPLE WHO CAN USE IT. SO THE SIREN IS AN EFFORT TO CATALYZE HIGH QUALITY RESEARCH IN THIS AREA AND GET IT OUT TO ALL OF YOU. PLEASE DON'T HESITATE TO BROWSE OUR RESOURCES AND TO USE ANYTHING THAT COULD BE HELPFUL IN YOUR WORK. FINALLY, WE JUST IN JANUARY LAUNCHED A SERIES OF WEBINARS AND DOWNLOADABLE PODCASTS THAT ARE SORT OF INVITING EXPERTS TO WEIGH IN ON SOME OF THE MORE CONTROVERSIAL OR COMPLICATED ISSUES IN THIS FIELD. BOTH RESEARCH PRACTICE AND POLICY. AND IF ANYBODY IS INTERESTED WE WOULD WELCOME YOUR PARTICIPATION. THAT IS MY 20 MINUTES. IT GOES REALLY FAST. AND I'M GOING TO TURN IT OVER TO RACHEL. I GUESS BACK TO REBECCA TO INTRODUCE RACHEL, MY CLOSE COLLABORATOR, AND I REALLY HOPE YOU ENJOY THE REST OF TODAY'S TALK. I'M SORRY I CAN'T BE HERE FOR THE PANEL TODAY, THE CONVERSATION PART OF THE PANEL. >> THANK YOU SO MUCH, LAURA GOTTLIEB HAS CLINICAL RESPONSIBILITIES THIS AFTERNOON AND WILL NOT BE ABLE TO STAY WITH US. IT'S MY PLEASURE TO INTRODUCE RACHEL GOLD. >> GOOD MORNING. POWERPOINT TAKES A MINUTE. CAN YOU SEE MY SCREEN? IS IT SHOWING UP APPROPRIATELY? >> YES. >> AND THE CORRECT VIEW? >> YES. >> TECHNOLOGY DOES NOT ALWAYS HELP. GOOD MORNING, I'M RACHEL GOLD, THANK YOU FOR THE INTRODUCTION BEFORE, REBEKAH. I'M GOING TO DIVE INTO THE TALK. I'M GOING TO TALK ABOUT HOW TO IMPLEMENT THESE INTERVENTIONS THAT ARE TARGETING SOCIAL DETERMINANTS, SOCIAL RISK, BASED ON VERY MUCH ON THE SAME FRAMEWORK THAT MY FRIEND AND COLLEAGUE LAURA JUST DESCRIBED TO YOU. I DO WANT TO MAKE IN THE FIRST COUPLE SLIDES, MAKING A POINT ABOUT WHY WE'RE DEALING WITH SOCIAL DETERMINANTS, SOCIAL RISKS IN THE FIRST PLACE. I'M SURE THIS IS OBVIOUS TO ALL OF YOU BUT IT'S IMPORTANT I THINK TO KEEP PROVIDING OURSELVES THE REASON SOCIAL DETERMINANTS EXIST IS BECAUSE PRIMARILY BECAUSE OF POVERTY AND INCOME AND INEQUALITY AND REASON THAT WE HAVE POVERTY AND INCOME INEQUALITY IS VERY SOLELY BECAUSE OF NATIONAL AND LOCAL POLICIES THAT ENHANCE THAT INEQUALITY. THEY ARE OVERLAID WITH RACISM, WHICH INFORMS THOSE POLICIES. AND I JUST WANT TO -- THE POINT HERE IS SOCIAL DETERMINANTS ARE NOT LIKE A VIRUS. WE COULD GET RID OF THEM IF WE WANTED TO. SO WHAT WE HAVE NOW IS THIS SITUATION BECAUSE OF THE COMPLEMENT OF RACISM AND NATIONAL POLICIES WHERE WE HAVE FAR HIGHER POVERTY RATES, AS YOU CAN SEE IN THE FIGURE, AMONG A NUMBER OF COMMUNITIES OF COLOR, COMPARED TO WHITE COMMUNITIES, AND AS A RESULT POVERTY-RELATED SOCIAL RISKS 2 TO 2 1/2 TIMES MORE PREVALENT IN BLACK AND HISPANIC PEOPLE, FOR EXAMPLE, ENTIRELY ALIGNED WITH THE DIFFERENTIAL POVERTY RATE. SO AGAIN POVERTY LEADS TO SOCIAL RISK, RACISM CREATES MORE POVERTY IN SOME GROUPS, RACISM ALSO IMPACTS HEALTH ON ITS OWN. I UNDERSTAND THAT. TALKING, YEAH, JUST WANT TO CALL THAT OUT. AND PREJUDICE AND DISCRIMINATION OF THIS SORT HAS SIMILAR NEGATIVE IMPACTS ON OTHER MINORITY GROUPS LIKE TRANSGENDER FOLKS, THIS IS WHY WE HAVE HEALTH INEQUALITY AND HEALTH DISPARITIES. WE'VE GOT SOCIAL RISKS EVEN THOUGH WE COULD GET RID OF THEM, BUT WE HAVE THEM. NOW WHAT? WHAT CAN HEALTH CARE SYSTEMS DO? WHAT SHOULD HEALTH CARE SYSTEMS DO, HOW CAN HEALTH INFORMATION TECHNOLOGY HELP US AND HOW DO WE IMPLEMENT THESE ACTIVITIES? THERE ARE BARRIERS TO IMPLEMENTING ANY PRACTICE CHANGES, NOT EASY, YOU ALL KNOW IT'S NOT EASY TO MAKE CHANGE IN A CLINIC. YOU HAVE STAFF TURNOVER. YOU HAVE TO ADOPT WORKFLOWS, YOU NEED TO HAVE CORRECT -- NOT JUST A CHAMPION BUT IT HAS TO BE THE RIGHT PERSON. I'VE SEEN EXAMPLES CLINICS ASSIGN THE NEWEST PERSON TO BE THE CHAMPION FOR CHANGE. THAT PERSON DOESN'T HAVE THE SOCIAL CAPITAL TO REALLY MAKE CHANGE HAPPEN. YOU HAVE TO HAVE LEADERSHIP SUPPORT, AND BE VERBAL, FRONT AND CENTER. YOU HAVE TO HAVE ADEQUATE RESOURCES AND THERE ARE ALWAYS COMPETING PRIORITIES FOR ANY KIND OF CHANGE. AND FOLKS ESPECIALLY IN COMMUNITY HEALTH CENTERS WHERE I WORK ARE OVERWORKED, SO THERE ARE A LOT OF BARRIERS TO IMPLEMENTING CHANGE, PERIOD. NOW, LAURA TALKED ABOUT THE NATIONAL ACADEMIES REPORT. I'LL GO THROUGH THE PATIENT FACING INTERVENTIONS, AWARENESS, ADJUSTMENT, ASSISTANCE, TALK ABOUT WHAT WE KNOW ABOUT BARRIERS TO IMPLEMENTING THEM. STARTING WITH AWARENESS, STRATEGIES ARE REALLY AROUND JUST CAN WE IDENTIFY WHAT'S GOING ON WITH THE PATIENT, DOCUMENT IT, KNOW ABOUT IT. TO IMPLEMENT SOCIAL RISK DOCUMENTATION, HEALTH CARE LEADERS, LEADERSHIP NEEDS TO BUY IN. THEY MAY BE CONCERNED WE DON'T HAVE ENOUGH RESOURCES, IS THIS GOING TO MAKE A DIFFERENCE, THERE MAY BE CULTURAL BARRIERS. IT'S NOT MY JOB, I'M A CLINICIAN, NOT A SOCIAL WORKER, FOR EXAMPLE. SOME FOLKS MAY THINK YOU CAN'T ADDRESS SOCIAL NEEDS OR IT WON'T HELP OR I ALREADY KNOW MY PATIENT'S NEEDS, WHICH I THINK CAN BE TRUE BUT CAN ALSO REFLECT SOME IMPLICIT BIAS. OR I DON'T HAVE TIME TO DO IT. WE HEAR ALL THE TIME WHY SHOULD I SCREEN IF I CAN'T REFER, IF I CAN'T MAKE ASSISTANCE INTERVENTION? I'M GOING TO TALK ABOUT THAT A BIT MORE LATER. THE REASONS WHY YOU COULD. SO, AGAIN, OTHER BARRIERS TO IMPLEMENTING SOCIAL RISK SCREENING, THERE'S NOT VERY CLEAR GUIDANCE ON WHICH PATIENTS SHOULD BE SCREENED AND WHEN, HOW OFTEN, WHICH SCREENING TOOLS SHOULD WE USE, AS LAURA SPOKE, YOU HAVE TO BE SET UP TO IMPLEMENT, YOU NEED STRUCTURE, A STRATEGY, TO TEST IT. IF YOU'RE GOING TO DO IT, HAVE TO HAVE RELATIONSHIP. DO YOU HAVE ENOUGH STAFF, ARE EHR STOOLS ADEQUATE? THESE ARE BARRIERS IDENTIFIED IN LITERATURE. TECHNOLOGICAL PIECE AROUND COLLECTING THE DATA IS COMMONLY DONE WITH SCREENING HAPPENING AT THE DATA ENTRY, CLINIC STAFF, PERHAPS AT SOCIAL WORKER VISIT. THERE ARE OTHER TECHNOLOGIES WE COULD USE. SOME FOLKS INTRODUCE THE PORTAL BUT NOT ALL PATIENTS HAVE PORTAL ACCOUNTS, PATIENTS MOST AT RISK WHO MAY NOT HAVE THE PORTAL ACCOUNT. CAN WE USE A TABLET AT CHECK-IN, NOT ALL CLINICS HAVE THAT AND NOW WITH COVID I'M NOT SURE HOW YOU WOULD KEEP THAT HYGIENIC. TEXTING, NOT ALL CLINICS CAN DO BOTH TEXTING, NOT ALL PATIENTS TEXT OR FEEL COMFORTABLE ANSWERING THOSE KINDS OF QUESTIONS, PERHAPS WE NEED TO STUDY THAT MORE. MY POINT HERE IS THERE ARE PROBABLY -- THERE ARE OPTIONS FOR HOW TO COLLECT DATA BUT NONE ARE PERFECT. SO WE'RE TALKING ABOUT ASSISTANCE STRATEGY, BARRIERS TO ASSISTANCE STRATEGIES. I WILL SAY I THINK THIS IS IMPLICIT, WHAT LAURA SAID, THERE IS EMERGING EVIDENCE THAT MAKING EITHER INTERNAL OR EXTERNAL SYSTEMS REFERRALS, INTERNAL REFER TO THE CLINIC SOCIAL WORKER WHO MIGHT THEN HELP MAKE EXTERNAL REFERRALS, FOR EXAMPLE, THEY CAN LEAD TO MODESTLY IMPROVED HEALTH OUTCOMES. WE'RE SEEING THAT HAPPEN IN A SMALL NUMBER OF HIGH QUALITY STUDIES. AND SOME SYSTEMATIC REVIEWS SUMMARIZED THAT INCLUDING ONE THAT LAURA HAS A GOOD PAPER I HIGHLY RECOMMEND. THERE ARE ALSO ACCEPTANCE BARRIERS. I'LL TALK ABOUT THAT LATER WHERE PATIENTS ARE NOT ALWAYS INTERESTED IN REFERRAL ALSO. THERE ARE NATIONAL GUIDELINES, WE'VE LOOKED AT HYPERTENSION SO FAR, OBVIOUS EXAMPLE IF A PATIENT HAS FOOD INSECURITY MAKE A RECOMMENDATION FOR FOOD ASSISTANCE. HOW DO YOU REFER PATIENTS TO SOCIAL SERVICE AGENCIES? WHAT ARE BARRIERS? THIS IS ONE OF THE -- THIS SLIDE GETS AT ONE OF THE MOST CHALLENGING THINGS WE'RE DEALING WITH RIGHT NOW, I'M SURE MANY OF YOU DEALT WITH THIS IN YOUR PRACTICES AS WELL. YOU HAVE TO MAKE SURE YOUR STAFF KNOW ABOUT THE LOCAL COMMUNITY-BASED ORGANIZATIONS OR SOCIAL SERVICE AGENCIES, COMMUNITY-BASED ORGANIZATIONS, A LOT OF CLINICS, WE'VE GOT A BINDER OF AGENCIES WE WORK WITH. OKAY, HOW DO YOU KEEP THAT UP TO DATE, MAKE SURE YOU KNOW A GIVEN AGENCY IS STILL SERVING, WHICH PATIENTS ARE THEY SERVING, THAT CHANGES A LOT. AND IF THE CLINIC IS KEEPING ITS OWN LIST OF SERVICE AGENCIES TO WHICH THEY CAN REFER THROUGH EHR IT HAS TO BE UPDATED, PART OF THE WORKFLOW. SSRLs, SOCIAL SERVICE RESOURCE LOCATORS, THERE'S A NUMBER OF VENDORS OFFERING UP-TO-DATE LISTS OF SOCIAL SERVICES THAT CAN BE PLUGGED INTO THE EHR. BUT TO PLUG THAT INFORMATION INTO THE EHR IS NOT FREE. THAT CAN BE PRETTY COSTLY FOR CLINICS. THE CLINICS SERVING THE MOST LOW INCOME PATIENTS MIGHT NEED THIS THE MOST PROBABLY THE LEAST LIKELY ABLE TO AFFORD THIS. YOU CAN ACCESS SOME OF THESE LISTS OUTSIDE OF THE EHR BUT, FOLKS, THAT SLOWS DOWN WORKFLOWS. WHEN THERE ARE EHR-BASED LISTS NONE OF THE TOOLS FOR USING THE EHR ARE SMOOTH. THEY INVOLVE A LOT OF CLICKS. YOU HAVE TO UNDERSTAND HOW TO GET THERE. THE SOCIAL RISK DOCUMENTATION, REFERRAL TOOLS ARE SEPARATE. THEY MAY PRESENT A LOT OF OPTIONS THAT AREN'T VERY WELL CURATED. AND THERE'S A LOT OF INTERESTING COMMUNITY ORGANIZATIONS CLOSING THE LOOP AND ENTERING DATA BACK INTO THE INTERFACE TO SAY, YES, WE SAW THIS PATIENT, THERE ARE A LOT OF CHALLENGES WITH MAKING THAT HAPPEN EFFECTIVELY. I HAVE NOT SEEN THAT HAPPEN EFFECTIVELY IN A FORMAL TRIAL. BUT I HOPE WE CAN PULL THAT OFF. THE OTHER POINT I WANT TO MAKE GIVE BE WE DO HAVE A NUMBER OF DIFFERENT SOCIAL SERVICE RESOURCE LOCATOR VENDORS, IF YOU'VE GOT A COMMUNITY-BASED ORGANIZATION WORKING WITH PATIENTS FROM MULTIPLE CLINICAL SITES, YOU'RE ASKING THEM TO BOTH REMEMBER WHICH SOCIAL SERVICE RESOURCE LOCATOR INTERFACE THEY ARE WORKING WITH FOR A GIVEN PATIENT, THAT'S JUST NOT GOING TO WORK. SO THERE'S A LOT OF BARRIERS, WE HAVE TO FIGURE OUT HOW TO MAKE THIS WORK. THESE BARRIERS NOT TO SAY WE SHOULDN'T DO THIS STUFF, WE SHOULD. BUT MORE TO CALL OUT CHALLENGES INVOLVED SO WE CAN TAKE THEM ON HEAD ON. OKAY. NOW I SAID ONE OF THE CHALLENGES AROUND ASSISTANCE IS THE PATIENTS OFFERED ASSISTANCE INTERVENTIONS DON'T ALWAYS ACCEPT THEM. OUR TEAM FOUND THAT ABOUT 80% OF COMMUNITY HEALTH CENTER PATIENTS WITH REPORTED SOCIAL RISK DECLINED OFFERED REFERRAL, NOT INTERESTED, VARIED BY NUMBER OF SOCIAL RISKS THEY HAVE, DOMAINS, BY GENDER, RACE/ETHNICITY, THE PAPER IS IN SUBMISSION. WE FOUND IT'S ABOUT 50% OF PATIENTS IN INTEGRATED CARE SETTING WHO HAD REPORTED RISKS DECLINED REFERRALS. OTHER FOLKS FOUND FOOD INSECURITY REFERRAL ACCEPTANCE RANGING FROM 21 TO 90% OF PATIENTS, HOUSING INSECURITY FROM 12 TO 20%, SO WE'VE GOT A LOT OF WORK TO FIGURE OUT WHY PATIENTS ARE NOT INTERESTED, WHY ARE SUCH A LARGE NUMBER OF PATIENTS WHO AREN'T NECESSARILY INTERESTED IN RECEIVING ASSISTANCE REFERRAL. NOW TALKING ABOUT ADJUSTMENT STRATEGIES, LAURA TALKED ABOUT HE'S A LOT. I DON'T THINK SHE MENTIONED, SHE AND I ARE CO-LEADING A TRIAL TO TRY AND FIGURE OUT HOW TO MAKE DECISION SUPPORT TOOLS RELATED TO ADJUSTMENT. SO WHAT WE REALLY -- THERE'S A BIG KNOWLEDGE GAP ABOUT WHAT ARE THE BEST WAYS TO ADJUST CARE TO ACCOUNT FOR SOCIAL RISKS. WE DON'T REALLY KNOW HOW PROVIDERS ARE DOING IT. THERE'S SOME RESEARCH, NOT A LOT. DATA DOESN'T COME WITH RECOMMENDATIONS, JUST LISTED IN THE EHR, NO SUGGESTIONS, DATA ARE USED INCONSISTENTLY. ONE PRIVATE CARE SETTING, LESS THAN A QUARTER OF CASES. AND THERE MAY BE BARRIERS TO PROVIDERS AND CARE TEAM MEMBERS ADOPTING ADJUSTMENT STRATEGIES, BOTH WHICH LAURA SPOKE TO AS WELL, PERHAPS THERE MAY BE NEGATIVE IMPACTS THAT WE HAVEN'T IDENTIFIED, A LOT TO THINK ABOUT HERE. BUT LET'S JUST ADD A BIT, WHAT ARE SOME ADJUSTMENT STRATEGIES, WHAT MIGHT THOSE LOOK LIKE? I PRESENT THESE NOT TO SAY THERE'S EVIDENCE BEHIND ALL OF THEM BUT GET YOU THINKING. FOR EXAMPLE IF A PATIENT DOES NOT HAVE STABLE HOUSING OR RESTROOM ACCESS YOU MIGHT WANT TO CONSIDER NOT PRESCRIBING A DIURETIC MEDICATION BECAUSE THAT MAY NOT BE FEASIBLE TO MAKE THEM USE THE RESTROOM. HOUSING INSECURITY, METFORMIN RATHER THAN INSULIN, TRANSPORTATION INSECURE MAYBE A TELEHEALTH VISIT, WITHOUT GETTING BACK TO THE CLINIC WHICH MIGHT BE A CHALLENGE. LOWER COST MEDS, INSULIN SUPPLY ACCOUNTS FOR LIMITED REFRIGERATION ACCESS. PERHAPS NEED TO PRIORITIZE MEDICATIONS, IF A PATIENT'S INCOME ALLOWS THEM TO PAY FOR ONE MED WHICH ONE IS THE MOST IMPORTANT. A LOT OF INTERESTING AND CHALLENGING QUESTIONS HERE. LET'S GET SOME POSITIVES, WAYS THAT WE MAY BE ABLE TO ADDRESS SOME OF THESE BARRIERS TO IMPLEMENTING SOCIAL RISK-RELATED ACTIVITIES. DEMONSTRATING UTILITY OF COLLECTED DATA, IF FOLKS ARE SAYING WHY SHOULD WE SCREEN, SHOW HOW DATA WESTBOUND USED. WE VERY MUCH RECOMMEND STARTING SMALL, TRYING OUT A NEW WORKFLOW, TESTING IT, BEING FLEXIBLE, TRYING AGAIN. FINDING THE RIGHT CLINIC CHAMPION, SUPPORTING THAT CHAMPION, NOT THE PERSON JUST HIRED, WE'VE DEALT WITH THIS A LOT. ENGAGE THE CLINIC STAFF WHO WILL BE DOING THESE ACTIVITIES IN YOUR PLANNING AND PROCESS ITERATION, GET THAT INFRASTRUCTURE IN PLACE FIRST IF YOU CAN, AGAIN VERY FRONT-FACING LEADERSHIP SUPPORT. AS LAURA NOTED THERE ARE SOME EXTERNAL MOTIVATORS AS WELL THAT MAY BE TIED TO REGULATION, GRANT PROGRAMS, CERTIFICATION, ET CETERA. ONE THING I WANT TO UNDERCORE IT'S IMPORTANT THE REASONS FOR DOING SOCIAL RISK SCREENING ARE COMMUNICATED TO TEAM MEMBERS AND PATIENT. I'LL TALK ABOUT THAT MORE IN A BIT. THIS IS A BUSY SLIDE. I WANT TO DRAW YOUR ATTENTION TO THE FIRST TWO COLUMNS. MY TEAM IS TESTING RIGHT NOW A FIVE-STEP IMPLEMENTATION PROCESS FOR SOCIAL RISKS SCREENING AND REFERRAL MAKING. I WANTED TO SHOW YOU GUYS SOME ELEMENTS OF THIS PROCESS TO SAY IF YOU'RE INTERESTED IN SEEING OUR TOOLS AND OUR GUIDES, YOU'RE WELCOME TO THEM, WE'RE FUNDED BY NIH, HAPPY TO SHARE ALL THESE MATERIALS WITH YOU WHICH IS WHY I'M SHOWING THIS TO YOU, FEEL FREE TO REACH OUT EITHER IN THE CHAT OR THROUGH MY E-MAIL AND WE'LL SEND YOU THESE GUIDEBOOKS, YOU CAN USE THEM. WE'VE BEEN SHARING THEM WITH FOLKS ALL OVER THE COUNTRY. JUST WALKING THROUGH FIVE STEPS, CREATE THE TEAM. SECOND IS IDENTIFYING CLINIC GOALS, WHY ARE WE DOING THIS, WHO DO WE SCREEN AND WHY? HOW ARE WE GOING TOO USE DATA? THIRD, CREATE SOCIAL DETERMINANTS PLAN. FOURTH TRAIN YOUR TEAM, TEST IT, SEE HOW IT WORKING. I WANT TO SHOW YOU TOOLS IN OUR MATERIALS. I JUST WOULD LOVE FOR FOLKS IF YOU'RE INTERESTED TO LET ME KNOW AND I'LL SHARE ALL THIS WITH YOU. YOU'RE WELCOME TO IT. WE'VE GOT A TOOL RIGHT HERE ABOUT IDENTIFYING YOUR GOALS. WHY DO YOU WANT TO DO THIS? WHAT'S OUR PRIORITY? IS OUR PRIORITY PROVIDING INFORMATION THAT MIGHT IMPACT TREATMENT PLAN? OR IS PRIORITY UNDERSTANDING WHAT'S GOING ON IN THE COMMUNITY? THERE ARE DIFFERENT REASONS. AND WE REALLY FEEL GOAL SETTING AND PRIORITIZATION IS A FAIRLY IMPORTANT PART OF THE PROCESS. ON THE RIGHT SIDE IS HOW WE HAVE TALK TO CLINICS ABOUT HOW THEY -- WHY THEY WANT TO IMPROVE THEIR SOCIAL RISK SCREENING ACTIVITIES. AND THEN THIS IS A SPREADSHEET TO FIGURE OUT WORKFLOWS. WALKS YOU THROUGH WHO IS GOING TO COLLECT SOCIAL DETERMINANTS DATA, FRONT DESK STAFF, NURSE? AND ABILITY TO WRITE IN SOMEONE DIFFERENT. HOW THE DATA WILL BE COLLECTED, IF YOU USE THE PORTAL, THE PROCESS. WE HEAR FROM CLINICS IT HELPS THEM THINK ABOUT HOW THEY ARE GOING TO DO SOCIAL RISK DOCUMENTATION AND REFERRAL MAKING. WE'RE HAPPY TO SHARE ALL THESE TOOLS WITH YOU, JUST ASK. I WANT TO TALK NOW ABOUT THIS ISSUE OF WHY SCREENING IF WE CAN'T REFER. THIS IS SOMETHING THAT WE HEAR OVER AND OVER AGAIN BUT I AM A BIG PROPONENT OF, A, YOU WANT TO CONSIDER THESE END CARE DECISIONS. WE'VE HEARD FROM SOME CLINICS THAT YOU'RE DOING SCREENING IN SYSTEMATIC WAY, BRING OUT FACTORS THAT YOU DIDN'T KNOW ABOUT, YOU MAY NOT KNOW EVERYTHING GOING ON EVEN IF YOU THINK YOU DO. YOU CAN USE THE DATA TO HELP ADDRESS NEEDS IN THE COMMUNITY. YOU CAN ALSO HAVE CLINIC ADVOCATE FOR RESOURCES, DECIDE IF THEY CREATE A CLINIC-BASED FOOD BANK OR CHILD CARE CENTER, THIS IS A WAY TO FIGURE THAT OUT. SOME CLINICS CAN USE DATA TO INFORM ADJUSTMENT, FOR PAYMENT RATES, TO AFFECT BILLING SUPPORT. IT'S SUPER IMPORTANT IN OUR EXPERIENCE THAT STAFF AND PATIENTS KNOW WHY RISK SCREENING IS BEING DONE SO THERE'S NOT THAT QUESTION WHY AM I DOING IT IF I CAN'T REFER YOU. THE WEBSITE TALKS ABOUT INQUIRY AND SOCIAL RISK SCREENING USING PATH OF INQUIRY. I WASN'T SURE I WOULD GET THROUGH MY SLIDES BUT I'M GOING TO. TWO MORE MINUTES. RESEARCH, WHAT'S NEXT? WE HAVE A LOT TO LEARN ABOUT WHICH SPECIFIC SOCIAL RISKS IMPACT WHICH OUTCOMES AND WHICH PATIENTS. WHAT'S THE PATHWAY? IS IMPACT MORE ON THE RISK OR HEALTH CARE ACCESS OR ABILITY TO MANAGE THE RISK? THERE'S A LOT OF QUESTIONS THERE. WHICH APPROACH TO ADDRESSING SOCIAL RISKS ARE MOST EFFECTIVE FOR WHICH PATIENTS? HOW CAN WE MAKE -- WHY DO PATIENTS DECLINE ASSISTANCE, AND SHOULD WE FIGURE OUT HOW TO ADDRESS THAT? THERE'S QUESTIONS ABOUT OPTIMAL WAYS FOR SCREENING, I'VE TALKED TO FOLKS INTERESTED CAN WE DO TREATMENTS LIKE A PHQ, ONE QUESTION, ONE SOCIAL RISK SCREENING QUESTION, IF THERE'S A POSITIVE ANSWER WE GET MORE DETAILS, WHICH TOOLS, HOW OFTEN, IMPACT ON CARE RELATIONSHIPS, PROVIDERS OF PATIENTS, POTENTIAL HARMS, MISTRUST, STIGMA, KEEP IN MIND THERE COULDING NEGATIVE IMPACTS OF DOING THIS. BEST PRACTICES FOR SOCIAL SERVICE REFERRALS, AND I WOULD PUT TO THIS GROUP WHAT ARE WE MISSING? LAURA AND I TALK ABOUT WHAT ARE WE MISSING AND I'LL END WITH A QUOTE BY DOUG PLAQUE. POVERTY IS A POLITICAL PROBLEM WOOD RADICAL SOLUTION WILL REQUIRE A RETURN TO DRIBBIVE JUSTICE. WHY WRITE ABOUT IT IN A MEDICAL JOURNAL? DOCTORS AND NURSES ARE ALSO CITIZENS, OPPORTUNITIES TO OBSERVE AND PERHAPS MITIGATE EFFECTS OF POVERTY AND SHOULD BE THE NATURAL ADVOCATE ARE POOR. MY QUOTE IS, ADDRESSING SOCIAL RISKS IN MEDICAL SETTINGS IS A BAND-AID BUT BETTER THAN DOING NOTHING. HERE IS MY E-MAIL. LET ME KNOW IF YOU WANT TO USE OUR TOOLKIT. I CAN THIS IN EXACTLY20 MINUTES. >> THANK YOU VERY MUCH. NEXT IS DR. CHANITA HUGHES-HALBERT. >> GOOD AFTERNOON, EVERYONE. I WAS TRYING TO GET MY TIME STRAIGHT. I'LL PULL UP MY SLIDES. I JUST WANT TO THANK THE CONFERENCE ORGANIZERS AND PRESENTERS FOR FANTASTIC TALKS. I HAVE REALLY LEARNED A LOT, THERE'S SO MUCH OPPORTUNITY FOR US TO COLLABORATE AND WORK TOGETHER. I'M THINKING ABOUT WHAT I THOUGHT I COULD ADD TO THIS IMPORTANT DISCUSSION WAS REALLY PROVIDING A DIFFERENT PERSPECTIVE, THINKING ABOUT HOW TO IDENTIFY AND ADDRESS SOCIAL DETERMINANTS OF HEALTH. WHAT I'LL DO IS SHARE A COUPLE OF EXAMPLES FROM AN ONGOING RESEARCH THAT'S FUNDED BY THE NATIONAL INSTITUTE ON MINORITY HEALTH AND HEALTH DISPARITIES WHERE WE HAVE USING DATA SCIENCE APPROACH TO UNDERSTAND PART OF OUR LONG-TERM GOAL TO BE ABLE TO IDENTIFY AND ADDRESS SOCIAL DETERMINANTS OF HEALTH TO UNDERSTAND THE WAYS IN WHICH THESE VARIABLES AND FACTORS ARE ALREADY BEING DOCUMENTED IN THE ELECTRONIC HEALTH RECORD. OUR VIEW AND THOUGHT PROCESS WAS THAT IF WE UNDERSTAND AND START FROM UNDERSTANDING OF WHAT TYPES OF SOCIAL DETERMINANTS ARE BEING DOCUMENTED, THE WAYS IN WHICH THEY ARE BEING DOCUMENTED, IF THEY ARE CONSISTENT WITH CONCEPTUAL AND OPERATIONAL DEFINITIONS OF SOCIAL DETERMINANTS OF HEALTH WE CAN HAVE A BETTER UNDERSTANDING AND INSIGHT ABOUT HOW TO DEVELOP STRATEGIES FOR ADDRESSING THESE ISSUES. SO, THE TITLE OF MY TALK IS "TRANSDISCIPLINARY DATA SCIENCE TO ADDRESS MINORITY HEALTH AND HEALTH DISPARITIES." NEXT SLIDE PLEASE. I THINK IT'S IMPORTANT AS I HEARD THE TWO PREVIOUS PRESENTERS WE ALL SORT OF COME ABOUT THIS RECOGNIZING IMPORTANCE OF SOCIAL DETERMINANTS OF HEALTH, ONE, BECAUSE WE ULTIMATELY WANT TO PROMOTE AND PROVIDE QUALITY HEALTH CARE, ENHANCE HEALTH OUTCOMES MAKING SURE THAT PATIENTS RECEIVEED RIGHT CARE, AT THE RIGHT TIME, IME, IN THE RIGHT WAY. WE KNOW THERE ARE THERE ARE MANY REASONS THAT DOESN'T HAPPEN, AND MANY OF THOSE REASONS, THOSE DETERMINANTS FALL WITHIN THIS CONSTRUCT OF SOCIAL DETERMINANTS OF HEALTH. NEXT SLIDE PLEASE. ELISEO TALKED ABOUT THIS FRAMEWORK. I OFTEN LIKE TO PRESENT IT TO SET THE STAGE FOR DISCUSSING SOCIAL DETERMINANTS OF HEALTH BECAUSE AS WE THINK ABOUT IT, I'M A BEHAVIORAL SCIENTIST BY TRAINING, AND I DO TYPICALLY TEND TO WORK WITHIN THE SPACE OF INDIVIDUAL LEVEL DETERMINANTS, BUT SOCIAL DETERMINANTS OF HEALTH AND CREATING A SYSTEM TO IDENTIFY THOSE VARIABLES WITH ACCURACY AND PRECISION WITHIN THE HEALTH CARE SYSTEM ULTIMATELY DOES HAVE IMPACT ON THE HEALTH CARE SYSTEMS, WE HAVE TO BEGIN THINKING ABOUT DEVELOPING IDENTIFICATION STRATEGIES AND INTERVENTION APPROACHES THAT ARE CONSISTENT AND REFLECT THE INDIVIDUAL PATIENT'S EXPERIENCE, ALSO FEASIBLE AND PRACTICAL TO ENTER AND IMPLEMENT WITHIN THE HEALTH CARE SYSTEM. SO IT REALLY DOES TAKE ON THIS MULTI-LEVEL PERSPECTIVE IN TERMS OF BEING ABLE TO IDENTIFY AND ADDRESS SOCIAL DETERMINANTS OF HEALTH. NEXT SLIDE PLEASE. SO, JUST TO KIND OF THINK ABOUT THIS WITHIN THE CONTEXT OF THE SCIENCE AND MINORITY HEALTH AND HEALTH DISPARITIES, THERE'S BEEN A HUGE HISTORY OF RESEARCH WITHIN TRYING TO UNDERSTAND WHY AND HOW RACIAL AND ETHNIC MINORITIES IN PARTICULAR EXPERIENCE GREATER RATES OF MORBIDITY AND MORTALITY ACROSS MULTIPLE DISEASE CONTEXTS. ONE OF THE WAYS WE'VE BEEN ABLE TO DOCUMENT, DESCRIBE, AND NOW INTERVENE UPON MINORITY HEALTH AND HEALTH DISPARITIES HAS BEEN FACILITATED THROUGH THIS BROADER CONTEXT OF DATA SCIENCE. THERE'S A QUOTE HERE FROM CHIEF ECONOMIST AT GOOGLE, ALSO A PROFESSOR AT UNIVERSITY OF CALIFORNIA BERKELEY WHICH DESCRIBES DATA SCIENCE AND WHY IT'S SO POWERFUL AS OUR EXTENT TO TAKE DATA, UNDERSTAND IT, PROCESS IT, EXTRACT VALUES, VISUALIZ AND COMMUNICATE IT. AND TO ME I THINK THAT'S WHERE WE SORT OF HAVE THE MOST EXCITEMENT AND OPPORTUNITY AND IMPACT TO BE ABLE TO DEVELOP ROBUST EFFECTIVE SYSTEMS FOR UNDERSTANDING DATA RELATED TO SOCIAL DETERMINANTS OF HEALTH, UNDERSTAND IT, PROCESS IT, BE ABLE TO USE IT AND APPLY IT TO IMPACT HEALTH CARE QUALITY AND HEALTH CARE OUTCOMES, PARTICULARLY AMONG RACIAL AND ETHNIC MINORITIES. NEXT SLIDE PLEASE. DATA SCIENCE AS YOU SEE HERE INCORPORATION A LOT OF DIFFERENT ACTIVITIES, WHAT I'LL FOCUS ON AS WE MOVE INTO THE NEXT PART OF THE SLIDE IS REALLY ON MACHINE LEARNING BECAUSE I THINK THERE'S SO MUCH POWER IN INFORMATION THAT'S ALREADY STORED IN THE ELECTRONIC HEALTH RECORD TO TELL US WHERE AND HOW WE CAN BE MOST PRECISE WITH TARGETING INTERVENTIONS RELATED TO IDENTIFYING PATIENTS WITH SOCIAL RISK FACTORS, AND DEVELOPING INTERVENTIONS TO ADDRESS THOSE. OUR APPROACH FROM THE UNDERSTANDING OF WHAT'S BEING DONE NOW TO BUILD A BETTER SYSTEM FOR THE FUTURE. NEXT SLIDE PLEASE. SO YOU'VE HEARD THIS, AND I'LL JUST REITERATE THE POINT THAT THERE'S GREATER RECOGNITION OF THE IMPORTANCE OF SOCIAL DETERMINANTS OF HEALTH AND BEST CASE SCENARIO IT SHOULD BE OBTAINED FROM PATIENTS. THIS IS AN IMPORTANT POINT TO EMPHASIZE BECAUSE PATIENTS ARE THE GOLD STANDARD WHEN IT COMES TO PROVIDING INFORMATION ABOUT THEIR LIVED EXPERIENCE. AND THE ISSUES AND CHALLENGES THAT THEY ARE FACING IN THEIR DAY-TO-DAY LIVES WITH RESPECT TO MANAGING A CHRONIC CONDITION, OR ENGAGING IN HEALTH PROMOTION AND DISEASE PREVENTION STRATEGIES. WE DO -- I THINK IT'S IMPORTANT TO HAVE SYSTEMS THAT ALLOW PATIENTS TO PROVIDE THIS INFORMATION TO US, AND THAT ALREADY HAPPENS. TO SOME EXTENT, OR SHOULD BE HAPPENING, JUST AS PART OF MEDICAL CARE. AS WE'VE HEARD THROUGH THE PREVIOUS PRESENTATIONS IT MAY NOT HAPPEN AND WHAT YOU'LL HEAR FROM THE WORK I'LL PRESENT IN JUST A MOMENT, DOESN'T NECESSARILY HAPPEN IN THE MOST ROBUST OR RELIABLE WAY. NEXT SLIDE PLEASE. SO THESE ARE REALLY IMPORTANT CLINICAL AND PUBLIC HEALTH PRIORITIES FOR SOCIAL DETERMINANTS OF HEALTH. ONE IS THAT THE INFORMATION THAT IS COLLECTED NEEDS TO BE STANDARDIZED AND MEASURABLE AND ACTIONABLE. AND IT NEEDS TO BE DOCUMENTED IN THE ELECTRONIC HEALTH RECORD. YOU'VE ALREADY HEARD FROM THE TWO PREVIOUS PRESENTERS ABOUT COMPANIES THAT ARE CREATING TOOLS TO -- AND NOW I THINK IT'S EPIC, THERE ARE FIELDS FOR DOCUMENTING SOCIAL DETERMINANTS OF HEALTH AND RESOURCES TO HELP CONNECT PATIENTS. BUT I THINK WE STILL HAVE SOME WORK DO IN UNDERSTANDING WHAT'S REALLY ACTIONABLE AND CAN BE ADDRESSED FROM THE HEALTH CARE SYSTEM. YOU'VE ALREADY HEARD ABOUT THE IMPORTANCE OF ESTABLISHING CLINICAL WORKFLOWS. THERE'S OPPORTUNITIES TO USE ENGAGEMENT STRATEGIES TO UNDERSTAND FROM BOTH PATIENTS AND PROVIDERS AND HEALTH SYSTEM LEADERS ABOUT WHAT'S PRACTICAL IN TERMS OF CLINICAL WORKFLOW AND WHAT'S ACTIONABLE AND ACCEPTABLE BY PATIENTS IN TERMS OF SOCIAL REFERRALS AND PATIENT OUTCOMES. AND ONE POINT I WANTED TO MAKE HERE AS I HEARD THE PREVIOUS PRESENTATION IS, YOU KNOW, AS WE THINK ABOUT THE GOOD INTENTIONS FOR ASKING PATIENTS ABOUT FINANCIAL STRAIN, FOOD INSECURITY, SOCIAL ISOLATION, I THINK THOSE COME -- ASKING THOSE QUESTIONS ARE REALLY IMPORTANT, BEING ABLE TO DOCUMENT THOSE IN THE ELECTRONIC HEALTH RECORD, AND THEN ACTING UPON THEM ARE REALLY IMPORTANT. AT THE SAME TIME I THINK WE HAVE TO BE COGNIZANT OF POSSIBILITY OF UNINTEND OF INTENDED CONSEQUENCE TO SUCH IN OUTCOMES SUCH AS PATIENT STIGMATIZATION. I'LL SHARE A RECENT EXPERIENCE WHETHER AN INVESTIGATOR WAS PROPOSING THAT WE USE GOOGLE MAPS TO BE ABLE, IF WE HAVE A PATIENT'S ADDRESS, TO GET A SNAPSHOT OF WHERE THAT PATIENT LIVES, TO BE ABLE TO BETTER UNDERSTAND THE SOCIAL ENVIRONMENT IN WHICH THEY ARE ACTUALLY LIVING. I THINK THAT'S IMPORTANT, CAN BE AN IMPORTANT STRATEGY, BUT I ALSO THINK IT COMES WITH SOME RISK IN TERMS OF VIOLATING PRIVACY AND CONFIDENTIALITY, PERHAPS POTENTIAL FOR BIAS AND INCORRECT ASSUMPTION BASED ON INTERPRETATION OF QUALITY OF SOMEONE'S HOUSING SITUATION. I DO THINK THERE'S A MISSED OPPORTUNITY BUT ONE THAT'S IMPORTANT TO BE ABLE TO UNDERSTAND ETHICAL, LEGAL, AND SOCIAL IMPLICATIONS OF OBTAINING THIS DATA, THE MORE THAT WE CAN USE AND IMPLEMENT DATA SCIENCE TOOLS AND STRATEGIES THAT COMES WITH SOME POTENTIAL UNINTENDED NEGATIVE CONSEQUENCES. NEXT SLIDE PLEASE. WHAT HAVE WE BEEN DOING TO FACILITATE THE PROCESS OF ADDRESSING THE CLINICAL AND PUBLIC HEALTH PRIORITIES RELATED TO SOCIAL DETERMINANTS OF HEALTH? WE'VE BEEN ADDRESSING IT AT THE œCAROLINA THROUGHY OF SOUTH TRANSDISCIPLINARY COLLABORATIVE CENTER AND PRECISION MEDICINE AND MINORITY HEALTH. WHAT'S BEEN EXCITING, IN ADDITION TO CONDUCTING TRANSLATIONAL RESEARCH ON UNDERSTANDING THE WAYS IN WHICH BIOLOGICAL, SOCIAL, PSYCHOLOGICAL AND CLINICAL FACTORS INTERACT AND PLAY A ROLE IN THE INITIATION OF DISEASE IN RESPONSE TO TREATMENT PARTICULARLY AMONG AFRICAN AMERICAN MEN THE STUDENT TO THINK ABOUT NEW AND EXCITING WAYS TO INTEGRATE DATA, UNDERSTAND THESE DATA, TO GENERATE STRATEGIES, TOOLS AND STRATEGIES THAT CAN BE USED FOR THE PURPOSE OF POPULATION HEALTH MANAGEMENT, AS WELL AS FOR THE PURPOSE OF IMPACTING HEALTH CARE DELIVERY WITHIN SPECIFIC CLINICAL SETTINGS. NEXT SLIDE PLEASE. SO, JUST A BIT ABOUT WHY WE'RE FOCUSING ON MINORITY MEN'S HEALTH. SO, AS YOU CAN SEE HERE, WE HAVE A LONG HISTORY OF DOING RESEARCH TO UNDERSTAND RACIAL DIFFERENCES, PARTICULARLY AS IT RELATES TO PROSTATE CANCER OUTCOMES. AND WE'VE PUBLISHED SEVERAL STUDIES THAT HAVE LOOKED AT RACIAL DIFFERENCES AND QUALITY OF LIFE FOLLOWING PROSTATE CANCER,PROSTATE CANCER SCREENINGS SPECIFICALLY AMONG AFRICAN AMERICAN MEN, WE'VE ALSO EXAMINED HOW SORT OF THE SOCIAL, CLINICAL AND CULTURAL ISSUES THAT INFLUENCE HOW MEN RESPOND TO THEIR PROSTATE CANCER DIAGNOSIS, ACROSS ALL OF THE STUDIES ONE OF THE CONSISTENT FINDINGS IS THAT MEN'S PERCEPTION OF STRESS OR THEIR PERCEPTION OF NOT BEING ABLE TO CONTROL OR MANAGE THE CHALLENGES THAT THEY ARE FACING IN DAY TO DAY LIVES PLAYS AN IMPORTANT ROLE, PERHAPS A MORE IMPORTANT ROLE THAN THEIR STAGE OF DISEASE OR GLEASON SCORE OR HOW LONG THEY HAVE BEEN -- WHEN THEY WERE DIAGNOSED AND TREATED FOR PROSTATE CANCER, IS THE MOST IMPORTANT ASPECT OF THEIR QUALITY OF LIFE OR THEIR PHYSICAL AND EMOTIONAL WELL BEING, SIMILARLY PERCEPTIONS OF STRESS, INFLUENCES, ASSOCIATED RATHER WITH PHYSICAL ACTIVITY AMONG PROSTATE CANCER PATIENTS. SO AS WE BEGAN THINKING ABOUT WHY WOULD SUPPRESS BE SUCH AN IMPORTANT DETERMINANT OR IMPORTANT VARIABLE, IN PROSTATE CANCER OUTCOMES AND CANCER THAT PREDOMINANTLY AFFECTS AFRICAN AMERICAN MEN, WE BEGAN THINKING ABOUT THIS AND ASKING BROADER QUESTIONS ABOUT, WELL, WHAT IS THE DAY-TO-DAY LIVES OF AFRICAN AMERICAN MEN, AND WHAT IS IT ABOUT THEIR LIVED EXPERIENCE THAT MIGHT BE CONTRIBUTING TO THE ROLE THAT WE'RE SEEING FOR PERCEPTIONS OF STRESS. NEXT SLIDE PLEASE. THIS LED US TO REALLY THINK ABOUT THE UNIQUE ACUTE AND CHRONIC STRESSORS THAT AFRICAN AMERICAN MEN EXPERIENCE IN THEIR DAY TO DAY LIVES. THERE HAVE BEEN STARTLING EXAMPLES OF THAT OVER THE PAST YEAR WHERE WE'VE SEEN THE LEAST VIOLENCE AND KILLINGS, PARTICULARLY DIRECTED TOWARDS AFRICAN AMERICAN MEN AND AS WE WERE WRITING, DEVELOPING THE CONTEXT AND OVERARCHING FRAMEWORK FOR OUR CENTER THERE WAS A SPECIFIC EXPERIENCE HERE IN CHARLESTON WHERE POLICE VIOLENCE AGAINST AN AFRICAN AMERICAN MAN, SO WE STARTED THINKING ABOUT AND REALLY DREW OUR FOCUS TO THE IMPACT THAT SOCIAL AND PSYCHOLOGICAL STRESSORS ARE ON BIOLOGICAL PROCESSES THAT ARE INVOLVED IN THE INITIATION AND PROGRESSION OF DISEASE. AND WE THOUGHT THAT IT WAS -- WOULD BE AN INNOVATIVE AND IMPORTANT CONTRIBUTION TO OUR UNDERSTANDING OF PRECISION MEDICINE AND MINORITY MEN'S HEALTH TO CONCEPTUALIZE IN TERMS OF ALLOSTATIC LOAD. AND YOU CAN SEE THE DEFINITION OF ALLOSTATIC LOAD HERE BUT WHAT'S PARTICULARLY INTRIGUING ABOUT THE ABILITY TO USE ALLOSTATIC LOAD AS A BIOMARKER FOR FACILITATING PRECISION MEDICINE, VARIABLES USED TO DERMAL OH STATIC LOAD ARE CLINICAL DERIVED INFORMATION THAT IS GENERATED FOR MOST PATIENTS AS PART OF A PRIMARY CARE VISIT. SO, ALLOSTATIC LOAD INCLUDES DATA FOR BODY MASS INDEX, DIASTOLIC AND SYSTOLIC BLOOD PRESSURE, HBA1C, TYPICAL FOR MOST PATIENTS IN A PRIMARY CARE SETTING. OUR GOAL SELECTING ALLOSTATIC LOAD, SOMETHING THAT'S ACCESSIBLE TO THE MAJORITY OF PATIENTS REGARDLESS OF -- IT COULD BE INFORMATION GENERATED AND STANDARDIZED USING DATA SCIENCE APPROACH, USING TOOLS THAT ARE CURRENTLY AVAILABLE WITHIN THE SPACE OF MINING AND PULLING DATA FROM THE ELECTRONIC HEALTH RECORD TO CREATE THIS INDEX FOR THE MAJORITY OF PATIENTS. AND WE THOUGHT THIS WAS REALLY IMPORTANT BECAUSE WHEN WE THINK ABOUT PRECISION MEDICINE IN MOST INSTANCES IT REALLY SORT OF IS ON THIS GENOMICS WHOLE EXOME OR WHOLE GENOME EXPENSING WHICH IS NOT READILY ACCESSIBLE -- SEQUENCING, WHICH IS NOT READILY ACCESSIBLE FOR THE MAJORITY OF CLINICAL PRACTICES. >> I WANT TO TELL YOU, A COUPLE MINUTES LEFT. >> THANK YOU. SO, WITH THAT RACIAL DIFFERENCES AND ALLOSTATIC EXIST. NEXT SLIDE PLEASE. AND THIS SORT OF DESCRIBES OUR PRIMARY QUESTION WHICH IS TO UNDERSTAND HOW PSYCHOSOCIAL STRESS INFLUENCES CELLULAR STRESS ACROSS THREE DIFFERENT TYPES OF PROJECTS THAT ALL EMPHASIZE UNDERSTNDING STRESS REACTIVITY AND STRESS RESPONSES. NEXT SLIDE PLEASE. SO, AS PART OF THAT WE'VE CREATED A TRANSDISCIPLINARY DATA SCIENCE APPROACH WHERE WE'RE INTEGRATING BEHAVIORAL SCIENCE WITH MACHINE LEARNING APPROACHES, BIOETHICS, AND GEOSPATIAL INFORMATION SYSTEMS TO INTEGRATE ALL OF THESE DIFFERENT DATA SOURCES TO REALLY BEGIN TO UNDERSTAND THE WAYS IN WHICH SOCIAL DETERMINANTS OF HEALTH ARE MANIFESTED, DOCUMENTED, TO PROVIDE PLATFORM FOR DEVELOPING CLINIC-BASED INTERVENTIONS TO ADDRESS VARIABLES. NEXT SLIDE PLEASE. THIS SHOWS HOW WE'RE BRIDGING THESE TWO SORT OF FIELDS OF BEHAVIORAL SCIENCE AND MACHINE LEARNING AND INFORMATICS, AS PART OF OUR DATA INTEGRATION CORE. SO FROM OUR BEHAVIORAL SCIENTISTS EXPERTS ARE GUIDING WHAT SOCIAL DETERMINANTS ARE MOST IMPORTANT AND TO IDENTIFY AND EXTRACT AND COLLEAGUES WITH EXPERTISE IN MACHINE LEARNING AND INFORMATICS ARE USING THAT TO DEVELOP ALGORITHMS FOR NATURAL LANGUAGE PROCESSING AND DEEP LEARNING TO BE ABLE TO APPLY THOSE TOOLS TO THE ELECTRONIC HEALTH RECORD, TO BE ABLE TO EXTRACT AND UNDERSTAND THE WAYS IN WHICH SOCIAL DETERMINANTS ARE CURRENTLY BEING DOCUMENTED. NEXT SLIDE. THIS SHOWS WHAT WE'RE -- THE TOOLS AND QUESTIONS WE'RE ASKING BY PATIENT SELF-REPORT TO UNDERSTAND SOCIAL BACKGROUND. NEXT SLIDE. AND THIS DEMONSTRATES THE NLP PIPELINE DEVELOPED FOR EXTRACTING AND CREATING NATURAL LANGUAGE PROCESSING TOOLS TO IDENTIFY AND UNDERSTAND -- TO DETERMINE EXTENT TO WHICH VARIABLES ARE DOCUMENTED. NEXT SLIDE. SO A COUPLE -- ONE EXAMPLE OF OUR PUBLISHED WORK WHETHER WE HAVE USED OUR NATURAL LANGUAGE PROCESSING TOOL TO UNDERSTAND THE EXTENT TO WHICH AN AUTOMATICALLY IDENTIFIED ASSOCIATE ISOLATION FROM CLINICAL NARRATIVES AMONG PROSTATE CANCER PATIENTS. WE EACH CONTRIBUTED EXPERTISE TO DEVELOP NATURAL LANGUAGE PROCESSING TOOLS TO CREATE A SOCIAL ISOLATION LEXICON. NEXT SLIDE. SHOWS AN EXAMPLE OF WHERE AND HOW THIS SORT OF TOOL COMES OUT. AND NEXT SLIDE SHOWS PERFORMANCE. I MIGHT STOP HERE BY CONCLUDING WE SHALL USING THIS APPROACH NOW TO APPLY THIS SAME METHOD FOR DETERMINING ALLOSTATIC LOAD AS ONE OF OUR PRIMARY VARIABLES. I THINK I'M AT TIME. I KNOW THERE'S -- WITH TECHNICAL SNAFUS I PROBABLY USED MY TIME. >> IF YOU WANT TO GO FOR A COUPLE MINUTES WE'RE RUNNING EARLY, MAYBE IF YOU WANT TO GO FOR A COUPLE MORE MINUTES THROUGH THE SLIDES THAT WOULD BE GREAT. >> OKAY. SO, THIS REFLECTS ALLOSTATIC LOAD CAN BE OBTAINED FROM ELECTRONIC HEALTH RECORD. THIS ALSO CERTAINLY IN LABORATORY SETTING CAN COLLECT DATA ON VITAL STATISTICS, BLOOD PRESSURE, BMI FROM PATIENTS DIRECTLY AND SELF-REPORTED AND COMMUNITY LEVEL DATA ON PSYCHOLOGICAL AND SOCIAL STRESSORS. AND SO NEXT SLIDE PLEASE, IS WE SORT OF INTEGRATED THESE APPROACHES TO UNDERSTAND NATURE AND DISTRIBUTION OF ALLOSTATIC LOAD AND ALLOSTATIC LOAD BIOMARKERS WITHIN OUR PROSTATE CANCER COHORT. THESE ARE FROM ELECTRONIC HEALTH RECORDS. YOU CAN SEE THAT WHAT THIS IS OUR COHORT FROM PROSTATE CANCER SURVIVORS WHO ARE IDENTIFIED FROM OUR REPOSITORY WHERE THEY HAVE AN AVERAGE ALLOSTATIC LOAD OF 1.26, AND IT'S BASED ON BIOMARKER DATA THAT'S AVAILABLE IN THE ELECTRONIC HEALTH RECORD, AT THE TIME OF THEIR PRE-SURGICAL CONSULT. NEXT SLIDE. WE EXPANDED THIS TO LOOK AT SORT OF WHERE AND HOW ALLOSTATIC LOAD DIFFERS. CAN YOU SEE IT DIFFERS BY RACIAL BACKGROUND AND EDUCATION. CLINICAL MODEL FOR ALLOSTATIC LOAD, RACE AND PSA LEVEL HAS A SIGNIFICANT ASSOCIATE WITH ALLOSTATIC LOAD. WHEN WE MOVE TO OUR SOCIAL DETERMINANTS MODEL, NEXT SLIDE PLEASE, YOU CAN SEE IT'S REALLY -- THERE'S A DIFFERENT STORY TO TELL. ASSOCIATION BETWEEN RACE AND ALLOSTATIC LOAD IS NOT SIGNIFICANT BUT THERE IS A SIGNIFICANT ASSOCIATION BETWEEN ALLOSTATIC LOAD AND SOCIAL ISOLATION AND THERE'S A MARGINALLY SIGNIFICANT ASSOCIATION BETWEEN INCOME AND AGE. SO A COUPLE KEY TAKEHOME POINTS HERE IS THAT IF WE THINK ABOUT THE CLINICAL DETERMINANTS, THAT'S REALLY IMPORTANT, BUT WE REALLY DO NEED TO HAVE SORT OF THE SELF--REPORTED EXPERIENCE OF SOCIAL DETERMINANTS TO REALLY UNDERSTAND ANY TYPE OF PHENOMENON, IN THIS CASE ALLOSTATIC LOAD, WHICH REFLECTS PHYSIOLOGICAL EFFECTS OF CHRONIC STRESS EXPOSURE. NEXT SLIDE PLEASE. AND THIS SORT OF THE SAME TYPE OF DATA, ALLOSTATIC LOAD AMONG OUR V.A. SAMPLE. NEXT SLIDE PLEASE. AND THEN SHOWING THAT WHEN WE LOOK AT SORT OF TEASING OUT AFRICAN AMERICAN AND WHITE PROSTATE -- MEN AT RISK FOR PROSTATE CANCER IT'S REALLY AMONG THE WHITE VETERANS WHERE WE SEE SIGNIFICANT ASSOCIATIONS BETWEEN ALLOSTATIC LOAD AND SOCIAL AND CLINICAL DETERMINANTS BUT NOT IN OUR AFRICAN AMERICAN PATIENTS. WE HAVE THOUGHTS ABOUT WHY THIS MAY BE THAT WE'RE FURTHER EXPLORING BUT IN THE NEXT SLIDE WHAT WAS RECENTLY PUBLISHED FINDING, IF WE LOOK AT ALLOSTATIC LOAD AS SORT OF THIS OUTCOME OF CHRONIC SOCIAL AND PSYCHOLOGICAL STRESS EXPOSURE, THAT ALLOSTATIC LOAD IS ACTUALLY GREATER AMONG MEN WHO REPORT THAT THEY ARE MORE RESILIENT IN TERMS OF THEIR ABILITY TO BOUNCE BACK OR ADAPT TO CHALLENGING SITUATIONS. IT RAISES AN IMPORTANT POINT OF IF WE THINK ABOUT WANTING TO ADDRESS SOCIAL DETERMINANTS OF HEALTH, BECAUSE IT HAS NEGATIVE IMPLICATIONS, NOT JUST FOR THE CLINICAL CARE BUT ALSO FOR THE PHYSIOLOGICAL FUNCTIONING, IN TERMS OF STRESS AND STRESS REACTIVITY, THAT WE NEED TO BEGIN THINKING ABOUT WAYS WE CAN PROMOTE MORE EFFECTIVE COPING STRATEGIES AND SKILLS SO IT DOESN'T -- MEN MAKE EFFORTS TO ADAPT TO CHALLENGING SITUATIONS OR BOUNCE BACK THAT IT DOESN'T HAVE A FURTHER ADVERSE EFFECT ON PHYSIOLOGICAL FUNCTIONING. NEXT SLDE. WHICH IS MY LAST SLIDE. WHICH IS TO SHOW WE'VE DEMONSTRATED AS CONSISTENT WITH PREVIOUS STUDIES THERE ARE RACIAL DIFFERENCES IN ALLOSTATIC LOAD, BUT THAT WHEN WE CONSIDER RACE WITH OTHER SOCIAL DETERMINANTS OF HEALTH IT'S ACTUALLY THESE OTHER SOCIAL ISOLATIONS, PERCEPTIONS OF STRESS, EDUCATION AND INCOME MIGHT BE PERHAPS HAVE A GREATER IMPORTANCE WHEN WE THINK ABOUT SORT OF PHYSIOLOGICAL MARKERS. AND THEN JUST A CONCLUDING COMMENT ABOUT NEED TO STANDARDIZE MEASUREMENT AND DATA COLLECTION STRATEGIES FOR SOCIAL DETERMINANTS. I THINK JUST TO SORT OF REITERATE A COUPLE POINTS THAT WERE MADE BY THE PREVIOUS PRESENTERS, THERE ARE SEVERAL WAYS TO ASK PATIENTS ABOUT SOCIAL DETERMINANTS, SEVERAL DIFFERENT MEASURES OF SOCIAL DETERMINANTS THAT HAVE BEEN GENERATED THROUGH BEHAVIORAL SCIENCE STUDIES. WE NEED MORE WORK TO STANDARDIZE HOW THESE ARE ASKED AND DOCUMENTED IN THE ELECTRONIC HEALTH RECORD. ORGANIZERS AGAIN AND ACKNOWLEDGE OUR RESEARCH TEAM FOR THEIR CONTRIBUTIONS AND THE OPPORTUNITY TO PARTICIPATE IN THIS SEMINAR, IN THIS ROUNDTABLE. THANK YOU.. >> WE THANK OUR SPEAKERS ENORMOUSLY. EXPECTED AND UNEXPECTED CONCLUSION AND FINDINGS THAT LEFT ME WITH A LOT TO THINK ABOUT. WE'RE GOING TO TAKE A BREAK NOW. LET ME JUST TAKE A LOOK AT MY CALENDAR. WE'LL TAKE A BREAK AND COME BACK AT 1 P.M. AND AT THAT TIME WE'LL BEGIN WITH THE SECOND HALF OF THE SESSION. THANK YOU AGAIN AND A ROUND OF APPLAUSE IN OUR VIRTUAL SETTING. >> WELCOME BACK TO THIS AFTERNOON'S SESSION. THE THEME IS MINING DATA TO INFORM CLINICAL INTERVENTIONS, LET ME INTRODUCE THE SPEAKERS. FIRST IS DR. JENNIFER WOO BAIDAL, INAUGURAL DIRECTOR OF PEDIATRIC OBESITY INITIATIVE IN DEPARTMENT OF PEDIATRICS AND DIRECTOR OF PEDIATRICS WEIGHT MANAGEMENT, DIVISION OF PEDIATRIC GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION, AT COLUMBIA UNIVERSITY, AND NEW YORK-PRESBYTERIAN MORGAN STANLEY CHILDREN'S HOSPITAL. AS PRINCIPAL INVESTIGATOR ON SEVERAL FUNDED PROJECTS, DR. WOO BAIDAL IS LEADING ACTION ORIENTED RESEARCH TO ADDRESS SOCIAL DETERMINANTS OF HEALTH, FOOD AND HEALTH CARE SYSTEMS, INTERVENTIONS FOR OBESITY AND ADVERSE HEALTH CONSEQUENCES AMONG VULNERABLE POPULATIONS. SECOND SPEAKER IS DR. ELHAM HATEF-NAIMI, ASSISTANT SCIENTIST, RESEARCH TRACK ASSISTANT PROFESSOR AT CENTER FOR POPULATION HEALTH I.T., DEPARTMENT OF HEALTH POLICY AND MANAGEMENT AT JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH. AS PREVENTIVE MEDICINE PUBLIC HEALTH PHYSICIAN, AND CLINICAL INFORMATIAN, MAIN FIELD OF INTEREST IS SOCIAL DETERMINANTS OF HEALTH ON HEALTH-RELATED OUTCOMES USING HEALTH I.T. AND BIG DATA. AT CPHIT, SHE LED THE DEVELOPMENT OF THE POPULATION HEALTH FRAMEWORK AND MEASUREMENTS FOR MARYLAND, A COLLABORATION WITH MARYLAND HEALTH INFORMATION EXCHANGE. IN ADDITION, IN COLLABORATION WITH OTHER FACULTY SHE WORKS ON NEW METHODS OF DATA MINING AND NATURAL LANGUAGE PROCESSING TO ADDRESS SOCIAL DETERMINANTS OF HEALTH USING STRUCTURED AND UNSTRUCTURED ELECTRONIC HEALTH RECORDS DATA AND PUBLICLY AVAILABLE POPULATION LEVEL DATA SUCH AS U.S. CENSUS. THIRD SPEAKER IS DR. SARAH COLLINS ROSSETTI, ASSISTANT PROFESSOR OF BIOMEDICAL INFORMATICS AND NURSING AT COLUMBIA UNIVERSITY, RESEARCH ON IDENTIFYING AND INTERVENING ON PATIENT RISK FOR HARM BY APPLYING COMPUTATIONAL TOOLS TO MINE AND EXTRACT VALUE FROM ELECTRONIC HEALTH RECORD DATA AND LEVERAGING USER-CENTERED DESIGN FOR PATIENT-CENTERED TECHNOLOGIES. PREVIOUSLY, SHE WAS SENIOR INFORMATICIAN AT BRIGHAM AND WOMEN'S HOSPITAL, HARVARD MEDICAL SCHOOL, AN EXPERIENCED CRITICAL CARE NURSE, SHE WAS NOMINATED AND SELECTED AS 2019 RECIPIENT OF THE PRESIDENTIAL EARLY CAREER AWARD FOR SCIENTISTS AND ENGINEERS. THIS AWARD IS THE HIGHEST HONOR WE STOWED BY THE UNITED STATES GOVERNMENT TO OUTSTANDING SCIENTISTS AND ENGINEERS WHO ARE BEGINNING THEIR INDEPENDENT RESEARCH CAREERS AND WHO SHOW EXCEPTIONAL PROMISE FOR LEADERSHIP IN SCIENCE AND TECHNOLOGY. TIME SPEAKER IS DR. HEATHER COATS, PALLIATIVE NURSE PRACTITIONER, ASSISTANT PROFESSOR UNIVERSITY OF COLORADO COLLEGE OF NURSING AND DIRECTOR OF RESEARCH FOR HOSPICE AND PALLIATIVE NURSES ASSOCIATION. HER PROGRAM OF RESEARCH FOCUSES ON PERSON-CENTERED NARRATIVE INTERVENTIONS TO IMPROVE QUALITY OF COMMUNICATION BETWEEN PATIENTS AND CLINICIANS AND IMPROVE PSYCHOLOGICAL, SOCIAL AND SPIRITUAL WELL BEING EVER -- OF PERSONS LIVING WITH SERIOUS ILLNESS, SUPPORTED BY A PATHWAY TO EXCELLENCE AWARD, RESEARCH IS DEFINING, REFINING AND TESTING A PERSON CENTERED NARRATIVE INTERVENTION INTEGRATED INTO THE PERSON'S ELECTRONIC HEALTH RECORD AND TESTING EFFECTS ON PERSON-CENTERED OUTCOMES. PLEASE JOIN ME IN WELCOMING THEM, THEY WILL EACH SPEAK FOR 15 MINUTES. AGAIN, WE ARE REQUESTING THAT YOU HOLD YOUR QUESTIONS FOR THE PANEL DISCUSSIONS. HOWEVER, PLEASE USE THE CHAT FUNCTION TO BEGIN SUBMITTING YOUR QUESTIONS AT ANY TIME DURING THE PRESENTATIONS. THEY CAN BE QUESTIONS FROM THIS MORNING'S PANEL OR THIS AFTERNOON'S PANEL. AND THEN AT THE BREAK THE CHAT MODERATOR WILL CURATE FOR THE PANEL MODERATOR FOR THE PANEL DISCUSSION. WE'LL GO THAT WAY. I'VE GOT A TWO-MINUTE SIGN I'LL HANG UP TO SHOW UP AT TWO MINUTES, WHEN YOU HAVE TWO MINUTES LEFT AND LET YOU KNOW VERBALLY IF NEEDED. SO THANK YOU AND WE'LL JUST TURN THE TIME OVER NOW TO DR. WOO BAIDAL. >> THANK YOU. I'LL SEE IF I CAN PASS THE CHALLENGE OF SHARING MY SCREEN. IT MIGHT BE WORKING. GREAT. SO THIS MORNING WE HEARD ABOUT INTEGRATION OF SOCIAL SERVICES INTO HEALTH CARE, AND CONSIDERING SOCIAL DETERMINANTS OF HEALTH AND HEALTH DISPARITY IN GENERAL TERMS, AND I'M BRINGING THE PERSPECTIVE OF PEDIATRIC RESEARCHER FOCUSED ON REDUCTION OF RACIAL, ETHNIC AND ECONOMIC DISPARITY IN CHILDHOOD BEATS. I HAVE THE GOOD FORTUNE WORKING IN A HEALTH CARE SYSTEM WHERE LEADERSHIP AT THE HIGHEST LEVELS PRIORITIZES HEALTH EQUITY AND RACIAL JUSTICE WITH MEDICAL AND COMMUNITY CHAMPIONS IN OUR SYSTEM WHO ARE DEDICATED TO ADDRESSING CERTAINLY DETERMINANTS AND SOCIAL NEEDS. I WAS GRATEFUL FOR THESE THINGS AS I WAS HEARING THE EARLIER TALKS. I CAN TAKE NO CREDIT FOR IMPLEMENTATION OF MANY CLINICAL AND PROGRAM ASPECTS TO WHAT I'LL BE PRESENTING BUT I'M EXCITED TO SHARE AN EXAMPLE WITH YOU OF HOW YOU CAN THINK ABOUT USING CLINICAL BIG DATA ON SOCIAL DETERMINANTS OF HEALTH THAT MAY EXIST AT VARIOUS HEALTH CARE SETTINGS. OVER WEIGHT AND OBESITY PREVALENCE CONTINUE TO BE PERSISTENTLY HIGH GLOBALLY, AND OBESITY IS RESPONSIBLE FOR MORE THAN 4 MILLION DEATHS ACROSS THE WORLD, THIS MAP SHOWING DATA FOR CHILDREN AT AGE 6 YEARS GRADIENTS FROM YELLOW TO ORANGE TO RED REPRESENT INCREASING LEVELS OF NATIONAL OBESITY PREVALENCE AND IN THE UNITED STATES AS YOU CAN SEE IN RED CHILDHOOD PREVALENCE OF OBESITY. IN THE UNITED STATES ALSO RACIAL, ETHNIC AND SOCIOECONOMIC DISPARITIES IN OBESITY START IN CHILDHOOD. PREVALENCE OF OBESITY FOR BLACK NON-HISPANIC CHILDREN IN ORANGE BAR AND THAT HISPANIC AND LATINO IN GRAY BAR TWO-FOLD HIGHER THAN WHITE COUNTERPARTS IN THE BLUE BAR. THIS SAME PATTERN HOLDS FOR SEVERE OBESITY. THE ALREADY HIGH PREVALENCE OF OBESITY AND SEVERE OBESITY AMONG CHILDREN AND ADOLESCENTS AND PERSISTENT AND WIDENING OF RACIAL DISPARITIES IN THAT AGE GROUP SUPPORTS THE NEED TO INTERVENE EARLIER IN LIFE TO REDUCE OBESITY AND ITS DISPARITIES. ONE TYPE OF APPROACH TO REDUCING CHILDHOOD OBESITY TO TAKE A WHOLE COMMUNITY APPROACH. ONE SUCH EXAMPLE AMONG MANY INTERVENTIONS IS MA-CORD STUDY, COLLABORATION BETWEEN THE STATE DEPARTMENT OF HEALTH AND MULTIPLE ACADEMIC INVESTIGATORS TO EVALUATE IMPLEMENTATION OF MULTIPLE EVIDENCE-INFORMED INTERVENTION ACROSS SECTORS AND LEVELS. IN PRIMARY CARE AND WIC SECTORS, EVALUATING OVER TIME IN INTERVENTION VERSUS COMPARISON SITES, IMPROVING BMI AND BEHAVIORAL OUTCOMES IN ONE SITE, SOME EVIDENCE THIS TYPE OF APPROACH MAY HELP REDUCE RACIAL AND ETHNIC DISPARITIES IN OBESITY AMONG CHILDREN BUT FINDINGS WERE SOMEWHAT MODEST. ALSO DESPITE EXISTENCE OF A NUMBER OF EVIDENCE-BASED INTERVENTIONS FOR CHILDHOO OBESITY REDUCTION OVER TWO DECADES THERE HAS BEEN NO IMPROVEMENT IN CHILDHOOD OBESITY PREVALENCE IN THE UNITED STATES. IN FACT WE'RE SEEING WORSENING OF OBESITY PREVALENCE IN OLDER CHILDREN AND ADOLESCENTS, PRIMARILY DRIVEN BY INCREASES AMONG RACIAL AND ETHNIC MINORITY CHILDREN. SO WHY ARE WE NOT MAKING MUCH PROGRESS? THERE ARE MANY REASONS, COMPLICATED, BUT I WANT TO FOCUS ON TWO IMPORTANT GAPS IN KNOWLEDGE. FIRST, I THINK THAT INTERVENTIONS NEED TO START EARLIER IN LIFE, EXTEND THROUGH MULTIPLE LIFE COURSE STAGES. THERE'S EVIDENCE FOR CRITICAL PERIODS OF HEALTH AND DISEASES WE HEARD ABOUT YESTERDAY FROM DR. GALEA, EARLY LIFE EXPOSURES IN THE FIRST 12 MONTHS SEEM TO SET THE STAGE FOR LATER HEALTH. SECOND, PREVENTION INTERVENTIONS FOCUSED ON INDIVIDUAL BEHAVIOR CHANGE, WITHOUT ADDRESSING SOCIAL RISK. BUT WE KNOW THAT POVERTY AND OTHER SOCIAL DETERMINANTS OF HEALTH ARE DRIVERS OF HEALTH INEQUITIES AND SO INTERVENTIONS THAT TARGET NOT JUST INDIVIDUAL HEALTH BEHAVIORS BUT ALSO CONSIDER SOCIAL DETERMINANTS AND SOCIAL RISK ARE NEEDED IN HEALTH DISPARITY POPULATIONS. DISPARITIES IN HEALTH OUTCOMES ARE COMPLEX AND THEY VARY BY REGION, COUNTRY AND EVEN NEIGHBORHOOD. THE COLUMBIA, NEAR PRESBYTERIAN MEDICAL CAMPUS, IN NORTHERN MANHATTAN, OUR COMMUNITIES SPAN HARLEM, WASHINGTON HEIGHTS, INWOOD, SOME PORTIONS OF THE BRONX, THESE NEIGHBORHOODS ARE PREDOMINANTLY HISPANIC AND LATINO, AND NON-HISPANIC BLACK POPULATIONS, ALSO THE MEDIAN HOUSEHOLD INCOME IN THOSE NEIGHBORHOODS IS LOWER THAN OTHER AREAS OF MANHATTAN. SO, IT'S NOT SURPRISING THAT OUR PREVALENCE OF CHILDHOOD OBESITY IS HIGHER BUT I THINK NUMBERS, PROPORTION IS ACTUALLY QUITE SHOCKING EVERY TIME I SEE IT OR LOOK AT IT WHERE 47% OF OUR SCHOOL AGE CHILDREN HAVE OVERWEIGHT OR OBESITY, SO ALMOST ONE IN TWO CHILDREN, COMPARED TO NEW YORK CITY WHERE THE PREVALENCE IS STILL HIGH AT 38%, THERE HAVE BEEN SMALLER DECLINES IN NEW YORK CITY. SO WE HAVE A DISPROPORTIONATE BURDEN COMPARED TO THE REST OF THE CITY. TO GIVE YOU THE CONTEXT OF WHERE WE'RE SITUATED IN BROADER SENSE IN THE NEW YORK AND NEW JERSEY REGION, YOU CAN SEE THE OTHER NY-P CAMPUS, AN ACADEMIC HEALTH CARE SYSTEM WITH TEN CAMPUSES AND TWO MEDICAL SCHOOLS. IN BLUE ARE CIRCLING WHERE COLUMBIA CAMPUSES ARE LOCATED. IN OUR COLUMBIA NY-P CAMPUS WE'RE ONE OF 29 ACCOUNTABLE HEALTH COMMUNITIES, AHC SITES. OUR PROGRAM, ANCHOR, INVOLVES SOCIAL NEEDS SCREENING USING AHC HEALTH-RELATED SOCIAL SCREENING TOOL DR. GOLD MENTIONED EARLIER, SCREENING FOR FIVE CORE DOMAINS. IF A PATIENT SCREENS POSITIVE FOR SOCIAL NEED, THEY ARE FURTHER STRATIFIED BY RISK. LOWER RISK PATIENTS ARE PROVIDED WITH A COMMUNITY REFERRAL SUMMARY. FOR THOSE WHO HAVE TWO OR MORE E.D. VISITS IN THE PAST YEAR OR POSITIVE SCREEN FOR INTERPERSONAL SAFETY CONCERNS, THEY ARE ADDITIONALLY REFERRED TO A COMMUNITY NAVIGATION THROUGH ONE OF OUR COMMUNITY SOCIAL SERVICES ORGANIZATIONS. SO THIS REALLY IS THE MAIN CRUX OF THE AHC ALIGNMENT MODEL TO ALIGN COMMUNITY PARTNERS WITH SOCIAL NEEDS. AND CMMI, CENTERS FOR MEDICARE AND MEDICAID INNOVATION IS PERFORMING MULTI-SITE EVALUATION OF THIS PROGRAM AND ANOTHER MODEL. WHAT I AM DOING IS USING THIS DATA THAT WE HAVE ON SCREENING AND REFERRALS FOR LINK WHICH IS LEVERAGING I.T. FOR NEIGHBORHOODS IN CHILDHOOD, MY FIRST R01 FUNDED MY NIMHD. IN LINC WE'RE QUANTIFYING EFFECTS ON SOCIAL NEEDS AND NEIGHBORHOOD SOCIAL DETERMINANTS OF HEALTH. AND HOW THEY RELATE TO INFANT WEIGHT TRAJECTORIES IN THE FIRST TWO YEARS OF LIFE. WE WILL ALSO EXAMINE WHETHER RESOLUTION OF SOCIAL NEED MET GATES RISK FOR UNHEALTHY WEIGHT TRAJECTORY IN INFANCY. ALSO RELATED TO WHAT WE HEARD ABOUT EARLIER TODAY, WE ARE PERFORMING QUALITATIVE WORK TO ASK PARENTAL AND PROVIDER UNINTENDED CONSEQUENCES SUCH AS BIAS. TO CONDUCT THIS RESEARCH LINKING ELECTRONIC HEALTH RECORD FOR PATIENT CHARACTERISTICS, DEMOGRAPHICS, AND SELF-REPORTED SOCIAL NEEDS. WE ALSO ARE USING DATA FROM SOCIAL SERVICES DATA WAREHOUSE CALLED NOWPOW MENTIONED EARLIER. WE'RE USING GEO CODING TO DERIVE NEIGHBORHOOD MEASURES OF SOCIAL DETERMINANTS OF HEALTH USING RESIDENTIAL ADDRESS AT THE TIME OF VISITS AND EXTRACTING METRICS TO CONSTRUCT INFANT WEIGHT TRAJECTORIES OVER TIME AS OUR MAIN OUTCOMES. IT'S TOO EARLY IN THE STUDY TOO FORMALLY PRESENT RESULTS, BUT QUALITATIVELY IN THE FIRST SIX MONTHS OF THIS RESEARCH WE'VE ACCRUED DATA FOR 1,130 INFANTS THAT WERE BORN FULL TERM. THE MAJORITY OF THESE INFANTS HAVE BLACK, NON-HISPANIC OR HISPANIC ALREADY SLAY -- - HISPANIC-LATINO RACE/ETHNICITY, MOST PARENTS HAVE NOT ATTENDED COLLEGE. THIS HAS BEEN USED BY THE COLUMBIA NYP HEALTH CARE SYSTEM. HERE I'M SHOWING DATA FROM 41,063 ENCOUNTERS OVER A TWO-YEAR TIME PERIOD. AND THE PATTERN IS SIMILAR OVERALL TO WHAT WE'RE SEEING IN THE INFANTS WHERE THE MOST COMMON SOCIAL NEED IS HOUSEHOLD FOOD INSECURITY, AT 28%. FOLLOWED BY HOUSING NEEDS. AND AS A RESULT OF IDENTIFYING FOOD SECURITY, INSECURITY, AS A COMMON SOCIAL NEED AMONG OUR PATIENTS WE BEGAN TO DESIGN AND PILOT TEST INTERVENTIONS, YOU COULD CONSIDER ASSISTANCE INTERVENTIONS IF WE WERE GOING TO USE THE FRAMEWORK DR. GOLD DISCUSSED. I'M SHOWING WE LAUNCHED IN PARTNERSHIP WITH WEST SIDE CAMPAIGN AGAINST HUNGER. THIS WAS A PILOT MOBILE FOOD PANTRY INTERVENTION FOR FAMILIES WITH A CHILD UNDER AGE 5 YEARS WHO ALSO HAD HOUSEHOLD FOOD INSECURITY. WHEN COVID-19 ARRIVED IN NEW YORK CITY, THE SYSTEM CONVERTED FROM FOOD SELECTION MODEL TO FOOD DISTRIBUTION SYSTEM. AND GIVEN THE CONCERNS FOR FOOD SCARCITY AND RISING HOUSEHOLD FOOD INSECURITY, HEALTH CARE SYSTEM EXPANDED TO ALL OF ITS CAMPUSES, TEMPORARILY. AND SO AS A RESULT WE HAVE BEEN ABLE TO SCALE UP TO SERVE OVER 6,000 FAMILIES, REPRESENTING ALMOST 26,000 INDIVIDUALS, AMOUNTING TO OVER A MILLION POUNDS OF FOOD, I'M CURRENTLY LEADING RESEARCH AND EVALUATION OF THIS EFFORT. BUT, AGAIN, I WANT TO POINT OUT THIS CANNOT BE A LONG-TERM SUSTAINABLE APPROACH TO ADDRESSING FOOD SECURITY IN ALL OF NEW YORK CITY OR EVEN IN OUR PATIENT POPULATION BUT I DO THINK THAT PROVIDING THE TANGIBLE ASPECT OF FOOD CONNECTS PEOPLE WHO HAVE SOCIAL NEEDS TO SOCIAL SERVICE ORGANIZATIONS IN THEIR COMMUNITIES AND IN TURN THESE ORGANIZATIONS CAN PROVIDE ASSISTANCE TO RESOLVE SOCIAL NEEDS THROUGH THINGS LIKE SUPPORTING EMPLOYMENT, SKILLED TRAINING AND BENEFITS ENROLLMENT. TO SUMMARIZE THROUGH THE LENS OF A PEDIATRICS, FOCUSED ON CHILDHOOD OBESITY PREVENTION AND TREATMENT IN HEALTH DISPARITY POPULATIONS SIMILAR TO THE PRIOR SPEAKERS WHERE I SEE AREAS IN NEED FOR FURTHER RESEARCH AND ALSO TO FURTHER RESEARCH IN CLINICAL BIG DATA FOR SOCIAL DETERMINANTS OF HEALTH ARE IN HAVING THIS COMMON SET OF TERMS AND COMMON MEASUREMENT TOOLS THAT INCLUDE MEASUREMENTS OF HEALTH EQUITY AND UNDERSTANDING THE BEST WAY TO COLLECT THIS DATA. I THINK THERE'S ALSO ROOM TO APPLY A LIFE COURSE LENS AND EXAMINE EFFECTS NOT JUST AT DIFFERENT TIME POINTS BUT ALSO OUTCOMES OVER TIME. AND WE WILL ALSO NEED TO BETTER UNDERSTAND COST AND COST EFFECTIVENESS FROM VARIOUS PERSPECTIES TO INFORM STAKEHOLDERS AND POLICYMAKERS. FINALLY I DO WANT TO EMPHASIZE THAT BUILDING THESE RELATIONSHIPS WITH COMMUNITY MEMBERS AND COMMUNITY-BASED SOCIAL SERVICES ORGANIZATIONS REALLY TAKES A LOT OF TIME AND SO UNDERSTANDING HOW WE CAN STRENGTHEN OUR ABILITIES AS RESEARCHERS TO BUILD AN MAINTAIN THESE RELATIONSHIPS WILL ALLOW FOR TIMELY INTERVENTIONS THAT ALSO CAN BE EVALUATED. I WANT TO ACKNOWLEDGE DODI MYERS AND THE TEAM AND COMMUNITY PARTNERS DOING THIS WONDERFUL WORK AS WELL AS OUR RESEARCH COLLABORATORS AND MY TEAM IN FUNDING AND THANK ALL OF YOU FOR YOUR TIME AND LOOK FORWARD TO YOUR QUESTIONS AT THE END OF THE SESSION. >> THANK YOU. DR. HATEF? >> YES, LET ME SHARE MY SCREEN. GREAT. HI, EVERYONE. THANK YOU FOR THE OPPORTUNITY TO PRESENT MY WORK AND THANK EVERYODY FOR JOINING THIS SECOND SESSION. WE HEARD A LOT ABOUT THE TYPE OF DATA THAT WE CAN COLLECT IN THE ELECTRONIC HEALTH RECORD, SOCIAL AND BEHAVIORAL DETERMINANTS. I WANT TO TALK A LITTLE BIT ABOUT MINING THAT DATA IN THE EHR AND ALSO LINKING IT TO THE POPULATION LEVEL DATA TO ADDRESS THE PATTERNS OF HEALTH CARE UTILIZATION AND ALSO HEALTH OUTCOMES IN MINORITY POPULATIONS. AND TO JUST GIVE A LITTLE BIT OF INTRODUCTION I GUESS WE ALL KNOW THE OPPORTUNITIES THAT THE EHR AND INFORMATION EXCHANGES PROVIDED IN THE PAST FEW YEARS. WITH THE DATA THAT'S AVAILABLE IN EHR AND POPULATION LEVEL NOW WE HAVE THE CAPACITY TO DESIGN DATA ORIENTED ASSESSMENT OF THE SOCIAL NEEDS AND SOCIAL DETERMINANTS, AND ALSO DESIGN INTERVENTIONS AT POINT OF CARE, HEALTH CARE DELIVERY SYSTEM, OR IN THE COMMUNITY. AT HOPKINS FOR THE LAST FEW YEARS I'VE BEEN LEADING THIS EFFORT TO BASICALLY GO IN THE ELECTRONIC HEALTH RECORD, EHR IS EPIC, LOOKING INTO THE STRUCTURE AND STRUCTURED TO FIGURE OUT WHAT NEEDS WE CAN IDENTIFY. WE'VE HAD ACCESS TO STRUCTURED DATA FROM 2003 TO 2018, THIS IS THE FIRST OF THE STUDY. AT HOPKINS, FROM 2003 TO 2012 THERE HAVE BEEN A NUMBER OF ELECTRONIC HEALTH RECORDS AT DIFFERENT ENTITIES ACROSS THE INSTITUTION AND IN 2013 HOPKINS MODERATED ALL THE INFORMATION TO EPIC. BY 2016 CLINICS ARE ACCESS TO THE SAME ELECTRONIC HEALTH RECORD. BASICALLY USED THIS DATA ON FREE TEXT PART TO LOOK AT PATTERNS OF DOCUMENTING SOCIAL NEEDS IN THE FREE TEXT NOTES OF THE PROVIDERS. WE HAD 5.4 MILLION PATIENTS FROM STRUCTURED PART. I WANT TO GIVE A SUMMARY OF THE TYPE OF SOCIAL BEHAVIORAL DATA DOCUMENTED AT HOPKINS. AND WHEN WE WERE DOING THIS STUDY LOOKING AT OTHER REPORTS, THE TYPE OF PATTERNS THAT WE IDENTIFIED FOR DOCUMENTATION OF THESE SOCIAL BEHAVIORALS, WEREN'T THAT DIFFERENT FROM HOPKINS, WITH OTHER INSTITUTIONS. IT CAN BE BASICALLY KIND OF MODEL OR SAMPLE OF PATTERNS OF DOCUMENTING THE DATA. FOR SOME DEMOGRAPHIC CHARACTERISTICS LIKE LOCATION OR ADDRESS OF PATIENT MOST OF THE PATIENTS HAD THAT INFORMATION AVAILABLE. I WILL TALK LATER ABOUT LINKING THE EHR DATA TO POPULATION HEALTH DATA. SO HAVING INFORMTION ON LOCATION OF PATIENT HELPS LINK THAT WITH POPULATION DATA AND GIVES DIFFERENT CAPACITIES TO THIS TYPE OF DATA TO ASSESS SOCIAL NEEDS AT THE PATIENT LEVEL AND ALSO SOCIAL DETERMINANTS AT THE COMMUNITY OR POPULATION LEVEL. SOME OTHER DEMOGRAPHICS SUCH AS RACE WAS ALSO GETTING COLLECTED BUT WHEN YOU GOT TO BEHAVIORAL ONES LIKE ALCOHOL USE, LESS THAN 10% OF PATIENTS HAD ANY HISTORY OF DOCUMENTATION OF ALCOHOL USE, OR SMOKING 30%. GOING DEEPER IN SOCIAL BEHAVIORAL DATA WE WEREN'T DOING THAT WELL. WE ALSO LOOKED AT THE PATTERNS OF USING AVAILABLE ICD CODES TO DOCUMENT SOCIAL BEHAVIOR OR CHARACTERISTICS FOCUSING ON SOCIAL CONNECTION OR ISOLATION, HOUSING ISSUES, INCOME OR FINANCIAL RESOURCES TO SEE WHAT TYPE OF INFORMATION WAS COLLECTED. YOU CAN SEE THE NUMBERS WERE VERY LOW, LESS THAN 1% OF PATIENTS HAD ANY INFORMATION ON ANY OF THESE SOCIAL ISSUES IN THE STRUCTURED PART OF THE EMR. WE'RE NOW PERFORMING THE SECOND PHASE TAKING MORE INTO THE EHR DATA TO LOOK AT PATTERNS OF DOCUMENTATION OF SOCIAL NEEDS. FIRST COLUMN SHOWS TOTAL POPULATION AT HOPKINS. THEN WE LOOK AT FOUR CATEGORIES FINANCIAL CHALLENGES, FOOD INSECURITY, HOUSING, TRANSPORTATION. THE SECOND COLUMN BASICALLY SHOWS CHARACTERISTICS OF PATIENTS THAT HAD SOME DOCUMENTATION OF ANY OF THOSE SOCIAL NEEDS. SO YOU CAN SEE FOR THE YOUNGER PATIENT POPULATION 3% OF THEM HAD SOME OF THE SOCIAL NEEDS DOCUMENTED FOR THEM. ON THE SAME PERCENTAGE FOR AFRICAN AMERICAN AND ASIAN AMERICAN, AND ALSO THESE ARE LOCATIONS OF THE PATIENTS THAT HAD MOST OF THOSE SOCIAL NEEDS DOCUMENTED FOR THEM IN THE EHR, IN BALTIMORE CITY THE PATIENTS THAT CAME FROM BALTIMORE CITY ABOUT 2 1/2% HAD SOME SORT OF SOCIAL NEEDS DOCUMENTED. I WANT TO MAKE THIS NOTE THAT BECAUSE DOCUMENT ASKING AND DOCUMENTING SOCIAL NEEDS IN THE EHR ESPECIALLY IN THE STRUCTURE EHR IS NOT A COMMON PRACTICE, WE SHOULDN'T LOOK AT THESE NUMBERS AS THE PREVALENCE OF SOCIAL NEEDS OR FREQUENCY OF THE NEEDS. I'M SURE EVERY EVERYBODY AGREES FOR REFERRAL HOSPITAL LIKE HOPKINS IT IS IN ONE THE MOST SOCIALLY ECONOMICALLY CHALLENGED NEIGHBORHOODS IN BALTIMORE, THE PATIENTS HAVE MANY MORE SOCIAL NEEDS THAN WHAT IS DOCUMENTED HERE. THIS TABLE SHOWS PATTERNS OF ASKING AND DOCUMENTING THESE NEEDS BY OUR PROVIDERS IN OUR HEALTH CARE SYSTEM. WE ALSO LOOKED AT THE PATTERNS OF DOCUMENTING SOCIAL NEEDS BASED ON TYPE OF ENCOUNTER THE PATIENTS HAD WITH THE HEALTH SYSTEM BUT THEY HAD AN OUTPATIENT ENCOUNTER, EMERGENCY DEPARTMENT, INPATIENT. AND THE FIRST RULE SHOWS THE MEAN NUMBER OF ENCOUNTERS IN EACH OF THE THREE CATEGORIES, ACROSS ALL PATIENT POPULATIONS, AND THEN THE PATIENTS THAT HAD SOME SORT OF -- ONE OR MORE OF THESE SOCIAL NEEDS. SO AS EXPECTED THE PATIENTS THAT HAD ANY DOCUMENTATION OF SOCIAL NEEDS HAD MANY MORE OUTPATIENT ENCOUNTERS COMPARING TO SOCIAL POPULATION OF PATIENTS AT HOPKINS, SAME THING WITH EMERGENCY DEPARTMENT VISIT AND INPATIENT. THEY ALSO LOOKED AT MOST COMMON Z CODES, ICD CODES, USED IN OUR HEALTH CARE SYSTEM TO DOCUMENT SOCIAL NEEDS. AND THESE ARE TOP THREE ONES. YOU CAN SEE HOMELESSNESS IS AMONG THEM. AS YOU MAY EXPECT, PATIENT WITH HOMELESSNESS DOCUMENTED HAD MUCH HIGHER NUMBER OF ENCOUNTERS, WHETHER OUTPATIENT OR EMERGENCY DEPARTMENT. AND ALSO A LITTLE BIT OF INCREASED INPATIENT ENCOUNTER. BECAUSE THE NUMBERS IS NOT THAT HIGH, THE NEXT QUESTION WAS WHAT ARE PATTERNS OF DOCUMENTING THIS INFORMATION IN THE FREE TEXT UNSTRUCTURED, DEVELOPING ALGORITHMS TO DO DATA MINING FOCUSING ON SOCIAL CONNECTION, HOUSING, AND INCOME AND FINANCIAL RESOURCES STRAIN. BECAUSE THERE ISN'T ANY BASICALLY UNIVERSAL TERMINOLOGY TO ASK AND DOCUMENT SOCIAL NEEDS œCONDITIONS OR CLINICALAL CONDITIONS WE HAVE WELL DEVELOPED TERMINOLOGY FOR. WE LISTED ALL AVAILABLE CODES FROM ICD AND LOINC, LOOKED AT ALL THE AVAILABLE PUBLIC HEALTH SURVEYS AND INSTRUMENTS THAT ASK ABOUT SOCIAL NEEDS AND DOCUMENT THEM. WE LOOKED AT LITERATURE AND TYPE OF PHRASES THAT OTHER STUDIES HAVE USED AND MANUAL ANNOTATION BASICALLY HUMAN READ FREE TEXT NOTES AND IDENTIFIED DIFFERENT PHRASES PROVIDED USED TO DOCUMENT SOCIAL NEEDS. BASED ON THOSE, DEVELOPED ALGORITHMS THAT WENT THROUGH THE DATA AND IDENTIFIED NOTES WITH MENTIONS OF THESE SOCIAL NEEDS. FIRST NUMBER IS SOCIAL CONNECTION ISOLATION, NUMBER OF PATIENTS AND PERCENTAGE OF PATIENTS THAT HAD AT LEAST ONE NODE WITH SOME DIMENSIONS OF SOCIAL CONNECTIONS, 2.5% OF PATIENTS HAD SOME MENTION OF SOCIAL CONNECTION IN FREE TEXT. FOR HOUSING 3%. FOR INCOME, FINANCIAL RESOURCES, LESS THAN 1%. NUMBERS ARE NOT THAT HIGH YET BUT IF YOU COMPARE THEM WITH WHAT YOU GET FROM STRUCTURE EHR YOU CAN SEE AT LEAST WE'RE ALL PROVIDED, THEY WERE USING FREE TEXT NODES MUCH MORE OFTEN TO DOCUMENT THE SOCIAL NEEDS OF THE PATIENTS. WE LOOKED AT TYPE OF PROFILE THAT DOCUMENTED THIS INFORMATION IN FREE TEXT NODES, PHYSICIANS WERE DOING MOST, LOOKING AT TYPE OF NODES WITH DISINFORMATION AND PROGRESS NOTES ARE THE ONES THAT HAD MOST OF THE MENTIONS OF SOCIAL NEEDS. WE STARTED COLLABORATING CAN KAISER PERMANENTE, DEVELOPING COMPARABLE COHORTS IN EACH HEALTH SYSTEM, PATIENTS OF 18 YEARS AND OLDER IN A THREE-YEAR PERIOD AND LOOKED AT PATTERNS OF DOCUMENTING HOUSING ISSUES IN THE FREE TEXT NOTES, USING NLP ALGORITHM DEVELOPED AT HOPKINS. BASED ON INFORMATION THEY HAD AVAILABLE USED SLIGHTLY DIFFERENT APPROACH TO MEASURE PERFORMANCE OF THOSE ALGORITHMS. WITHOUT GETTING THAT MUCH INTO THE DETAIL, I WANT TO SHOW SENSITIVITY AND SPECIFICITY FOR DETECTING INFORMATION RELATED TO HOUSING ISSUES IN THE FREE TEXT NOTE OF EACH OF THESE HEALTH SYSTEMS WAS PROMISING, AND THEY ARE COMPARABLE. SHOWS ALGORITHM WAS GENERALIZABLE. SO WE COULD BASICALLY DEVELOP THIS ALGORITHM, SHARE WITH ANOTHER HEALTH SYSTEM, THEY COULD RUN IT IN THEIR EHR AND IDENTIFY THE PATIENTS THAT HAD MENTION OF HOUSING ISSUES. SO, I'M GOING TO BRIEFLY GIVE EXAMPLE OF WHAT WE CAN DO WITH THIS DATA. WE SAW THAT WASN'T MUCH DATA IN STRUCTURE OF EHR. THERE'S MORE INFORMATION IN THE UNSTRUCTURED EHR, ALSO WE HAVE POSSIBILITY OF LINKING THE EHR DATA TO POPULATION LEVEL DATA BECAUSE EHR DATA IS GEO CODED. WE USE THIS APPROACH LINKING OUR EHR DATA TO U.S. CENSUS AMERICAN COMMUNITY SURVEY TO BASICALLY LOOK AT PATTERNS OF UTILIZATION FOR THE PATIENTS THAT HAD SOME SORT OF HOUSING ISSUES. THE QUESTION WAS WHETHER HAVING SOCIAL NEED AT INDIVIDUAL LEVEL OR LIVING IN A COMMUNITY THAT HAS SOME SOCIAL ECONOMICAL CHALLENGES, THEY DO IMPACT THE PATTERNS WITH HEALTH SYSTEM. USING AREA DEPRIVATION INDEX, A COMPOSITE MEASURE THAT RANKS NEIGHBORHOODS IN THE NATION BASED ON SOCIOECONOMIC CHALLENGES, HIGHER MEANS THEY HAVE HIGHER CHALLENGES. 1.2MILLION PATIENTS FROM 2016 TO 2018, AND WE LOOKED AT A NUMBER OF DIFFERENT FACTORS THAT COULD IMPACT ENCOUNTER WITH HEALTH SYSTEM, HERE IS THE OUTPUT, OUTCOME WAS BASICALLY THE NUMBER OF ENCOUNTERS. AFTER ADJUSTING FOR DEMOGRAPHIC VARIABLES, ADDRESSING NUMBER OF COMORBIDITIES THAT THE PATIENTS HAD, THE PATIENTS AT INDIVIDUAL LEVEL HAD HOUSING ISSUES COMPARING TO ONES THAT DIDN'T HAVE ANY HOUSING NEEDS HAD SOME INCREASE IN THEIR NUMBER OF ENCOUNTERS WITH THE HEALTH SYSTEM. WHETHER IN OVERALL POPULATION, WE DID THIS MODELING, WE DID IT IN THE MEDICAID POPULATION AND YOU CAN SEE HIGHER, PATIENTS THAT HAD HOMELESSNESS, THEY HAD LIKE 30% INCREASE IN NUMBER OF ENCOUNTERS WITH THE HEALTH SYSTEM. THE SAME THING LIVING IN A NEIGHBORHOOD WITH SOCIOECONOMIC CHALLENGES. FOR PATIENTS WHEN WE TOOK OTHER FACTOR, IT MEANS FOR THE PATIENTS AT THE SAME AGE, RACE, SEX, AND HAD SAME LEVEL OF INDIVIDUAL LEVEL OF HOUSING NEEDS, JUST LIVING IN A COMMUNITY THAT WAS MORE SOCIOECONOMICALLY DISADVANTAGED, NUMBERS WENT UP FOR GENERAL POPULATION AND ALSO FOR MEDICAID. THIS IS AN EXAMPLE OF BASICALLY MAKING USE OF WHATEVER DATA IS AVAILABLE IN THE HEALTH SYSTEM, POPULATION LEVEL TO LOOK AT PATTERNS OF UTILIZATION. I HOPE I WAS ABLE TO GIVE HOPE IN THE FACT THERE IS INFORMATION AVAILABLE IN THE EHR, MAY NOT BE THAT MUCH BUT IS STILL VALUABLE. LINKING TO POPULATION LEVEL DATA GIVES ANOTHER PERSPECTIVE TO THE SOCIAL NEEDS AND SOCIAL CHALLENGES. THE FACT THAT THE OTHER SPEAKERS MENTIONED THERE'S NOT A UNIVERSAL WAY OF ASSESSING AND ADDRESSING THE APPROACH AND HAVING BEST PRACTICES WHO NEEDS TO BE SCREENED AND HOW THEY SHOULD BE SCREENED AND HOW THE INFORMATION SHOULD BE COLLECTED AND DOCUMENTED, IN THE EHR, THERE ARE A LOT OF RESEARCH ACTIVITIES GOING ON. ANOTHER MAJOR BURDEN IS BASICALLY THE COST. THE FACT AS LONG AS THERE'S THE COST BURDEN ON PROVIDERS AND HEALTH SYSTEM IT'S DIFFICULT FOR THEM TO BASICALLY DO VERY UNIVERSAL ASSESSMENT AND DOCUMENTATION OF SOCIAL ISSUES. THE OTHER CHALLENGE IS RELATED TO THE DATA, FOR THE MOST PART SOCIAL NEEDS WHEN THEY GET ASSESSED IN HEALTH SYSTEM ADDRESSING THEM REQUIRES SOME KIND OF REFERRAL TO ENTITY OUTSIDE THE HEALTH SYSTEM SO THERE ARE A LOT OF CHALLENGES RELATED TO INTEROPERABILITY, WHO NEEDS TO RECEIVE AND HOW WE SHOULD COMMUNICATE GOING OUTSIDE CLOSE EHR ENVIRONMENTS. WITH ALL THESE CHALLENGES, I GUESS EVERYBODY AGREES THERE ARE PRESSURES FROM PAYERS AND POLICYMAKERS ON PROVIDERS AND HEALTH SYSTEMS TO PROVIDE SERVICES THAT HAVE HIGHER QUALITY BUT HAVE LOWER COST. FOR THE HEALTH SYSTEM TO ADDRESS THAT ISSUE THEY REALLY CANNOT IGNORE THE SOCIAL BEHAVIORAL RISK FACTORS OF THEIR PATIENTS. THERE'S A NEED FOR DEVELOPING MORE EVIDENCE ON BEST PRACTICES HOW TO APPROACH THE SOCIAL NEEDS AND SOCIAL DETERMINANTS BUT ALL THESE CHALLENGES THERE IS NO QUESTION THAT WHATEVER APPROACH THAT WE HAVE TO PATIENT CARE AND FOR POPULATION HEALTH INTERVENTION WE CANNOT IGNORE IMPACT OF SOCIAL BEHAVIORAL DETERMINANTS AND WHATEVER SOLUTION WE COME UP WITH THEY NEED TO ADDRESS THE SOCIAL BEHAVIOR ON NEEDS OF THE PATIENT AND DETERMINE AT POPULATION LEVEL. WITH THAT I WOULD LIKE TO THANK MY CO-WORKERS AT HOPKINS AND THANK YOU FOR YOUR ATTENTION. >> THANK YOU, DR. HATEF. DR. ROSSETTI? >> GREAT, THANK YOU. CAN YOU SEE MY SCREEN? >> WONDERFUL. THANK YOU SO MUCH FOR HAVING ME TODAY. WHAT A WONDERFUL DAY TO BE A PART OF. I'LL BE SPEAKING ABOUT OUR CONCERN STUDY FUNDED BY NINR WHERE WE LEVERAGE BIAS IN SOME ASPECTS IN A POSITIVE WAY, BIAS FROM EHR DATA PATTERNS IN ORDER TO PREDICT RISKY PATIENTS, USING CLINICAL DECISION SUPPORT BUT AS PART OF THAT WORK WE HAVE OPPORTUNITIES AND RESPONSIBILITIES TO MONITOR AND MITIGATE RACIAL AND ETHNIC BIAS IN PREDICTIVE MODELS AND I'LL TALK ABOUT HOW WE'RE DOING THAT. I'D LIKE TO ACKNOWLEDGE MY RESEARCH TEAM FROM BOTH COLUMBIA UNIVERSITY AS WELL AS HARVARD AND BRIGHAM AND WOMEN'S HOSPITAL AND NEWTON WELLESLEY HOSPITAL, ALSO ACKNOWLEDGE MY MULTI-P.I. AND SITE P.I. I HAVE NO CONFLICTS TO DISCLOSE. WHAT IS THIS CONCERN PROJECT THAT WE HAVE? IT'S ACTUALLY AN EARLY WARNING SYSTEM FOR PATIENT DETERIORATION BASED ON NURSING DOCUMENTATION PATTERNS OR SIGNALS FROM THE EHR WHERE WE DETECT THE NURSE'S EXPECT CLINICAL JUDGMENT PERCEIVING CHANGES IN A PATIENT'S CLINICAL STATE. WHAT WE'VE DEVELOPED IS PREDICTIVE MODEL THAT ALERTS EARLIER THAN OTHER EARLY WARNING SYSTEMS, I'LL TALK ABOUT HOW AND WHY. BUT BECAUSE THESE SUBTLE CHANGES WE DETECT USUALLY OCCUR WELL BEFORE PHYSIOLOGIC ALTERATIONS IN PATIENT, WHAT MOST OTHER EARLY WARNING SYSTEMS ARE BASED ON, BASED ON VITAL SIGNS. WE LEVERAGE EXISTING DOCUMENTATION IN OUR WORK WHICH THEN PREVENTS INCREASES TO DOCUMENTATION BURDEN AS WELL WHICH IS IMPORTANT FROM OUR PERSPECTIVE. SO THIS PREDICTIVE MODEL WE'RE ACTUALLY LOOKING AT WHEN PATIENTS MAY ENTER A RISKY STATE AS OPPOSED TO THEY ARE ALREADY IN THE RISKY STATE BECAUSE WE REALLY WANT TO MAXIMIZE LEAD TIME FOR CLINICIANS IN ORDER TO INTERVENE ON THESE PATIENTS. AND THIS IS FOCUSED IN THE INPATIENT SETTING BOTH IN ACUTE CARE AND CRITICAL CARE UNITS. SO A LITTLE BIT OF CONTEXT AND BACKGROUND AROUND THIS, IT'S A DATA SCIENCE RESEARCH STUDY. SO IT'S MULTI-SITE AS I SAID. USING DATA FROM UP AT THE PARTNERS HEALTH CARE SYSTEM IN MASSACHUSETTS, AS WELL AS FROM COLUMBIA UNIVERSITY MEDICAL CENTER. SO IN ORDER TO DO THAT WE HAVE TO TAKE DATA FROM TWO DIFFERENT ELECTRONIC HEALTH RECORDS ON AND HARMONIZE THAT DATA SO WHAT YOU SEE HERE IS ONTOLOGY THAT WE DEVELOPED. SO WE HAD, YOU KNOW, MANY DIFFERENT TEMPLATES AND FLOW SHEET GROUPS AND SOME OF THESE PHRASES MAY BE FAMILIAR WITH THOSE THAT WORK WITH SOME EHRs. BUT IT ESSENTIALLY RESULTED IN 35 DATABASE ROWS OF SIMPLY CONCEPTS THAT WE WERE HARMONIZING BETWEEN THE TWO SITES, AND THIS TAKES A LONG TIME TO GET THAT WORK DONE. AND THAT RESULT -- SO MULTIPLE YEARS, REALLY. THAT RESULTED IN REALLY WHEN WE QUANTIFY FROM ONE OF OUR SITES IN ONE YEAR OF DATA FROM ONE OF OUR SITES IT'S OVER 94 MILLION FLOW SHEET ROW DATA POINTS, AND WE HAVE MORE THAN THAT SO WE FEEL FORTUNATE WE NOW HAVE QUITE THE ROBUST DATASET TO ANALYZE WHERE WE'RE LOOKING AT NURSING DOCUMENTATION AND FROM MULTIPLE SITES. SO IN OUR WORK WE LEVERAGE SIGNALS OF VARIABILITY IN NURSING EHR BEHAVIOR AS ONE TYPE OF BIAS, POSITIVELY USING THIS BIAS IN EHRs. I WANT TO EMPHASIZE EHRs ARE FULL OF BIAS. AND SO THIS IS ONE ASPECT THAT WE CAN ACTUALLY USE TO PREDICT SOME PATIENT OUTCOMES AND USE IT IN A POSITIVE MANNER. SO WHAT WE FIND, WHAT WE'RE LOOKING AT IS EXPERTS ARE OFTEN UNABLE TO ARTICULATE THE CUES THAT GUIDE THEM, WE KNOW FROM PRIOR WORK, GREAT POTENTIAL FOR PREDICTS PREDICTSIVE MODELING BUT WE CAN TAP IN SPECIFICALLY, LOOKING AT WHEN NURSES INCREASE FREQUENCY OF SURVEILLANCE OF THE PATIENT THEY SUBSEQUENTLY INCREASE FREQUENCY OF DOCUMENTATION FOR PATIENTS THAT FIT A CONCERNING PATTERN. NURSES SYNTHESIZE CLINICAL ASSESSMENTS, OTHERWISE BURIED IN STRUCTURED FLOW SHEET FIELDS IN SHORT NARRATIVE COMMENTS. FOR EXAMPLE, NURSE MAY HIGHLIGHT RELATIONSHIP BETWEEN SPO2 VALUE AND AMOUNT OF SUPPLEMENTAL OXYGEN PERHAPS INCREASED TO THE PHYSICIAN IN NARRATIVE COMMENTS AS INDICATOR OF DETERIORATING STATUS. AND SO WE'VE BEEN ABLE TO FIND BIAS IN DIFFERENT METADATA PATTERNS OF NURSING DOCUMENTATION AS A SIGNAL OF CONCERN. SO WHEN I SAY BIAS IN THIS CONTEXT WE'RE TAPPING INTO VARIABILITY IN WHAT NURSES ARE DOCUMENTING AND BEING ABLE TO ASSOCIATE THAT WITH OUTCOME AN USE AS PREDICTOR. SO WE FIND THAT THE ACT OF DOCUMENTS FREE TEXT COMMENTS OR OTHER OPTIONAL DATA IN A FLOW SHEET ROW IS INFORMATION THAT THE NURSE LIKELY DETERMINED AN EVENT WITH CLINICALLY SIGNIFICANT ENOUGH TO RECORD. IN OUR WORK WHEN I SAY LOOKING AT METADATA PERSONS, LOOKING AT FREQUENCY WHICH THIS DOCUMENTATION IS OCCURRING AS OPPOSED TO LOOKING AT PHYSIOLOGICAL VALUE. YOU KNOW, WHAT WAS THE HEART RATE AND BLOOD PRESSURE? WE'RE LOOKING AT THIS METADATA INSTEAD. SO WE FIND A FOCUS ON VALUES IN THE EHR DATA WILL MISS HEALTH CARE PROCESSES IN NURSING INTERVENTIONS ACTIVATED FAR BEFORE A PATIENT'S VITAL SIGNS ARE BE A NORMAL. THIS CAN CHANGE HOW WE UNDERSTAND AND LEVERAGE CLINICAL OBSERVATIONAL SKILLS AND CLINICIAN-ENTERED DATA IN A CHART AND THIS GRAPH SHOWS THAT WHEN NURSES DOCUMENT MORE COMMENTS, THOSE PATIENTS ARE MORE LIKELY TO HAVE A CARDIAC ARREST. SO, WHAT WAS KIND OF THE FRAMEWORK THAT WE HAVE DEVELOPED AND WE'RE WORKING FROM IS WHAT WE CALL HEALTH CARE PROCESS MODELING. WE IDENTIFY FEATURES FROM USER INTERACTION WITH CLINICAL SYSTEMS, PATTERNS OF CLINICAL BEHAVIOR. WE USE THOSE PATTERNS AND INTERPRET THEM AS PROXIES OF INDIVIDUALS' DECISION KNOWLEDGE, EXPERTISE, AND WE USE THOSE PATTERNS AND PREDICTIVE MODELS FOR ASSOCIATION WAS OUTCOMES. AND WHAT'S ABSOLUTELY IMPERATIVE IS UTILIZING CLINICAL DOMAIN EXPERTISE, SPECIFICALLY NURSING DOMAIN EXPERTISE, IN OUR CASE FOR ACCURATE AND COMPREHENSIVE INTERPRETATION OF THESE DATA AND THESE PATTERNS THAT WE IDENTIFY. SO, THIS IS JUST AN ILLUSTRATION OF FEATURES IN OUR CONCERN PREDICTIVE MODEL. I HIGHLIGHTED MANY OF THESE TALKING ABOUT HOW WE LOOK AT VITAL SIGN ENTRY FREQUENCY AND VITAL SIGN COMMENT FREQUENCY. BUT WE ALSO ARE LOOKING AT MEDICATION ADMINISTRATION FREQUENCY SPECIFICALLY, WHEN PRN MEDICATIONS ARE GIVEN THAT'S A VERY INFORMATIVE SIGNAL FOR PATIENTS THAT ARE AT RISK OF DETERIORATION, ESPECIALLY WHEN PARTICULAR MEDICATIONS, PRN MEDICATIONS, ARE GIVEN AS OPPOSED TO OTHERS AND WHEN MEDICATIONS ARE WITHHELD, CORE PARTS OF NURSING PRACTICE AND NURSING DECISION MAKING, PARTICULARLY IN THE INPATIENT SETTING WHERE WE'RE FOCUSED. WE LOOK AT NURSING NOTE CONTENT, SO MENTIONS OF FOR INSTANCE COMMUNICATING WITH THE PHYSICIAN, MENTIONS OF ADDITIONAL PROCEDURES DONE OR OBTAINED. WE INCLUDE DEMOGRAPHICS, AGE, GENDER, AND RACE, AND I'LL TALK ABOUT THAT, HOW WE'RE STARTING TO LEVERAGE. AND THEN WE ALSO LOOK AT FREQUENCY IN WHICH NURSING NOTES ARE DOCUMENTED. THESE FEATURES ON THE LEFT SIDE OF THE SCREEN HERE THEN INFORM -- ARE USED IN CONTINUOUS TIME DEPEND SCALING, LOOKING AT DIFFERENT THINGS IMPORTANT TEMPORALLY FROM EHR DATA AND BEGIN TO CATEGORIZE THOSE. AND THEN WE USE DIFFERENT CATEGORICAL FEATURES AS KNOWN CONFOUNDERS IN VARIATIONS AND CLINICAL WORK FLOW. WE KNOW DEMOGRAPHICS HAVE SOME OF THOSE IMPLICATION, HOSPITAL LOCATION IS, ICU, ACUTE CARE UNITS IMPACTS PATTERNS OF DOCUMENTATION THAT WE EXPECT TO SEE, TIME FEATURE, HOUR OF DAY. ICU YOU CAN EXPECT MORE OVERNIGHT DOCUMENTATION THAN PERHAPS OTHER SETTINGS IN THE HOSPITAL, AND PREVIOUS OUTCOMES, COMBINE THESE INTO OUR PREDICTIVE MODEL. AND ASSIGN A COLOR CODE, GREEN, YELLOW RED. NOTE WAS BUILT, CLINICIANS SEE, NURSES AND PHYSICIANS. JUST SOME RESULTS WERE FOUND IN OUR TIME VARYING SURVIVAL OF REGRESSION WE COMPARED OUR CONCERN SCORE TO LEADING EARLY WARNING SCORES, WE FOUND THAT OUR CONCERN HIGH RISK SCORE IMPLIED GREATER, AND MODERATE IMPLIED GREATER HAZARD THAN BOTH. WE WERE ABLE TO DEMONSTRATE BETTER PERFORMANCE THAN THOSE BUT EVEN MORE EXCITING THAN THAT WAS THAT WE FOUND THE LIKELIHOOD OF EVENT OCCURRING 48 HOURS AFTER -- FOR EXAMPLE, LIKELIHOOD OF AN EVENT OCCURRING 48 HOURS AFTER OBSERVING A CONCERNED HIGH RISK SCORE IS COMPARABLE TO LIKELIHOOD OF AN EVENT OCCURRING SIX HOURS AFTER OBSERVING A HIGH RISK MUSE OR NEWS SCORE, DIFFERENCE OF 42 HOURS, INCREASED LEAD TIME OF 42 HOURS FOR CARE TEAM MEMBERS TO INTERVENE ON A PATIENT AT RISK OF DETERIORATION. AND THIS IS BECAUSE WE'RE TAPPING INTO NURSING DOCUMENTATION THAT REFLECTS THE KNOWLEDGE OF THE NURSE THAT THEY SEE THIS PATIENT IS NOT DOING WELL, BEFORE VITAL SIGNS ARE INDICATING THAT. SO WE KNOW US INS IN -- NURSES KNOW PATIENTS WELL, AND OUR WORK IS WORKING TO QUANTIFY THAT. SWITCHING GEARS A LITTLE BIT, THE CONCERN STUDY IS DESIGNED TO LEVERAGE BIAS, I TALKED ABOUT WAYS WE'RE POSITIVELY LEVERAGING BIASES IN THE EHR, DIFFERENT PATTERNS WE SEE. BUT WE ACTUALLY CERTAINLY THERE ARE MANY OTHER TYPES OF BIASES AS WELL THAT WE WANT TO BE AWARE OF AND MITIGATE. SO WE SET UP OUR STUDY SO THAT WE HAVE THIS KIND OF -- WE FOLLOW THE STRUCTURE PROCESS OUTCOME MODEL BUT WE HAVE DIVERSITY IN DATA STRUCTURES AND -- OOPS. LET ME GO BACK. SORRY. AND WE INTENTIONALLY USE THOSE STRUCTURES IN ORDER TO UNDERSTAND WHAT'S GOING ON. IN OUR DATA MODELING AND PROCESSES WE MEASURE AND CHECK FOR SOURCES OF BIAS. BECAUSE WE DON'T WANT TO PUT A PREDICTIVE MODEL OUT THERE THAT HAS SOURCES OF BIAS THAT WE DON'T WANT. AND IN OUR CLINICAL OUTCOMES WE ACTUALLY NEED TO BE ABLE TO PLOD PHI ALGORITHMS BASED ON FINDINGS. AND SO -- MODIFY ALGORITHMS BASED ON FINDINGS. WE HAVE DIVERSITY IN OUR DATASETS, FROM OUR TWO DIFFERENT SITES, THAT INDIVIDUALLY HAVE DIFFERENT POPULATIONS AND SO THAT ADDS TO DIVERSITY IN OUR DATASET. WE REALLY BELIEVE YOU NEED THAT ROBUST DATASET TO MAKE SURE YOUR PREDICTIVE MODEL IS NOT AMPLIFYING BIAS AND MONITOR YOUR MODEL FOR FEATURES IN THE CONTEXT OF DIVERSE DATASETS AS YOU IMPLEMENT PREDICTIVE MODEL YOU NEED TO UNDERSTAND WHAT'S THE UNDERLYING DISTRIBUTION OF THAT POPULATION AND HOW IS THE MODEL PERFORMING SIMILAR OR DIFFERENT TO PERHAPS WHERE YOU DEVELOPED THAT MODEL. WE LOOKED AT OUR COMPARED TO MEWS AND NEWS IN TERMS OF PERFORMANCE BETWEEN -- ON DIFFERENT RACE POPULATIONS, SO WE COMPARED WHITE AND CAUCASIAN TO BLACK AND AFRICAN AMERICAN. WE ANTICIPATED, YOU SEE THE CONCERN HERE ON THE LEFT, ANTICIPATED THAT RACE AND OTHER PATIENT DEMOGRAPHICS WOULD PLAY A ROLE IN OUR EARLY WARNING SCORE BASED ON DOCUMENTATION PATTERNS. AND WE INCLUDED DEMOGRAPHIC INFORMATION IN OUR MODEL BUILDING AND POST PROCESSING STEPS TO REDUCE RACIAL BIAS. YOU CAN SEE PRETTY GOOD PERFORMANCE HERE BETWEEN THE TWO RACIAL GROUPS AND THE PERFORMANCE IS NOT STATISTICALLY SIGNIFICANT. SO WHILE WE SEE SOME DIFFERENCE THERE IN THE GRAPH, YOU KNOW, WE'RE DOING PRETTY WELL THOUGH WE HAVE ROOM FOR IMPROVEMENT CERTAINLY. BUT IN THE NEWS AND MEWS BASED ON PATIENTS PHYSIOLOGIC STATE AND DON'T ACCOUNT FOR RACIAL BIAS, WHITE RECEIVE HIGHER AVERAGE SCORE THAN BLACK OR AFRICAN AMERICAN PATIENTS SO WE KNOW THERE IS BIAS EMBEDDED IN THOSE MODELS AND THOSE MODELS ARE BEING USED AT A LOT OF DIFFERENT CLINICAL SITES. SO TO WRAP UP, REALLY, WE KNOW THERE'S BIAS IN EHR DATA. THERE'S AN OPPORTUNITY AND RESPONSE TO IDENTIFY AND INTERVENE. IN THE CONTEXT WE HAVE TO MONITOR FOR BIAS, IN A VARIETY OF BIASES. WE HAVE TO THEN MITIGATE THE BIAS IN PREDICTIVE MODELS, MONITORING AND FINDING THAT THERE ARE DISPARITIES BETWEEN DIFFERENT POPULATIONS IS NOT GOOD ENOUGH. OUR TEAM IS AT BEGINNING STAGES OF THIS WORK BUT WE ARE BUILDING IN FEATURES INTO OUR MODEL TO MITIGATE RACIAL AND ETHNIC BIAS AND WE HOPE TO EXPAND THAT WORK AS WELL. AND TRANSPARENCY IN DATA MODELS IS FOUNDATIONAL FOR THIS WORK IN ORDER TO CHECK YOUR MODEL ASSUMPTIONS BUT REALLY IMPORTANT WHEN YOU THINK ABOUT WE BUILD PREDICTIVE MODELS TO BE IMPLEMENTED. YOU HAVE TO ACTUALLY KNOW HOW THAT MODEL IS WORKING AND KNOW IF THAT MODEL IS PERFORMING THE SAME OR IF THOSE ARE NEWBY AS THAT NEED TO BE HANDLED. AND SO IN CONCLUSION, FUTURE DIRECTIONS AND QUESTIONS OUR TEAM IS GRAPPLING WITH, HOW YOU STRUCTURE DATABASES IS CRITICALLY IMPORTANT. THE WAY WE WERE ABLE TO DO IT FROM MULTI-SITES WITH DIVERSE POPULATIONS ENABLED THE FINDINGS THAT WE HAD AND ABILITY TO LOOK AT DIFFERENT TYPES OF BIAS. SO NEED TO ACTUALLY DO THE MONITORING FOR THOSE BIAS AND HAVE TRANSPARENCY IN DERIVED DATA MODELS TO UNDERSTAND HOW THEY ARE PERFORMING AND MITIGATE AND CHANGE HOW THEY ARE PERFORMING SO WE DON'T HAVE CLINICAL DECISION SUPPORT IN OUR SETTINGS, CLINICAL SETTINGS, THAT IS PROPAGATING BIAS. WHAT SHOULD THE CRITERIA FOR DIVERSITY AND OUR DATASETS BE AS WE BUILD THESE PREDICTIVE MODELS? WE THINK WE FAVOR MULTI-SITE STUDIES, WHAT'S THE VARIABILITY OF EHR BIAS ACROSS CLINICAL SITES, WHAT APPROACHES FOR BIAS CHECKING SHOULD BE USED IN CDS MODELS? HOW DO WE MITIGATE BIAS ONCE IT'S DETECTED FOR MODELS ALREADY IN BROAD CLINICAL USE? AND HOW DO WE MEASURE IMPACT OF CLINICAL STAFFDIV STAFF -- STAFF - DIVERSITY IS ALSO A FACTOR. THANK YOU FOR HAVING ME. IT'S A PLEASURE TO BE PART OF THIS CONVERSATION, I'D LIKE TO ACKNOWLEDGE MY MULTI-P.I. KENRICK CATO FOR THIS WORK. THANK YOU. >> THANK YOU, DR. ROSSETTI. DR. COATS? >> HI, EVERYBODY. IT'S SO GREAT TO BE HERE TODAY. LET'S SEE IF I CAN PASS THE TEST OF SEEING MY SLIDES. HOW ARE WE LOOKING OUT THERE? IS THIS OKAY? ALL RIGHT. HELLO, EVERYONE. STAND UP AND ZOOM FATIGUE IS REAL. I'M HEATHER COATS, A PLEASURE TO TALK ABOUT MY PROGRAM OF RESEARCH. I FEEL IT'S BEEN GREAT TO HEAR ABOUT THE NASEM REPORT INTEGRATIONING SOCIAL CARE IN HEALTH CARE DELIVERY AS A WAY TO ADDRESS MAJOR CHALLENGES THAT'S FACING THE U.S. HEALTH CARE SYSTEM. SPECIFICALLY, I'D LIKE TO DRAW ATTENTION TO GOAL 1 OF THAT REPORT WHICH URGES US TO CONSIDER THE USE OF PATIENT-CENTERED CARE MODELS TO MORE ROUTINELY INCORPORATE THIS DATA INTO CARE DECISIONS. OF COURSE, BEING NARRATIVE INTERVENTIONIST I'LL START WITH THE PART OF MY STORY, WHY THIS IS IMPORTANT TO ME. DURING MY 25 YEARS OF EXPERIENCE IN HEALTH CARE AS ONCOLOGY AND PALLIATIVE CARE CLINICIAN WITNESSED DISREGARD OF PEOPLE'S BELIEFS, PREFERENCES, AND VALUES IN A FRAGMENTED DEHUMANIZING HEALTH CARE SYSTEM. IT'S MAYBE BECAUSE WE'RE ASKING HOW THE PATIENT IS, WE DON'T HAVE MECHANISMS TO KNOW WHO THE PATIENT IS. THAT'S WHAT MY PROGRAM OF RESEARCH IS ALL ABOUT. GETTING PATIENTS' PERSONAL NARRATIVES, THEIR STORIES IN THE ELECTRONIC HEALTH RECORDS. I HAVE NO DISCLOSURES. JUST ACKNOWLEDGE FUNDING SUPPORT THUS FAR. KEEPING STORIES IN MIND, COMING FROM THE UNIVERSITY OF COLORADO IN DENVER, I WOULD LIKE TO JUST ALL TAKE A MOMENT EVEN AS WE'RE GIVING VIRTUALLY TO HONOR THESE TRADITIONAL TERRITORIES IN ANCESTOR HOMELANDS OF THE NATIONS REPRESENTED ON THIS SLIDE. SO, WHAT ARE WE TALKING ABOUT TODAY IN THE PURPOSE OF MY PRESENTATION IS AS A PALLIATIVE NURSE CARE PRACTITIONER DESCRIBE FOUNDATIONS AND TALK ABOUT THE DEVELOPMENT, DESIGN, IMPLEMENTATION OF A CO-CREATED PERSON CENTERED NARRATIVE INTERVENTION. FINALLY SUMMARIZE RESULTS DISCUSS FACILITATORS AND BARRIERS EXPERIENCED IN IMPLEMENTATION OF THIS INTERVENTION. SO WHAT'S HIGH QUALITY HIGH VALUE CARE? I THINK THIS IS PART OF THE DISCUSSION WE'VE ALL BEEN HAVING ACROSS THE ROUNDTABLE PRESENTATION. AND COMPLEXITIES. WE'RE GROUNDED IN FOURTH EDITION OF THE GUIDELINES MADE UP OF EIGHT DOMAINS, SPECIFICALLY THESE HIGHLIGHTED HERE ARE A MUST, MOVING FORWARD AS WE CONTINUE TO FOCUS ON INTEGRATION OF THE WHOLE PERSON INTO HEALTH CARE DELIVERY. FOR MY TEAM AND I THIS IS ABOUT HEARING THE PERSON'S NARRATIVE. YOU MIGHT BE ASKING WHAT'S NARRATIVE? QUICKLY, LAYMAN TERMS, STORY, NARRATIVE. ACADEMIC TERM, NARRATIVE. THE IDEA OF NARRATIVE HAS BEEN AROUND FOR EVERY, VIA ORAL TRADITION, FOUND ACROSS MANY DISCIPLINES. TEXT BOOK REPRESENTED HERE TALKS ABOUT NARRATIVE BEING USED FOR MEANING MAKING BETWEEN THE TELLER AND RECEIVER OF THE STORY. SHE SPEAKS TO HOW NARRATIVES CAN BE STRATEGIC, FUNCTIONAL, PURPOSEFUL. USING THIS METHOD JOINED WITH MY CLINICAL YEARS OF EXPERIENCE, THAT'S PART OF MY NARRATIVE, I BEGAN TO WONDER HOW COMMUNICATION THROUGH THE USE OF NARRATIVE COULD BE A WAY TO SEE MORE OF THIS PSYCHOLOGICAL, SOCIAL, CULTURAL AND SPIRITUAL EXPERIENCES THAT IMPACTS A PERSON'S BELIEFS, VALUE, PREFERENCES. ESPECIALLY IN THE FACE OF SERIOUS ILLNESS, WHERE THE OPPORTUNITY TO HAVE THAT PHYSICAL HEALING IS NOT ALWAYS POSSIBLE. THIS IS ONE AIM OF MY PRE-DOCTORAL NINR-FUNDED DISSERTATION STUDY, A DESCRIPTIVE DESIGN USING NARRATIVABLE SIS TO LOOK AT PSYCHOSOCIAL SPIRITUAL HEALING AND SUFFERING OF AFRICAN AMERICAN ELDERS LIVING WITH SERIOUS ILLNESS. USING THESE NARRATIVE METHODS THIS INCLUDED OPEN ENDED INTERVIEW QUESTION SUCH AS TELL ME ABOUT YOU, TELL ME ABOUT YOUR ILLNESS, AND TELL ME HOW THAT ILLNESS HAS IMPACTED THOSE PSYCHOLOGICAL, SOCIAL, SPIRITUAL BELIEFS, VALUES, PREFERENCES. SO JUST BRIEFLY THESE FINDINGS WERE NARRATIVES OF FAITH AND RELIANCE ON GOD PROVIDING INTERNAL STRENGTH TO OVERCOME AND KNOW THERE'S LIFE THAT'S BETTER, AND YOU CAN READ MORE ABOUT DETAILS OF METHODS AND FINDINGS IN THIS PUBLICATION NOTED. DURING THIS STUDY I HAD AN UNEXPECTED FINDING, THOSE AHA MOMENTS WE GET DURING DATA COLLECTION. AS THE P.I. I WAS COLLECTING RUBY'S NARRATIVE IN HER HOME. SHE DIDN'T LOOK PHYSICALLY WELL, HUNCHED OVER, BREATHLESS. I SAID I'LL COME BACK. SHE WANTED TO CONTINUE. I BEGAN NOTICING DURING THAT NARRATIVE INTERVIEW HER DEMEANOR CHANGED, SHE BECAME VIBRANT. SHE EVEN TOOK OFF OXYGEN, WENT TO THE BATHROOM, CAME BACK, NEVER PUT IT BACK ON. WE FINISHED. SHE NEVER DEVELOPED BREATHLESSNESS. AND AFTER I TURNED OFFER THE AUDIO RECORDER, SHE BROKE MY CLINICIAN HEART. SHE SAID TO ME, AND I QUOTE, NO ONE HAS EVER ASKED ME THESE QUESTIONS BEFORE. YOU CAN SEE ON THIS SCREEN HER MEDICAL STORY. A HIGH UTILIZER WE WOULD LABEL. THUS BEGAN THE LINK TO HOW WE COULD USE NARRATIVE METHOD AS INTERVENTION. œWITH ME, THINKING ABOUT LEVELS OF INFLUENCE FROM THE NIMHD RESEARCH FRAMEWORK. SPECIFICALLY TARGETING INTERPERSONAL LEVEL OF INFLUENCE, PATIENT-CLINICIAN RELATIONSHIP, IN DOMAIN OF INFLUENCE, THE HEALTH CARE SYSTEM, COULD ALLOW FOR SHARED DECISION MAKING TO DELIVER HIGH-QUALITY HIGH-VALUE CARE IN THE PALLIATIVE AND HOSPICE FIELD. I TURNED MY WORK TO CONTINUE TO THINK ABOUT WAYS WE CAN IMPROVE THIS PERSON-CLINICIAN COMMUNICATION IN AN EFFORT TO PROVIDE TRUE PERSON-CENTERED CARE AND HOW THAT CO-CREATION OF A NARRATIVE, THE METHODS IN MY PRIOR STUDY, COULD BE USED LEADING TO THESE QUESTIONS. HOW COULD THEY BE USED PRACTICALLY, IN A FAST-PACED CLINICAL ENVIRONMENT? HOW COULD THEY BE CAPTURED AND REFLECTED TO THE TEAM? AND WHAT EFFECTS WOULD IT HAVE FOR ALL INVOLVED? IT'S DURING THIS FELLOWSHIP I STARTED USING THE ORBIT MODEL TO THINK ABOUT STEPS TO BUILDING A BIOBEHAVIORAL INTERVENTION PROGRAM OF RESEARCH AROUND THE SIGNIFICANT CLINICAL QUESTIONS YOU JUST HEARD. NOW I NEEDED A MORE FULLY DEFINED AND REFINED NARRATIVE METHODS TURN TO INTERVENTION. HERE WE ARE, THE PERSON-CENTERED NARRATIVE INTERVENTION. IT'S PREVIOUSLY DESCRIBED, COLLECTING OPEN-ENDED AUDIO RECORDED INTERVIEW BETWEEN THE TELLER AND RECEIVER. INTERVIEWER USES AUDIO RECORDING AND FIELD NODES MEMOS TO CREATE A FIRST PERSON WRITTEN NARRATIVE, THAT BECOMES A DOCUMENT. THIS DOCUMENT GOES BACK TO THE PERSON WITH ILLNESS, AND THE TEAM -- THE PERSON WITH ILLNESS DOES A MEMBER CHECK, SOMETHING WE USE IN QUALITATIVE METHODS TO CHANGE, ADD OR DELETE ANYTHING IN THAT NARRATIVE THEY WANT. ONCE THEY APPROVE IT, WE TAKE THAT WRITTEN NARRATIVE AND UPLOAD INTO THAT PERSON'S ELECTRONIC HEALTH RECORD. HEALTH CARE SETTINGS, WE WANT TO MAKE SURE THE CLINICIAN IS ALERTED THAT THIS NARRATIVE HAS BEEN UPLOADED TO EVALUATE HOW THIS CHANGES THAT INTERACTION BETWEEN THE TWO INDIVIDUALS. PERSON NEEDING CARE AND THE PERSON PROVIDING THAT CARE. SO AS PART OF THIS, FEASIBILITY STUDY HAD TWO MAIN CAMES, AGAIN LOOKING AT FACILITATORS, ASSESSING ACCEPTABILITY AND USABILITY FROM STAKEHOLDERS, THE PATIENT AND ACUTE CARE BEDSIDE NURSE. STILL USING THAT NARRATIVE ANALYSIS METHOD FROM MY DISSERTATION, THIS FEASIBILITY STUDY WAS GROUNDED AROUND SAFER FRAMEWORK WHICH FOCUSES ON IMPROVING QUALITY OF HEALTH CARE THROUGH IMPLEMENTATION OF INNOVATIONS INTO ROUTINE CLINICAL PRACTICE. AS WELL AS USES FIVE DOMAINS REFLECTED HERE TO ASSESS THOSE FACILITATORS OF THE INNOVATIONS. LET'S TALK ABOUT A FEW OF THE RESULTS. INTERVENTION CHARACTERISTICS, AVERAGE NARRATIVE INTERVIEW WAS 45 TO 60 MINUTES. WRITING OF THE FIRST PERSON NARRATIVE BY RESEARCH TEAM AND I TOOK 60 TO 90 MINUTES. THAT MEMBER CHECKING PROCESS FOR APPROVAL WAS ABOUT 30 MINUTES. AFTER THE APPROVAL IMMEDIATELY UPLOADED INTO EHR, NURSES REPORT AVERAGE OF TWO MINUTES TO READ NARRATIVE DURING THEIR BUSY DAY. DESPITE ACUTE CARE NURSE HAVING MANY ARMS DOING MANY THINGS, LET'S JUST HEAR A FEW OF THEM, VERBATIM DATA FROM THE NURSE EXIT INTERVIEWS WHAT THEY HAD TO SAY ABOUT INTEGRATING THIS PERSON'S NARRATIVE INTO THE CARE AND WHAT IT MEANT FOR THEM. ONE NURSE SAYS READING HISTORY HELPED YOU UNDERSTAND HOW TO DEAL WITH HIM BECAUSE WE HE FLAT OUT SAID I DON'T WANT YOU TO BEAT AROUND THE BUSH, GIVE IT TO ME STRAIGHT. ANOTHER NURSE STATED SO HELPFUL TO US, FOR OTHERS, PT, OT, NUTRITION, DOCTORS, INTERNS, ESPECIALLY FOR THEM THEY DON'T ALWAYS GET THAT OPPORTUNITY TO LEARN PERSONAL DETAILS ABOUT THEIR PATIENTS. ANOTHER NURSE SAID I GOT TO LEARN WHAT HE VALUE MOST IN LIFE, AND HEALTH CARE DECISIONS, AFTER READING THE STORY IT MADE SENSE BECAUSE I WAS LIKE THAT'S WHAT'S IMPORTANT TO YOU. ANOTHER NURSE SAYS EVERYTHING WAS JUST MORE PERSONAL, COMMUNICATING IN GENERAL SO MUCH EASIER. SO IF WE HAD TO DISCUSS MORE DIFFICULT THINGS ABOUT CARE IT WAS EASIER TO TALK ABOUT THOSE CHALLENGING ISSUES. ALL THE NURSE AND PATIENT EXIT INTERVIEWS HAD THIS WORD, CONNECTIONN THEM, DESPITE NONE OF THE EXIT VIEW CONNECTIONS HAD THE WORD CONNECTION SO WE WEREN'T ASKING ABOUT IT. THIS WAS BEST STATED BY A NURSE WHO SAID HAVING HIS STORY CONNECTED THE DOTS FOR ME, I'VE TAKEN CARE OF HIM MANY TIMES BEFORE AND INTERACTED WITH HIM, NOW IT MADE SENSE AFTER I READ HIS STORY. OVERALL THE STUDY WAS FEASIBLE IN ACUTE CARE SETTINGS, ACCEPTABILITY WAS 100%. YOU HEARD THAT THE FACILITATORS WERE IMPROVED COMMUNICATION AND CONNECTION. FOR THE NURSES THERE WAS A DEFINITE NEED FOR IMPROVING LOCATION OF THAT NARRATIVE IN THE PATIENT'S EHR. NURSE PARTICIPANTS COMPLETED THIS SYSTEM USABILITY SURVEY, OVERALL SCORE 89.71, OVER 90 IS SUPERIOR. EVALUATING THE INDIVIDUAL SCORES OF THOSE 10 ITEMS, ALL OF THEM ARE ABOVE THE SCORE OF 19 WITH EXCEPTION -- OF 90 EXCEPT NUMBER FIVE, FOUND THEM WELL INTEGRATED, A SCORE OF 56. THIS WAS CONSISTENT WITH NURSE EXIT INTERVIEW RESPONSES THAT SUPPORT NEED FOR PATIENT'S NARRATIVE TO BE LOCATED IN A MUCH MORE PROMINENT PLACE IN THE EHR. SO BUILDING ON THIS RESULT MY TEAM AND I SPENT TIME WORKING WITH OUR EPIC CLINICAL DECISION SUPPORT TEAM MEMBERS FOR IMPROVED INTEGRATION OF THE NARRATIVE INTO THE EHR. THIS IS BASED ON WHERE THE NURSES TOLD ME IT SHOULD BE WHEN WE FIRST LOG IN. THIS SLIDE IS A SNAPSHOT OF WHERE THE PATIENT'S STORY IS NOW œTHAT'S FOUND ON THE INITIAL LANDING PAGE, ABOVE ALLERGIES, BELOW THE PATIENT IDENTIFIERS. ONCE THE PATIENT'S NARRATIVE IS UPLOADED, THERE'S A ONE-TIME BEST PRACTICE ALERT THAT STATES GET TO KNOW YOUR PATIENT, FOR CLINICIANS, WHEN THEY OPEN THAT PERSON'S CHART. SO WHAT'S NEXT? GOING BACK TO THE ORBIT MODEL MY TEAM ANDRIY CONDUCTING OUR FIRST PROOF OF CONCEPT AS PART OF PHASE 2 TESTING OF PCNI, THIS IS FOCUSING ON COMPARING EFFECTS, TESTING PERSON-CENTERED OUTCOME, PATIENT'S PERSPECTIVE, TWO PROMIS MEASURES AND FOCUSING ON DATA, STAY TUNED FOR EFFICACY RESULTS, SUGGESTED READING GIVES MORE ABOUT THE PROTOCOL. LET'S PAUSE AND IMAGINE WITH ME A PERSON CENTERED HEALTH CARE CULTURE THAT PROVIDES MORE THAN JUST MEDICAL TREATMENT PLANS, THAT'S THE HOW THE PATIENT IS, ALSO PLANS OF CARE THAT MORE FULLY INCORPORATION A PERSON'S BELIEFS, VALUES, PREFERENCES. THAT'S THE WHO THE PATIENT IS. KEEPING THEM AT THE CENTER OF THE CARE THEY RECEIVE. FOR FUTURE DIRECTIONS I'LL CONTINUE TO BUILD THE PROGRAM OF RESEARCH ON DEVELOPMENT TESTING AND IMPLEMENTATION OF CO-CREATED PERSON-CENTERED NARRATIVES, TO PROVIDE OPPORTUNITIES FOR CULTURALLY SENSITIVE CARE TO EMPOWER THE PERSON AND CARE PARTNERS LIVING WITH SERIOUS ILLNESS TO BE HEARD AND UNDERSTOOD. IN CLOSING I'D LIKE LEAVE YOU WITH REMINDER CONSENSUS REPORT WE'VE HEARD ABOUT. THIS URGES US TO CONTINUE INTEGRATION, SOCIAL CARE, HEALTH CARE DELIVERY, WE MUST USE PATIENT-CENTERED CARE MODELS TO INCORPORATE A PERSON'S NARRATIVE. WITH GRATITUDE MY PROGRAM OF RESEARCH WOULD NOT BE POSSIBLE WITHOUT MANY PERSONS BEING PART OF MY STORY, FIRST AND FOREMOST ALL THE RESEARCH PARTICIPANTS, MENTORS ON THE PUBLICATIONS NOTED IN THE PREVIOUS SLIDES, AND WIN, MY SCHOLARLY HOME. SPECIFICALLY, THE NINR AND OFFICE OF PALLIATIVE CARE RESEARCH, DR. BANKS, ADAMS, AND MILLER. THANKS FOR LISTENING. AND THESE ARE MY CONTACT E-MAILS. PLEASE, PLEASE DON'T HESITATE TO REACH OUT IN THIS VIRTUAL WORLD. I'M ALWAYS HAPPY TO TALK ABOUT THE USE OF PERSON-CENTERED NARRATIVE INTERVENTIONS AND OPPORTUNITIES FOR COLLABORATIONS. >> THANK YOU FOR YOUR WONDERFUL PRESENTATIONS. SO THOUGHT PROVOKING AND WELL DONE. WE WILL HAVE A BREAK UNTIL 2:20 >> WELCOME BACK. DR. PEREZ-STABLE IS UNABLE TO JOINED BUT WE'RE PLEASED TO WELCOME DR. ANNA NAPOLES, SCIENTIFIC DIRECTOR NATIONAL INSTITUTE ON MINORITY HEALTH AND HEALTH DISPARITIES, JOINING FROM THE UNIVERSITY OF CALIFORNIA SERVED AS PROFESSOR AND BEHAVIORAL EPIDEMIOLOGIST IN DIVISION OF GENERAL INTERNAL MEDICINE, DEPARTMENT OF MEDICINE, SINCE 2001. SHE'S BEEN AT THE FOREFRONT OF DEVELOPING METHODS FOR TRANSATIONAL RESEARCH TO IMPROVE HEALTH OF DISPARITY POPULATIONS THAT BUILD COMMUNITY CAPACITY TO DIFFER EVIDENCE-BASED BEHAVIORAL INTERVENTIONS. I'VE HAD THE PLEASURE OF WORKING WITH HER FOR THE UNITE INITIATIVE AND MY RECENT ADDITION TO NIMHD RESEARCH PROGRAM, THOUGHTFULNESS HAS BEEN STRIKING SO IT'S REALLY A PRIVILEGE TO HAVE HER MODERATE OUR DISCUSSION. THANK YOU, DR. NAPOLESE. >> THANK YOU, DR. ZENK. YOU MADE ME SOUND BETTER THAN I SEE MYSELF. IT'S GREAT. WE ALL ASPIRE TO MEET OUR INTRODUCTIONS AND GLOWING ACCUMULATES TO LIVE UP TO THOSE. I WANT TO SAY I ADMIRE THE WORK PRESENTED, AND I DO THINK THERE WILL BE A VERY RICH AND INTENSE DISCUSSION AND I'M LOOKING FORWARD TO IT. I WANT TO THINK OUTSIDE THE BOX, I'M GOING TO START BY PRESENTING A QUICK QUOTE BECAUSE I THINK THIS IS A CRISIS THAT WE'RE OPERATING IN RIGHT NOW, THIS PAST YEAR HAS SHOWN US THAT. I FIND THIS TO BE VERY APPROPRIATE. SCIENTIFIC REVOLUTIONS ARE INAUGURATED BY A GROWN SENSE OFTEN RESTRICTED TO NARROW DIVISION OF SCIENTIFIC COMMUNITIES THAT EXISTING PARADIGM HAS CREASED TO FUNCTION ADEQUATELY IN THE EXPLORATION OF AN ASPECT OF NATURE. IN POLITICAL AND SCIENTIFIC DEVELOPMENT, THE SENSE OF MALFUNCTION THAT CAN LEAD TO CRISIS IS PREREQUISITE TO REVOLUTION. SO I THINK WHEN I READ THAT QUOTE I THINK OF THINGS THAT WE'RE PROBABLY IN A NARROW SEGMENT OF THE SCIENTIFIC COMMUNITY BUT CRITICAL BECAUSE WE'RE SEEING THE PARADIGMS, BIOMEDICAL MODELS THAT HAVE BEEN SUCH A GO-TO IN HISTORICAL TIMES, MAYBE BEING LESS RELEVANT NOW. THE WORK THAT WE'VE SEEN PRESENTED AT THE SEMINAR ATTEST TO NEED FOR NEWER WAYS OF THINKING, REVOLUTIONARY METHODS AND INCORPORATION AND CROSS-CUTTING SEGMENTS OF OUR SOCIETY, SOME OF THESE PUBLIC HEALTH INTERVENTIONS THAT HAVE PREVIOUSLY BEEN RELEGATED TO ONLY PUBLIC HEALTH SETTINGS. WE'RE AT A TIPPING POINT WHERE WE CAN GARNER ATTENTION TO STRUCTURAL AND RACIAL INEQUITIES IN THIS COUNTRY, AT A TIME WHEN WE KNOW THAT IT CAN MATTER AND MAKE A DIFFERENCE. REALLY HAS SOME IMPETUS BEHIND US. WE'RE CLEARLY IN A CRISIS THAT REQUIRES THESE REVOLUTIONARY APPROACHES TO IMPROVE AND ACHIEVE HEALTH EQUITY. DURING THE FIRST HALF OF 2020 THERE WAS AN ESTIMATED LOSS OF ONE YEAR CDC RECENTLY RELEASED STATISTICS FOR AFRICAN AMERICAN MALES LIKE EXPECTANCY DROPPED BY 3 YEARS, LATINO MALES DECREASE IS 2.4 YEARS. BLACK FEMALES SAW DECREASE IN LIFE EXPECTANCY OF 2.3 YEARS, AND LATINA FEMALES FACED DECLINE OF 1.1 YEARS, FOR EVEN LATINA POPULATIONS WHO HAD A RELATIVELY POSITIVE HEALTH PROFILE WE'RE SEEING IMPACT OF SOCIAL AND STRUCTURAL FACTORS TAKE THEIR TOLL. SO WE'RE IN A TIME WHEN THE FIELD OF NURSING SCIENCE RESEARCH IN NURSING SCIENCE IS SO CRITICAL AND AN IMPORTANT PART OF THE TAPESTRY THAT WILL MAKE UP SOLUTIONS TO THIS CRISIS. SO WITH THAT I'D LIKE TO OPEN UP THE CHAT. I WILL JUST READ QUESTIONS FROM THE CHAT FOR THE PANELISTS AND LOOK FORWARD TO THE DISCUSSION. THERE'S A QUESTION THAT SAYS I'M INTERESTED IN UNDERSTANDING HOW SHORT-TERM HEAVY STRESS ON NURSES DURING THE PANDEMIC MAY IMPACT THEIR ALLOSTATIC LOAD, I'M NOT SURE WHO THAT'S DIRECTED TOWARD ON THE PANEL BUT I WELCOME ANYONE TO RESPOND. PLEASE UNMUTE YOURSELF. >> WE KNOW ALLOSTATIC LOAD REFLECTS PHYSIOLOGICAL WEAR AND TEAR ON THE BODY, THERE'S NO ONE FEELING THAT NOW MORE THAN FRONT LINE NURSES AND HEALTH PROFESSIONALS. SO, STUDIES I'M SURE ARE IN PROCESS RIGHT NOW, WE'RE STILL IN THE MIDST OF THE PANDEMIC, AND WE'LL SEE MORE BEING RELEASED IN THE SCIENTIFIC LITERATURE, BUT IT'S DEFINITELY I WANT TO SAY SOMETHING WE HAVE VERY LITTLE DATA ON AND WILL CERTAINLY BECOME AN INCREASING PRIORITY AS WE RIDE OUT THE REST OF THE PANDEMIC. >> IS DR. HUGHES ON? I THINK IT WAS YOUR PRESENTATION THAT TALKED ABOUT ALLOSTATIC LOAD. IS THAT RIGHT? I DON'T KNOW IF SHE'S ON. I SEE HER. CHANITA, ARE YOU ON? MAYBE SHE'S JUST DELAYED GETTING BACK FROM BREAK. >> MAYBE WE CAN COME BACK TO THAT IF SHE COMES BACK. NEXT QUESTION IS FOR DR. BAIDAL. ARE THERE WAYS TO PREPARE (INDISCERNIBLE) EDUCATION HEALTHY RECIPES, ARE THOSE WAYS PROVIDED WITH INCREASED ACCESS TO FOOD? >> YEAH, THIS RAISES AN IMPORTANT ASPECT OF CONSIDERING ALSO KIND OF CULTURALLY APPROPRIATE FOODS AND MATTERS RELATED TO FOOD THAT I DIDN'T GET INTO. TO ANSWER THE QUESTION, WHEN DOING THE PILOT PROGRAM WITH THE MOBILE FOOD TRUCK, WE WERE ABLE TO -- THAT WAS A SPECIFIC TIME AND PLACE PEOPLE HAD TO COME TO SELECT THEIR FOOD, WE WERE ABLE TO HAVE OUR COMMUNITY DIETITIAN DO FOOD DEMOS, AND WE WERE ABLE TO INCLUDE RECIPES, BUT NOW WITH THIS VERY RAPID CONVERSION TO FOOD BOXES AND FOOD DELIVERIES, THE MOST WE CAN KIND OF DO IS INCLUDE RECIPES. AND SO I THINK THAT THESE ARE THINGS THAT FOLKS IN MY LINE OF WORK THAT DO ANY TYPE OF NUTRITION COUNSELING OR EDUCATION THINK ABOUT OFTEN, BUT ALSO CONSIDERING MATTERS RELATED TO LITERACY AND LANGUAGE ALSO HAVE TO BE CONSIDERED. >> THANK YOU. THIS QUESTION HERE FOR I THINK DR. COATS, FROM DR. COATS, TO DR. HATAF. YOUR PARENTHESES WAS WONDERFUL. CURIOUS IF YOU EVALUATE THE WHO IN THOSE PROVIDR NOTES AND WHETHER YOU WERE ABLE TO COMPARE OR CONTRAST ACROSS TYPES OF PROVIDERS, PHYSICIANS, P.A.s AND SO FORTH, AND NURSE PRACTITIONERS? >> YOU MEAN WHO DOCUMENTED? WE LOOKED INTO THE PATTERNS OF TYPE OF PROVIDERS AND PHYSICIANS DID MOST OF THE DOCUMENTATION, SOCIAL WORKERS AND NURSES. WE LOOKED AT DIFFERENT PRACTICES ACROSS THE JOHNS HOPKINS INSTITUTION AND IDENTIFIED PRACTICE OF DOCUMENTING SOCIAL NEEDS VARIED A LOT BUT THERE WERE SOME OUTPATIENT CLINICS, SPECIFICALLY LOOKED -- DOCUMENTED THE SOCIAL NEEDS, DEPENDING ON THE TYPE OF PROGRAMS THAT THE CLINICS HAVE TO ADDRESS THE SOCIAL NEEDS, THE PATTERN OF ASKING AND DOCUMENTING THEM VARIED A LOT. FOR INSTANCE, HOW THE SITUATION SPECIFICALLY HOMELESSNESS IS SOMETHING THAT HOPKINS EVALUATES, IN THE COURSES THEY HAVE A LOT OF HOMELESS PATIENTS WITH FREQUENT EVENTS, SO THEY HAVE THIS PROCESS OF BASICALLY ASSESSING HOUSING STATUS OF ALL THE PATIENTS AND THEY HAVE RELATIONSHIP WITH HEALTH CARE FOR THE HOMELESS INVOLVED WITH REFERRAL SO THOSE TYPE OF LOCALIZED PROGRAMS THAT HOPKINS HAS IN DIFFERENT HOSPITALS AND ALSO CLINICS ALSO AFFECT PATTERNS OF ASKING AND DOCUMENTING THE SOCIALNESS BY PROVIDERS IN DIFFERENT LOCATIONS. >> THANK YOU. AND NEXT QUESTION HAS TO DO WITH THE DELIVERY OF FAMILY-CENTERED CARE, VERY IMPORTANT MODEL AND CONSTRUCT. DR. COATS, CAN YOU PLEASE TALK ABOUT IMPLICATIONS AND PERHAPS FUTURE DIRECTIONS OF YOUR WORK FOR THE DELIVERY OF FAMILY-CENTERED CARE. WE OFTEN TALK ABOUT IT, IT'S HARD TO OPERATIONALIZE. >> SURE. THAT'S A GREAT QUESTION. THANK YOU FOR THAT. YOU KNOW, IT'S BEEN INTERESTING BECAUSE I'M AROUND THAT PATIENT AS PERSON, THOSE ARE THE OUTCOMES I'M STUDYING NOW. BUT IN THE PRACTICAL CAPTURING OF THESE NARRATIVE INTERVIEWS WE'V ALLOWED FAMILIES TO BE PRESENT AND THEY HAVE AT TIMES, WHEN THE WRITTEN DOCUMENT HAS BEEN CREATED, ASKED US FOR MULTIPLE COPIES OF NARRATIVES TO PASS TO THEIR 20 FAMILY MEMBERS BECAUSE THEY WANTED THEIR FAMILY MEMBERS TO HEAR WHAT HAVING THIS ILLNESS HAD MEANT TO THEM. SO, IT'S NOT SPECIFIC OUTCOMES THAT I'M LOOKING AT, THE FAMILY-CENTERED MODEL, BUT DEFINITELY WILL HOPEFULLY BE PART OF FUTURE OUTCOMES. >> AND I'LL ADD. IN YOUR PRESENTATION YOU MENTIONED THAT MEASUREMENT THAT WE MIGHT EXPAND OUR PERSON-CENTERED APPROACHES TO FOCUS ON HOUSEHOLDS AND HOW MIGHT THAT OCCUR, ANY THOUGHTS ABOUT THAT? >> THANK YOU. I THINK BEING IN PEDIATRICS, OUR PATIENT LISTED IN THE MEDICAL RECORD IS USUALLY NOT THE PERSON GETTING US THE HISTORY. IT'S BEEN REALLY A LARGE FOCUS HOW DO WE LINK MOTHERS TO INFANTS. I THINK THERE'S NO EASY WAY TO LINK FAMILY MEMBERS AND DATASETS OR IN THE ELECTRONIC MEDICAL RECORD, FROM A RESEARCH PERSPECTIVE. AND YET IN A NUMBER OF QUALITATIVE STUDIES AT LEAST FAMILIES REPORT AT LEAST PERCEIVED INFLUENCE OF NON-MATERNAL CAREGIVERS, ON CHILD BEHAVIORS. SO OTHER THAN HAVING MORE OF A QUESTION ABOUT HOW DO WE DO THAT, HOW DO WE EXAMINE AND HOW DO WE INVOLVE EXTENDED CARETAKERS OR OTHER FAMILY MEMBERS, I DON'T HAVE ANY REAL ANSWERS. IT'S JUST MORE QUESTIONS. >> GOOD POINT. ESPECIALLY IN MINORITY COMMUNITIES WHERE THE WAY INTO THE HOME OF, FOR EXAMPLE, AN ELDER OR OLDER ADULT THAT IT'S ADULT CHILDREN, THROUGH THE ADULT CHILDREN AS WELL. DEFINITELY AN IMPORTANT CONSIDERATION, CARE PROVISION AS WELL AS IN RESEARCH. I'M GOING TO CIRCLE BACK, IT WAS AN IMPORTANT QUESTION FOR DR. HUGHES-HALBERT. THERE WAS A QUESTION ASKED, I THINK YOU WERE ON BREAK, ABOUT WHETHER YOU WOULD EXPECT TO SEE AND IF THERE'S ANYTHING BEING DONE IN THE AREA OF ALLOSTATIC LOAD ON FRONTLINE NURSING AND HEALTH CARE PROFESSIONAL STAFF IN THE MIDST OF THE PANDEMIC. YOU'RE MUTED. PLEASE UNMUTE YOURSELF. >> I'M NOT HAVING A GOOD DAY TODAY. [LAUGHTER] I DID SEE THE QUESTION IN THE CHAT BOX, AND I'M NOT AWARE OF ANY WORK THAT'S BEEN DONE ON STRESS RESPONSES, ALLOSTATIC LOAD AMONG FRONT LINE WORKERS. AND I THINK AS -- MADE AWARE OF PROGRAMS TO ESTABLISH LIKE LONG-TERM COVID CLINICS FOR PATIENTS, I THINK ONE OF THE THAT'S THAT OCCURRED TO ME SEEING THE COMMENT WAS THAT IT'S EQUALLY IMPORTANT TO UNDERSTAND EFFECTS OF COVID AD DELIVERING COVID AS A CARE AS A FRONTLINE WORKER, HOW THAT'S IMPACTING NURSES, PHYSICIAN ASSISTANTS, THE WHOLE RANGE OF HEALTH CARE PROVIDERS, IN TERMS OF STRESS RESPONSES AND STRESS REACTIVITY. SO I THINK IT'S NOT A FOCUS THAT I'M AWARE OF BUT I THINK IT'S CERTAINLY ONE THAT COULD BE -- THAT WOULD MAKE A COMPELLING COMPONENT OF THE A RESEARCH PROGRAM. >> PTSD. >> ABSOLUTELY. >> FOR SURE. >> ABSOLUTELY. >> SO, THANK YOU FOR YOUR ANSWER. THERE'S A GENERAL QUESTION FOR EVERYONE, BIG PICTURE QUESTION, BUT I THINK IS A GREAT ONE, WHICH IS IN THE PAST TWO DAYS WE'VE HEARD MANY COMPELLING PRESENTATIONS ON THE INFLUENCE OF STRUCTURAL RACISM, AND OTHER STRUCTURALISMS ON HEALTH EQUITY. ALL OF US ARE CONVINCED AND WE'RE PART OF THE CHOIR BASICALLY, PREACHING TO THE CHOIR, SO ARE WE GOING TO CONVINCE FUNDERS AND GRANT REVIEWERS, ET CETERA, STILL SEEM TO BE STUCK IN THESE ARCHAIC I'M GOING TO SAY BIOMEDICAL MODELS CONSIDERING RACE AS A BIOLOGICAL VARIABLE, WHAT'S OUR WAY FORWARD? >> . >> THIS IS RACHEL. THERE HAS BEEN SOME IMPROVEMENT. SOMEONE NOTED IN THE BEGINNING, NIMHD JUST PUT OUT OR IS ABOUT TO PUT OUT AN RFA ON STRUCTURAL RACISM. I THINK WE'RE SEEING A CHANGE AT NIH IN THIS SPACE. KNOW FOLKS I WORK WITH AT NIDDK ARE INTERESTED IN FUNDING RESEARCH IN THIS SPACE. SO THERE IS SOME MOVEMENT WHICH IS GREAT. IN TERMS OF BREAKING FOLKS OUT OF BIOMEDICAL MODEL, THAT'S TRICKIER. BUT I THINK SOME OF THE ANSWER LIES IN DATA. WE JUST KEEP SHOWING FOLKS LIKE YOU'RE NOTREACHING THE -- YOUR CARE QUALITY GOALS AND THE REASON IS BECAUSE OF FACTORS THAT ARE NOT CLINICAL, NOT TECHNICALLY CLINICAL. I MEAN, WE'VE FRANKLY -- THE SHIFT IN INTEREST TO LOOK AT SOCIAL FACTORS HAS GROWN OUT OF THE SHIFT TO PAY FOR PERFORMANCE, ESPECIALLY AT FOLKS LIKE PRIVATE CARE SETTINGS, NOT NECESSARILY COMMUNITY HEALTH CENTERS WHERE THERE'S BEEN AN INTEREST IN PATIENTS CONTACT BUT FOR SETTINGS WHERE THERE'S SOME PROFIT INVOLVED IF THEY ARE FINDING I'M NOT GETTING PAID AS MUCH AS I WOULD LIKE TO BE, WHY AM I NOT ABLE TO GET WHAT I WANT IT'S ALWAYS BECAUSE HEALTH IS DRIVEN BY CLINICAL CARE. YOU KNOW, IN A LOT OF CIRCUMSTANCES. THAT MIGHT BE A GREAT IMPROVEMENT. IT MIGHT HELP US MAKE THAT SHIFT. MONEY TALKS. I HATE IT. IT'S NOT WHY I THINK WE SHOULD FOCUS ON THIS STUFF BUT IF THAT'S WHAT GETS PEOPLE TO PAY ATTENTION TO CAUSES OF HEALTH, FINE, SO BE IT. SO NOT TRYING TO BE SIMPLISTIC, THIS IS A COMPLICATED CHANGE. YEAH, BUT THERE IS SOME CHANGE HAPPENING. I'M GOING TO PUT A LINK TO THE NATIONAL ACADEMY THAT LAURA AND I TALKED ABOUT THIS MORNING, WELL MORNING FOR US, BECAUSE THERE'S A CHAPTER ON IMPLEMENTATION BARRIERS THAT MIGHT BE HELP FOLLOW FOR YOU. CHANITA, I DIDN'T MEAN TO CUT YOU OFF >> I WAS GOING TO ECHO AND AGREE WITH YOUR COMMENTS. I DO THINK HAVING AN EMPHASIS ON STRUCTURAL RACISM AS A PRIORITY FOR FUNDING IS CRITICALLY IMPORTANT AND I THINK, YOU KNOW, WHAT'S -- LOOK, AS PART OF THAT I THINK BECAUSE OUR INDIVIDUAL AND SOCIAL AND COLLECTIVE CONSCIOUSNESS HAS BEEN MOVED, IT'S IMPACTING A FEDERAL AGENCY, I THINK IS REALLY IMPORTANT. I DO HAVE CONCERNS, THE REASON I ASKED THE QUESTION I DID YESTERDAY, STRUCTURAL RACISM IS SOMETHING THAT'S BEEN WITH US THROUGH GENERATIONS. I WORRY, I HAVE -- NOT WORRY, BUT I HAVE CONCERNS ABOUT WHAT ARE THE EXPECTATIONS FOR FIVE-YEAR GRANT TO BE ABLE TO ADDRESS SOMETHING THAT HAS BEEN PERPETUATED THROUGHOUT GENERATIONS. SO I'M CURIOUS AND EXCITED TO SEE THE TENOR AND NATURE OF THE FUNDING ANNOUNCEMENTS THAT COME OUT BECAUSE IT WILL BE -- SEVERAL OF THEM, WELL, YEAH, COULD CERTAINLY RESPOND TO THAT PARTICULAR CALL BUT FIXING STRUCTURAL RACISM, THAT'S A TALL ORDER. I'M NOT SURE HOW, YOU KNOW, AN INVESTIGATIVE TEAM WILL DO IT. NOT TO BE SOMEONE THROWING DARTS AT A VERY IMPORTANT SHIFT IN HOW WE'RE THINKING ABOUT FUNDING, I DO THINK WHAT WILL BE ESSENTIAL IN THESE TYPES OF INTERVENTION ON STRUCTURAL RACISM IS ACTUALLY MEANINGFUL COMMUNITY ENGAGEMENT BECAUSE IN THE PROCESS OF THE DEVELOPING THE RESEARCH QUESTION, DEVELOPING THE INTERVENTION, AND EVALUATING WHATEVER INTERVENTION HAS BEEN PROPOSED AS A WAY TO ADDRESS STRUCTURAL RACISM, AND THE REASON I SAY THAT IS BECAUSE, YOU KNOW, WE -- IF YOU THINK ABOUT ONE OF THE PRIMARY WAYS TO ME, STRUCTURAL RACISM IS DEFINED IS BASED ON HOUSING, REDLINING, SEGREGATION, ALL OF THE THINGS THAT ARE REALLY BASED ON COMMUNITIES AND HOW COMMUNITIES ARE DEFINED. TO ME I THINK IT WOULD BE AN EFFORT THAT'S IMPLEMENTED IN VAIN IF WE DON'T INVOLVE PEOPLE FROM THE COMMUNITY, RESIDENTS FROM THE COMMUNITY, IN THOSE INTERVENTION EFFORTS. YOU CAN'T TELL SOMEONE HOW TO CHANGE THE NEIGHBORHOOD IF YOU DON'T LIVE IN THE NEIGHBORHOOD. >> EXACTLY. ANY OTHER COMMENTS? ANYONE ELSE? >> YEAH, I HAVE A COMMENT. I THINK THINKING ABOUT THAT SHIFT, AND I REMEMBER I'VE BEEN A CLINICIAN FOR MANY YEARS, THE TRIPLE AIM, THEN WE GOT THE QUADRUPLE AIM, THINKING ABOUT THAT IMPROVED PATIENT EXPERIENCE SO MY HOPE IS THAT WE REALLY ARE, DR. HALBERT AS YOU TALKED ABOUT, GETTING OUT TO THE COMMUNITY, TO THE PERSON RECEIVING THE CARE THAT WE IN HEALTH CARE THINK THIS IS FABULOUS, BUT MAYBE IT'S NOT, FOR THE PERSON THAT'S RECEIVING THE CARE AT THE END OF THAT CONTINUUM. SO I'M HOPEFUL THAT THE SHIFT HAS BEEN COMING AND WILL CONTINUE TO COME TO INCORPORATE THAT PERSON AND FAMILY-CENTERED CARE INTO IMPROVING THE HIGH-QUALITY HIGH-VALUE CARE AND FOR WHO. IT'S FOR THAT PERSON AND THEIR FAMILY. >> SOMEONE ELSE HAD A COMMENT. >> I WANTED TO ADD I AGREE WITH RACHEL THAT THE WAY TO MAKE PROBABLY HEALTH SYSTEM AND LEADERSHIP SENSITIVE TO THE ISSUE OF RACISM IS TO SHOW THAT ITS IMPACT ON THEIR PERFORMANCE AND THEIR COST, IT'S VERY UNFORTUNATE WE NEED TO KIND OF LINK IT TO HOW MUCH IT COSTS THE HEALTH SYSTEM NOT TO HAVE LIKE AN EQUITABLE APPROACH TO PHS ISES BUT NOT EVERYBODY HAS THE SAME MORAL STAND OR ETHICAL PRINCIPLES, BUT EVERYBODY EVERYBODY KNOWS COST OF CARE IS HIGH FOR HEALTH SYSTEM, MORE DIFFICULT TO NEED QUALITY MEASURES IN -- IF THEY DON'T ADDRESS CHALLENGES OF THEIR PATIENTS. A LOT OF RESEARCH ON THE IMPACT OF RACISM OR SERVICES PROVIDED THOSE ARE THE TYPE OF FINDINGS THAT KIND OF RESONATE WITH THEM, AND CONVINCES THEM THAT NO MATTER WHAT YOUR OWN ETHICAL STAND IS FOR YOUR ORGANIZATION IN ORDER TO STAY COMPETITIVE IN THE FIELD YOU BASICALLY NEED TO FIND A MORE SYSTEMATIC WAY OF ASSESSING AND ADDRESSING THESE NEEDS. MAYBE I'M LESS PHILOSOPHICAL, MORE PRAGMATIC ABOUT HOW TO ADDRESS IT, AND I FEET -- FEEL LIKE THIS MIGHT BE A COMMON GROUND BECAUSE MANY PEOPLE THAT ARE NOT THE MINORITY MAYBE DON'T FEEL MAKING ANY CHANGE IN THEIR STATUS AS LONG AS IT DOESN'T IMPACT MAYBE THEIR LIFE OR THEIR ORGANIZATION DIRECTLY. >> ARE THERE ANY OTHER COMMENTS BEFORE WE MOVE TO THE NEXT QUESTION? >> I THINK IT'S SO COMPLICATED, I REALLY APPRECIATE THIS DIALOGUE. FOR ME WHAT I HAD BEEN STRUGGLING WITH, THERE ARE SO MANY LEVELS TO THIS. AND WITHIN HEALTH CARE AND BIOMARKER RESEARCH IT'S HELPFUL TO HAVE A FRAMEWORK WHERE WE CAN MAYBE MOVE THE NEEDLE, BUT THEN OTHER ASPECTS WHERE WE NEED TO THINK ABOUT OTHER SECTORS, AND LEAN ON THEM TO FINANCE PUBLIC HEALTH ON ARE SCHOOLS OR CHANGES TO THE BUILT ENVIRONMENT BECAUSE WE'RE NOT GOING TO SOLVE IT ALL. THIS IS ECONOMIC POLICIES. SOMEONE PUT UP THAT PICTURE EARLIER OF THESE ARE THE POLICIES, LEADING TO POVERTY, AND THOSE ARE NOT HEALTH CARE POLICIES. ABSOLUTELY WE SHOULD BE DOING AND PUSHING OUR LEADERSHIP TO DO EVERYTHING THEY CAN TO ELIMINATE RACISM WITHIN OUR ORGANIZATIONS AND ALSO I THINK TO ADVOCATE FOR OTHER SOURCES TO INVEST AS WELL INTO THIS ASPECT OF HEALTH. >> THAT'S WHY I HAD OPENED PRECISELY WITH THE QUOTE FROM THOMAS KUHN, A TIME FOR SHIFTING PARADIGMS AND SHIFTING REVOLUTIONS. COVID IS POINTING THAT OUT SO DRASTICALLY, EFFECTS OF MANY CENTURIES OF STRUCTURAL RACISM IN OUR COUNTRY. ANY OTHER COMMENTS BEFORE WE MOVE ON? THE NEXT ONE IS I THINK RELEVANT FOR DR. HALBERT, HATIF AND ROSSETTI, SOCIAL RISK SCREENING AND HOW WE APPLY SOME OF THAT USING BIG DATA FROM ELECTRONIC HEALTH RECORDS. THE QUESTION IS SYSTEMS ARE SET UP TO FACILITATE BILLING, NOT COLLECT USABLE DATA FOR CLINICAL PURPOSES NECESSARILY. HOW CAN WE WORK WITH BIG EHR COMPANIES LIKE EPIC TO FACILITATE DATA COLLECTION FOR RESEARCH PURPOSES? I WOULD SAY ALSO FOR ADDRESSING THE SOCIAL NEEDS OF OUR PATIENTS. >> YEAH, I'M HAPPY TO JUMP IN HERE. WE KNOW WE HAVE A HUGE PROBLEM OF DOCUMENTATION BURDEN. CLINICIAN BURNOUT, RIGHT? A HUGE PROBLEM. A BIG DRIVER OF THAT IS DOCUMENTATION BURDEN. AND SO WE ACTUALLY HELD A SYMPOSIUM OVER THE PAST MONTH AND A HALF ON REDUCING DOCUMENTATION BURDEN BY 75% IN THE NEXT FIVE YEARS. IT WAS FUNDED BY NLM AND WE HAD GREAT PARTICIPATION FROM VARIOUS STAKEHOLDERS THROUGHOUT THE COUNTRY INCLUDING PROFESSIONAL ORGANIZATIONS, AS WELL AS CMS, OMC, AND SO FORTH, TO REALLY ACTUALLY IDENTIFY ACTIONS THAT WE CAN TAKE TO DO THIS. PART OF THIS SYMPOSIUM WE HAD A SPECIFIC TASK FORCE ON DIVERSITY, EQUITY, AND INCLUSION, THERE WERE SOME REALLY INTERESTING AND IMPORTANT POINTS MADE. WE WANT TO REDUCE THE AMOUNT OF DATA ELEMENTS OUR CLINICIANS NEED TO DOCUMENT, RIGHT? BUT AS WE DO THAT WE HAVE TO REFLECT ON WHAT ARE SOME ACTUALLY NEW CONCEPTS AND NEW DATA THAT WE WANT TO GET INTO THE RECORD? AND SO THERE COULD BE THAT TENSION OF WE ACTUALLY NEED TO BUILD NEW AS WELL AS TAKE AWAY THE OLD BECAUSE WE'RE CERTAINLY LEARNING ABOUT THE THINGS WE'RE NOT CAPTURING AND ATTENDING TO IN CLINICAL CARE AND I THINK PRESENTATIONS TODAY, YOU KNOW, WERE SPEAKING TO THAT. SO THERE'S ABSOLUTELY A BIG RECOGNITION WITHIN THE FIELD. WHEN I SAY THE FIELD I MEAN THE HEALTH CARE FIELD IN GENERAL THAT WE NEED TO CHANGE OUR ELECTRONIC HEALTH RECORDS. THIS IS RECOGNIZED BY THE EHR VENDORS TOO WHO ARE SOMETIMES TIED TO DIFFERENT REGULATIONS AND BILLING REQUIREMENTS, RIGHT? SO THERE ARE A LOT OF THINGS AT PLAY HERE. BUT REALLY SOME FINDINGS, TO SUMMARIZE, VARIOUS ASPECTS TO CHANGE, WE HAVE TO CHANGE BILLING ASPECTS WHICH SOME RECENTLY WERE CHANGED AND HAVE GOTTEN BETTER. I WOULD HAVE TO CHANGE REGULATION. SO WHAT'S COMING FROM, YOU KNOW, JOINT COMMISSION, LOCAL LEVEL. WHAT DO WE THINK WE HAVE TO DOCUMENT BUT DON'T ACTUALLY HAVE TO DOCUMENT, BECAUSE SOMETIMES THERE'S AMBIGUITY IN REGULATION OR INTERPRETATION. WE HAVE THIS CATEGORY OF WE'VE DONE IT TO OURSELVES, MEANING OUR HEALTH SYSTEMS, BUILD IN CONFIGURATIONS INTO RECORDS AND DATA ELEMENTS TO BE DOCUMENTED BUT DON'T NEED TO BE CAPTURED. AND CERTAINLY AS NURSES I CAN SPEAK AS A FORMER ICU NURSE, IF IT'S PREVENTED YOU, YOU FEEL YOU NEED TO COMPLETE IT, RIGHT? WE WANT TO SUPPORT OUR NURSES, END USERS, THAT IN THE CONFIGURATION OF OUR EHRs TO NOT ADD TO THAT BURDEN THAT THEY HAVE TO COMPLETE ALL OF THIS. SO, AS WE TAKE AWAY SOME OF THIS DATA THAT HASN'T SERVED US WELL, WE STILL WANT TO HAVE ROBUST DATA AND INFORMATION WHERE WE CAN LEARN, RIGHT? SO SOME IS IN REAL TIME. WORKING WITH SOCIAL BEHAVIORAL DETERMINANTS OF HEALTH. BUT OTHERS, OTHER DATA IS PRECISION MEDICINE AND REALLY IMPORTANT EFFORTS IN THAT REGARD. SO IT'S -- SO IT'S A RECOGNIZED PROBLEM. WE HAVE A LOT TO DO. BUT WE DO HAVE GROUPS THAT ARE ALIGNED WITH THE GOAL OF OPTIMIZING AND REVAMPING OUR EHRs, AND PART OF THAT, A REALLY IMPORTANT PART OF THAT, IS TO RECOGNIZE THE VARIOUS KIND OF DEI CONCEPTS THAT WE NEED TO INCORPORATE INTO OUR RECORD. >> THANK YOU. DOES ANYONE ELSE HAVE ANY COMMENTS BEFORE WE MOVE ON? >> I WOULD ALSO SAY DOING MORE RESEARCH ON USING EHR DATA TO ANSWER SPECIFIC QUESTIONS, PERHAPS TO IDENTIFY THE AREAS OF GAP, PROBABLY WORKING WITH EHR TEAM IN YOUR INSTITUTION TO FIGURE OUT HOW TO ADDRESS SOME OF THOSE. OF COURSE, THAT EHR IS NOT DESIGNED TO COLLECT VERY HIGH-QUALITY RESEARCH DATA OR EVEN FOR THE CLINICAL PURPOSES, SOMETIMES IT HAS DIFFICULTY TO MEET THE NEEDS BUT MY EXPERIENCE HAS BEEN EXTRACTING MORE AND MORE DATA FROM THE EHR HAS SHOWN LIKE AREAS THAT NEED IMPROVEMENT FROM THE RESEARCH PERSPECTIVE. AND EHR COMPANIES ARE SOMEHOW SENSITIVE TO THE FACT THAT EHR IS MOVING TOWARDS KIND OF SUBSTITUTING A LOT OF THIS ONE-TIME ONLY NEEDED SURVEYS THAT WE RUN. SO THAT WOULD BE ANOTHER WAY OF KIND OF APPROACHING, MAKING RECOMMENDATIONS FOR IMPROVING THE QUALITY AND IDENTIFYING THE GAPS. >> THERE ARE A FEW COMMENTS. DR. GOLD, EPIC HAS TOOLS TO SUPPORT THIS COLLECTION OF DATA, RESEARCH DATA, WITHIN A GIVEN EHR CLIENT AS WELL AS ALL EPIC RESEARCH. >> I DIDN'T MEAN TO CUT YOU OFF. >> GO AHEAD. I'M GLAD YOU JUMPED IN. >> EPIC IS THE BIG GUY AND NOT CHEAP. BUT JUST -- THERE IS MOVEMENT. EPIC IS TRYING TO MAKE THIS DOABLE. IT STILL REQUIRES HAVING EXPERTISE ON YOUR TEAM OF ABLE TO USE EVEN THE EPIC TOOLS, LIKE SLICE OR DICE, IT'S A TOOL FROM EPIC SET UP TO LET YOU LOOK AT YOUR OWN DATA IN A MEANINGFUL WAY AND THEY DO HAVE A NATIONAL RESEARCH INITIATIVE THAT I DON'T THINK IT'S GOTTEN REAL LEGS GOING BUT STARTING. THAT SAID, MAYBE WE USE COMPETITION AMONGST THE EHR VENDORS TO LEVERAGE. IF YOU'RE NOT USING EPIC GO TO THE OTHERS AND SAY HOW COME YOU'RE NOT PROVIDING WHAT EPIC'S PROVIDING? AGAIN, I'M NOT TRYING TO SAY THIS IS SIMPLE. IT'S NOT SIMPLE. THERE IS MOVEMENT IN THE RIGHT DIRECTION. JUST WE'RE NOT WHERE WE NEED TO BE YET. >> I'LL JUMP IN. THE EHR VENDORS TRY TO DEVELOP TOOLS USEFUL AND USABLE TO CLINICIANS AND ADMINISTRATORS FOR REFUSING TO ADD REALTIME REPORTS AND RESEARCHERS, IT DOES HAVE TO BOIL DOWN TO A BUSINESS CASE FOR THEM. I MEAN, THEY ARE COMPANIES. AND ONE CHALLENGE THAT ONCE YOU ADOPT AN EHR IT'S A BIG EFFORTS TO GO TO A DIFFERENT ONE, RIGHT? SITES ARE PRETTY WELL INVESTED IN THE EHR THAT THEY HAVE. BUT YOU CAN LOOK AT THERE IS A LOT OF GREAT DATA SCIENCE WORK THAT USES DATA FROM EHRs. A KEY IS TO USE -- FROM MY PERSPECTIVE USE THAT RAW DATA FROM THE -- EXTRACT IT YOURSELF FROM THE DATABASE, RIGHT? SO YOU'RE NOT ALWAYS USING THESE TOOLS THAT ALREADY EXIST, WITHIN THE DATABASE, BUT YOU'RE CURATING IT, YOU'RE LOOKING AT IT, AND YOU'RE VALIDATING IT. WHEN I SAY YOU, THAT'S A DATA SCIENTIST WITH CLINICAL DOMAIN EXPERT. THAT MAY BE A CLINICAL NURSE, MAY BE A PHYSICIAN, DEPENDS ON THE CONTEXT OF THE DATA THAT YOU'RE USING, BUT YOU CAN ANSWER A LOT OF IMPORTANT RESEARCH QUESTIONS WHEN DO YOU THAT, BUT IT'S SO INCREDIBLY IMPORTANT TO HAVE ALL OF THAT DOMAIN EXPERTISE BECAUSE WE KNOW THERE ARE QUALITY ISSUES, RIGHT? AND IN A CLINICAL END USER CAN PICK UP ON SOME REALLY KEY QUALITY ISSUES THAT DATA SCIENTIST WON'T PICK UP ON, AND IT'S QUITE AMAZING HOW THAT WORKS AND HOW THAT COLLABORATION CAN REALLY LEAD TO SOME GOOD WORK. >> DR. GOLD, YOU LISTED REFERENCES, I'D LIKE TO LEARN NOT SPECIFIC METHOD BUT LINKING PARENT AND CHILD DATA. >> OH, OKAY. I'LL ANSWER THAT AND QUICK RESPONSE TO SOMETHING THAT WAS SAID. THERE WAS A COMMENT MADE EARLIER ABOUT HOW HARD IT IS TO LINK PARENTS AND CHILD IN EHRs, I WANTED TO NOTE SOME YEARS AGO I WROTE A PAPER WITH COLLEAGUES ON PRELIMINARY METHODS FOR DOING THAT BUT IT MIGHT BE USEFUL, I PUT IT IN THE CHAT. THAT'S ALL. IT WAS NOT EASY. IT WAS A PRETTY CHALLENGING PROCESS BUT IF YOU'RE INTERESTED IN SEEING HOW WE TOOK THAT ON, YOU'RE WELCOME. THERE'S A REFERENCE. JUST QUICKLY RESPONDING TO THE COMMENT THAT SARAH MADE ABOUT DOCUMENTATION OVERLOAD, ASKING SO MUCH OF PEOPLE, I WOULD POINT FOLKS TO THE NATIONAL ACADEMIES REPORT THAT LAURA GOTTLIEB AND I WORKED ON, A WHOLE CHAPTER ABOUT EXACTLY THAT AND DIFFERENT STRATEGIES. SO PLEASE HOPEFULLY THAT WILL BE USEFUL. PUT THAT IN THE CHAT AS WELL. >> ANOTHER, FAMILIES DO SO MUCH FOR CAREGIVING WORK FOR SERIOUS ILLNESS AND EVERYDAY MANAGEMENT OF CHRONIC CONDITIONS ACROSS THE LIFESPAN. THERE'S A QUESTION, I'LL POSE TO ALL THE PANELISTS, CAN I FOLLOW UP ON THAT AND ASK ABOUT HOW YOU THINK ALLOSTATIC LOAD IS AS A MEASURE OF SOCIAL DETERMINANTS OF HEALTH AND WHETHER IT COULD BE A SUBSTITUTE FOR MORE DETAILED COLLECTIONS OF DATA ABOUT STRESSORS, HOW REDUNDANT ARE THEY, HOW. >> YEAH, SO THAT'S A GREAT QUESTION. THAT'S THE WHOLE REASON FOR OUR CENTER, ACTUALLY. WE'RE EXPLORING THAT NOW CURRENTLY WITH OUR DATA ACROSS THREE DIFFERENT STUDIES COLLECTING ALLOSTATIC LOAD, USING EHR AND DATA COLLECTED THROUGH SORT OF LABORATORY SO, YOU KNOW, I BELIEVE THAT -- I DON'T KNOW THAT I WOULD WANT TO GET TO A POINT WE DON'T ASK PATIENTS ABOUT THEIR OWN LIVED EXPERIENCES. I THINK ALLOSTATIC LOAD IS A VERY IMPORTANT CONCEPT TO UNDERSTAND THE IMPACT OR EFFECTS OF THE LIVED EXPERIENCE AND SOCIAL DETERMINANTS OF HEALTH BUT I DON'T THINK I WOULD WANT TO GET TO A PLACE WHERE WE DON'T ACTUALLY ASK PEOPLE ABOUT, YOU KNOW, ARE THEY SOCIALLY ISOLATED, ARE THEY EXPERIENCING FINANCIAL STRESS OR ARE THEY -- DO THEY FEEL LIKE THEY HAVE ENOUGH COMMUNITY RESOURCES AND SUPPORT. SO IT'S AN INTRIGUING QUESTION, ONE WE'RE TRYING TO UNDERSTAND. I THINK FIRST SET OF STUDIES FROM OUR CENTER WE'LL BE ABLE TO PROVIDE SOME ANSWERS TO THEIR QUESTION BUT I THINK PERHAPS MY BIAS IN TRAINING AS A BEHAVIORAL SCIENTIST IS COMING OUT, WE ABSOLUTELY HAVE TO ASK PEOPLE ABOUT WHERE AND HOW THEY LIVE AND WHAT IMPACT IT HAS. >> I WOULD ADD IF WE'RE SEEING THE ELEVATED ALLOSTATIC LOAD IT'S ALREADY HAPPENED, RIGHT? WE'RE ALREADY SEEING COMPROMISED HEALTH. WHAT WERE THE CAUSES OF THAT? >> RIGHT. >> EITHER OBSERVING IN THE ENVIRONMENT WHAT IT WAS, CONTEXTUALLY OR A COMBINATION. >> I CERTAINLY APPRECIATE THE IMPORTANT ISSUE TO INVESTIGATE, BUT -- >> I THINK IT'S FIGURING OUT HOW TO BETTER INTEGRATE THE TWO TYPES OF MEASURES, RIGHT? >> RIGHT. >> TO LEARN THE MOST. ANY OTHER COMMENTS ABOUT THAT BEFORE WE MOVE ON? >> I HAD A QUESTION, WONDERING IF THE MEASUREMENT YOU WERE TALKING ABOUT WITH ALLOSTATIC LOAD, IS THAT ONE THAT IS KIND OF CONSISTENT ACROSS DIFFERENT LIFE COURSE STAGES LIKE WOULD IT HOLD FOR SOMEONE WHO IS OLDER OR -- I KNOW DIFFERENT FOR SOMEONE YOUNGER BECAUSE WE DON'T ALWAYS HAVE MEASURES READILY AVAILABLE. >> THERE IS A STRONG ASSOCIATION BETWEEN AGE AND ALLOSTATIC LOAD WITH OLDER POPULATIONS REPORTING LOWER, IF I REMEMBER CORRECTLY, LOWER ALLOSTATIC LOAD, SO IT'S SOMETHING WHERE THE CONSTRUCT IN AND OF ITSELF, IF YOU COLLECTED ALLOSTATIC LOAD IN MIDDLE AGE AFRICAN AMERICAN MEN AND THEN ALSO MEASURED ALLOSTATIC LOAD IN A GROUP OF ELDERLY AFRICAN AMERICAN MEN, THE RELIABILITY OF THE MEASURE WOULD BE THE SAME BECAUSE IT'S MEASURING THE SAME CONSTRUCT, BUT THERE WOULD BE DIFFERENCES IN ALLOSTATIC LOAD BASED ON AGE. >> IN THE CHAT BOX THERE'S A RESOURCE FROM 25 BY 5 SYMPOSIUM TO REDUCE DOCUMENTATION BURDEN LEADING TO USABLE DATA, THERE'S A LINK IN THE CHAT BOX THAT WE CAN SHARE WITH EVERYONE. AND THERE'S MORE TO COME ON FINDINGS FROM THE SYMPOSIUM FUNDED BY NLM. THERE'S A FOLLOW-UP QUESTION FOR DR. HALBERT, YOU'RE POPULAR TODAY. CAN I FOLLOW UP ON ASKING ABOUT ALLOSTATIC LOAD, WELL, THAT'S ANOTHER QUESTION. DIFFERENTLY WORDED, ALSO ASKING ABOUT THE SOCIAL DETERMINANTS. SO WE DEALT WITH THAT ONE. AND THERE'S SOME RESOURCES IN THE CHAT ABOUT PARTICIPATORY ACTIONS RESEARCH, I BELIEVE, OR COMING UP AS A QUESTION. I DON'T KNOW WHO -- PARTICIPATORY ACTION RESEARCH. LET ME ADDRESS TO THE WHOLE PANEL, WHAT IS THE ROLE OF PARTICIPATORY ACTION RESEARCH WITH SOCIAL RISK FACTORS? >> I THINK THAT WAS A REFLECTION OF A COMMENT I MADE ABOUT THE IMPORTANCE OF ENGAGING STAKEHOLDERS AND PROCESS OF DEVELOPING STRATEGIES AND TOOLS FOR OBTAINING AND ADDRESSING SOCIAL DETERMINANTS OF HEALTH. I DON'T REMEMBER THE CONTENT BUT THE INFORMATION IN THE CHAT BOX WAS SORT OF CALLING WHAT I WAS SAYING LIKE A SPECIFIC NAME, PARTICIPATORY ACTION RESEARCH. IT'S ABOUT STRUCTURAL RACISM AND THE NEED TO INVOLVE COMMUNITIES, PEOPLE ACTUALLY LIVING IN AREAS THAT HAVE BEEN SHAPED AND INFLUENCED AND ARE CONSEQUENCE OF STRUCTURAL RACISM AND PROCESS OF DEVELOPING INTERVENTIONS TO ADDRESS IT. >> YEAH, AS I SAID, WE KEEP SAYING COVID IS ILLUSTRATING WHERE THOSE POCKETS OF POPULATIONS, SPECIFIC POPULATIONS AT REALLY HIGH RISK AND REALLY HOW WE NEED TO TEND TO THOSE NEIGHBORHOODS AND COMMUNITIES AND ENGAGE THEM. >> THERE'S A COMMENT HERE TO EVERYONE ENSURING IMPACT IN THIS RESEARCH ESSENTIAL AS WE MOVE FORWARD, AND MOVE ALL CLINICIANS TO INTEGRATED SYSTEM FOR ADVANCING HEALTH FOR ALL. ECONOMIC POLICIES NEED TO EVOLVE. I DON'T KNOW IF MARY BETH WANTS TO ADD TO THAT. DOES RACHEL HAVE HER HAND RAISED STILL? THAT'S NOT COMMENT BOX, I DON'T KNOW. OKAY. WE'LL KEEP GOING. >> MARY BETH HAS TURNED ON HER VIDEO, ARE YOU GOING TO JUMP IN? >> YEAH, SORRY I OPENED THE VIDEO BUT NOT THE MIC. I THINK ONE OF THE CHALLENGES I STRUGGLE WITH AS A PERSON WHO TEACHES APRNs, INPATIENT AND OUTPATIENT, WATCHING US CONSTANTLY TALK ABOUT THE ROLE OF APRN SO WELL APPRECIATED DURING COVID STATES ALLOWED MORE LATITUDE FOR APRNs TO FUNCTION AT PEAK OF PRACTICE, AND NOW ELEMENTS ARE ROLLING BACKWARDS IN MANY STATES. AND I ALSO THINK THE CHALLENGE, HEATHER HIT A CORD FOR ME. I TEACH A CNS PROGRAM AND WATCH THEM TRY TO GO INTO COMMUNITIES TO PROVIDE THAT PERSON-CENTERED CARE, BUT IT'S NOT REIMBURSED. AND SO I THINK WE'VE GOT OPPORTUNITIES FROM THE ECONOMIC MODEL IF WE'RE GOING TO ADVANCE HEALTH CARE FOR ALL, TO REALLY TURN THE PARADIGM UPSIDE DOWN. AS WE DO ALL OF THIS WORK, ESPECIALLY WHEN I THINK ABOUT HOW WE'RE MINING DATA CAN WE SHOW WHERE THE DATA IS COMING FROM? CLINICIAN IS PUTTING THAT DATA IN, AND PROVIDING US THE INSIGHT, MY PRACTICE WORLD IS CRITICAL CARE AND THEY SPEND A LOT OF TIME WITH PATIENTS IN QUIET MOMENTS AND CAN WE GET THAT DATA MORE CLEARLY IDENTIFIED IN THE EHR NOT NECESSARILY FROM REIMBURSEMENT PERSPECTIVE BUT TO TRULY TACKLE OR PEEL AWAY THE ONION FROM A MORE MEANINGFUL PERSPECTIVE ACROSS THE SPECTRUM OF HEALTH CARE. >> ANY OTHER COMMENTS ABOUT THAT? >> I'LL JUST RESPOND. THANKS, MARY BETH. WE'RE COLLEAGUES TOGETHER IN COLORADO. FABULOUS COLLEAGUE. WE TALK ABOUT EHR MEANINGFUL USE, THOSE WORDS, ALL THE TIME. MY ONE RESPONSE IS MEANFUL USE FOR WHO? ON OUR CAMPUS AT THE UNIVERSITY OF COLORADO HEALTH SYSTEM WE ACTUALLY ARE PART OF THE OPEN NOTES MOVEMENT, WHERE THAT EHR IS THE PERSON'S EHR. IT IS THEIR PROCESS. IT IS THEM BEING REFLECTED AS A HUMAN. AND SO I THINK IT'S REAL IMPORTANT FOR US IN NURSING TO BRING THAT ADVOCACY FORWARD AND THINK ABOUT THE CONSTRUCTION OF WHAT IS MEANINGFUL, WHO IS IT MEANINGFUL FOR, HOW CAN WE MAKE IT MORE PERSON CENTERED. THANKS FOR YOUR THOUGHTS, MARY BETH. >> ANY OTHER COMMENTS RELATED TO THAT BEFORE WE MOVE ON? THOSE ARE EXCELLENT POINTS. >> I THINK IT'S RELEVANT HERE THAT THERE ARE NEW REGULATIONS COMING FORWARD THAT WILL BE ACTIVE STARTING IN APRIL, AGAINST INFORMATION BLOCKING. AND SO THIS WILL REALLY ENABLE PATIENTS TO REQUEST ACCESS TO THEIR DATA. THEY CERTAINLY ALREADY HAVE, YOU KNOW, THAT RIGHT BUT THIS IS REALLY ENABLING THE ABILITY FOR THEM TO GET IT THROUGH APIs TO GET IT ELECTRONICALLY AND SAYING THAT HOSPITALS HAVE SYSTEMS REALLY NEED TO PROVIDE IT TO THEM. THERE ARE A FEW EXCEPTIONS TO IT WHEN A CLINICIAN, FOR EXAMPLE, THINKS THAT IT IS IN THE PATIENT'S BEST INTEREST NOT TO PROVIDE THAT DATA, YOU KNOW, TYPICALLY CITED AS PERHAPS IN SOME PSYCHIATRIC AREAS OR OTHERS THAT REALLY THERE'S A CLINICAL NEED OR RATIONALE NOT TO PROVIDE IT BUT INFORMATION BLOCKING RULE WILL BE GOING LIVE AND PATIENTS WILL BE ABLE TO USE AN APP FOR INSTANCE TO REQUEST ACCESS TO THEIR DATA AND SO THAT IS OPENING THAT ABILITY UP. >> YOU MEAN THE WHOLE MEDICAL RECORD, ALL OF IT? >> SO, WHAT WILL FIRST BE PART OF THE REGULATION ARE SOME SPECIFIED DATA ELEMENTS THAT ARE PART OF A STANDARD THAT ONC HAS PUBLISHED. I BELIEVE IT'S THEN IN A YEAR, ABOUT A YEAR, I'M PROBABLY NOT GETTING THE DATE QUITE RIGHT, THAT IT WILL BE WHAT IS, YOU KNOW, COINED AS LEGAL MEDICAL RECORD SO MY UNDERSTANDING THEN IS HOW THAT SITE DEFINES THE LEGAL MEDICAL RECORD. SEARCH I COULD BE A LITTLE OFF IN WHAT THAT EXACT INTERPRETATION IS IN THE LAW BUT IT IS STATED AS IT WILL BE LEGAL MEDICAL RECORD. >> THANK YOU. >> WE HAVE TO BE ALSO CONSCIOUS, THAT DOESN'T INCREASE HEALTH DISPARITIES, RIGHT? DISPARITIES IN ACCESS, WHAT THAT MEANS TO BEING ABLE TO ACCESS YOUR OWN ELECTRONIC HEALTH RECORD AND UTILIZE IT AND DO WHATEVER YOU CAN TO IMPROVE YOUR HEALTH STATUS USING THAT INFORMATION. THAT WILL NOT BE EQUAL ACROSS POPULATIONS. >> RIGHT. THERE'S CERTAINLY A ROBUST LITERATURE ABOUT RACIAL DIFFERENCES IN PATIENT PORTAL ACTIVATION. IF YOU THINK ABOUT THAT AS BEING -- I WOULD THINK THAT WOULD BE HOW MOST PEOPLE ONCE THE NEW LAW TAKES EFFECT WOULD HAVE -- THEY WOULD BE ABLE TO ACCESS THEIR MEDICAL RECORD THROUGH THE PATIENT PORTAL BUT IT'S INTERESTING BECAUSE AT MY INSTITUTION THERE WAS A POLICY THAT YOU HAD TO OPT IN TO LIKE CERTAIN THINGS LIKE BEING CONTACTED FOR RESEARCH STUDIES. WHAT IT DOES IS REALLY BIASES AGAINST CERTAIN GROUPS BECAUSE, YOU KNOW, I ACTUALLY HAVE MY -- ONE, BECAUSE AFRICAN AMERICANS, MINORITY PATIENTS DON'T ACTIVATE THEIR MY CHART AT THE SAME RATE. SECONDLY, YOU KNOW, UNTIL RECENTLY THE THING -- THE TEXT YOU HAD TO CLICK ON TO GET TO THE RESEARCH PERMISSIONS PART WAS BURIED DEEP DOWN IN THE MY CHART PORTAL, SO WHO CAN FIND THIS? YOU REALLY HAVE TO OVERCOME A BARRIER TO ACTIVATING YOUR CHART. I COULD NEVER REMEMBER MY PASSWORD, I HAVE TO RESET IT. >> THAT ASSUMES YOU SPEAK ENGLISH. >> RIGHT. A LOT OF BARRIERS. TO HAVE TO DIG THROUGH THE TECHNOLOGY TO FIND WHERE CAN I GO SIGN UP TO BE FOR THE RESEARCH PORTAL, THAT'S SO INEFFECTIVE. SO ANYWAY -- >> YEAH, THOSE ARE ALL FANTASTIC POINTS. WE'RE OUT OF TIME, DR. ZENK. SHOULD WE MOVE ON? >> ACTUALLY WE ARE OVER. SO IF YOU DIDN'T GET YOUR QUESTION ASKED AND ANSWERED, FEEL FREE TO REACH OUT TO US AND WE'LL PASS IT ALONG TO THE PRESENTER AS APPROPRIATE. SO THANK YOU. THANK YOU FOR THIS GREAT DISCUSSION. DR. NAPOPELS, FOR YOUR EXPERT MODERATION AND PANELISTS AND PARTICIPANTS. I'D LIKE TO TURN THIS OVER TO DR. YVONNE BRYAN, SENIOR ADVISER AT NINR, ONE OF THE PLANNERS OF THIS ROUNDTABLE. DR. BRYAN? >> I JUST WANT TO SAY THANK YOU, THANK YOU, TO ALL OF OUR SPEAKERS. WHAT A FABULOUS DAY. THIS HAS BEEN STIMULATING, THOUGHT PROVOKING, JUST SO INFORMATIVE. AND WE DO HAVE OUR WORK CUT OUT FOR US. BUT WITH THIS GROUP, I HAVE NO DOUBT WE ARE GOING TO MOVE THE NEEDLE. SO THANK YOU. I AM AWARE THAT MANY OF YOU HAVE AN INTEREST IN GETTING THE PRESENTATIONS. AND JUST SO THAT YOU KNOW, WE WILL CHECK WITH THE PRESENTERS AND WE WILL FOLLOW UP WITH YOU AFTER THE MEETING. I ALSO AM VERY PLEASED TO ANNOUNCE THE EMERGENCY NURSES ASSOCIATION HAS CONFIRMED THAT THEY WILL CO-SPONSOR THE 2022 MEETING, MARCH 3 AND 4. ALSO, THE ASSOCIATION OF WOMEN'S HEALTH OBSTETRIC AND NEONATAL NURSES HAVE CONFIRMED THAT THEY WILL CO-HOST THE 2023 MEETING. SO WE'RE DELIGHTED AND PLEASED AND WE LOOK FORWARD TO THOSE MEETINGS, AND IN THE MEANTIME IF YOU WOULD LIKE TO VOLUNTEER >> WHAT A WONDERFUL STIMULATING CONVERSATION. I LEARNED SO MUCH. WE'LL BE LEADING WITH IDEAS THAT CAN HELP US EVALUATE SOCIAL DETERMINANTS OF HEALTH, SO IMPORTANT. I'M PROBABLY ONE OF THE LAST THINGS STANDING BETWEEN YOU AND YOUR WEEKEND. SO I WILL JUST WISH YOU A HAPPY WEEKEND AND THANK YOU AGAIN FOR COMING. >> THANK YOU, DR. LASSETTER. AND THANK FOR JOINING US FOR THE 2021 ROUNDTABLE FOR IDENTIFYING MODELINGS OF NURSING CARE AND HEALTH CARE DELIVERY RESPONSIVE IN PEOPLE'S LIVES AND THEIR LIVING CONDITIONS. SO THANKS AGAIN TO THE WESTERN INSTITUTE OF NURSING FOR PARTNERING WITH US ON THIS MEETING PARTICULARLY DR. LASSETTER, DR. DONNA VILASQES AND BO PERRY. THANK YOU TO ALL THE PRESENTERS AS WELL AS DR. ELISEORY PEREZ-STABLE AND ANNA NAPOLES FROM NIMHD. WE HOPE TO SEE YOU NEXT YEAR FOR THE 2021 NURSING RESEARCH ROUNDTABLE AND HAPPY WEEKEND. THANKS FOR JOINING.