Reprise: Design Thinking with Bon Ku

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This week we are featuring a reprise show with Bon Ku, the Assistant Dean for Health and Design and an Associate Professor at the Sidney Kimmel Medical College at Thomas Jefferson University, to talk about design thinking and medicine. Bon is a practicing emergency medicine physician and the founder and director of JeffDESIGN, a first-of-its-kind program in a medical school that teaches future physicians to apply human-centered design to healthcare challenges. Bon has spoken widely on the intersection of health and design thinking (TEDx, South by Southwest, Mayo Clinic Transform, Stanford Medicine X, Association of Collegiate Schools of Architecture) and serves on the Design and Health Leadership Group at the American Institute of Architects. Bon talks with us about what design thinking is, how he got into it, why he thinks physicians would benefit from learning to think in this way, and how to apply it to common primary care challenges, like walk-ins. He also directs listeners to the following resources to learn more about design thinking in medicine: the Stanford Dschool, and ideou.

If you like the show, please rate and review us on itunes or stitcher, which makes the show easier for others to find; and share us on social media. We tweet at @rospodcast and are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you.

Understanding how to address social determinants of health with Laura Gottlieb

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These days, we hear about social determinants of health constantly – more of us are screening for social needs in our clinics and payers are searching for effective ways to address them as an avenue to improve outcomes and ideally reduce costs. Dr. Laura Gottlieb, a family physician and researcher at UCSF joins us today to talk about her research, which focuses on evaluating interventions to identify and address social factors in health care.

You can find many of Dr. Gottlieb’s publications here, as well as the Health Affairs blog post by Drs. Toyin Ajayi and Iyah Romm mentioned in the podcast. You can also use this link to the SIREN website to find more resources on the intersection of social and medical care.

A little more about our guest: Dr. Gottlieb is Associate Professor of Family and Community Medicine at the University of California, San Francisco and director of the Social Interventions Research and Evaluation Network (SIREN). Dr. Gottlieb’s current research focuses on evaluating interventions that identify and address social factors as part of health care delivery. These interventions include volunteer-powered social services Help Desks, payment reforms that support social programs, and other efforts that support responding to patients’ social needs in medical practice, like re-designing electronic medical records to incorporate social determinants data. Dr. Gottlieb also is an Associate Director of the Robert Wood Johnson Foundation Evidence for Action National Program and was a co-founder of HealthBegins, a non-profit organization providing education, consulting, networking, and technology services to health care providers interested in joining the effort to move medicine upstream. Prior to her current appointment, Dr. Gottlieb was a Robert Wood Johnson Health and Society Scholar at UCSF/UCB. She completed her MD at Harvard Medical School and both her MPH and residency training at the University of Washington.

If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

This interview has been lightly edited for length and clarity. Photo courtesy of Dr. Gottlieb.

Journal Club Lightning Round: evidence based policy and vaccine rates, municipal non-health spending and health rankings, and is less really more?

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For this week’s journal club, David, Thomas, and Audrey bring listeners short overviews of three articles. Audrey discusses an article published in the journal Pediatrics Dec 18 2017, called Exemptions from Mandatory Immunization After Legally Mandated Parental Counseling by Saad Omer, Kristen Allen, DH Chang, Beryl Guterman, Robert Bednarczyk, Alex Jordan, Alison Buttenheim, Malia Jones, Claire Hannan, Patricia deHart, and Daniel Salmon. David chats about the Dec 14, 2017 commentary published in New England Journal of Medicine by Dr. Lisa Rosenbaum entitled The Less is More Crusade – Are we Overmedicalizing or Oversimplifying. And Thomas shares a Health Affairs article, Government spending health and nonhealth sectors associated with improvement in county health rankings, published in their November 2016 issue.

If you enjoy the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

Reprise – Population Health Management with Dave Chokshi

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This week, we are joined by Dave Chokshi. Dave is the Chief Population Health Officer of OneCity Health and Senior Assistant Vice President at New York City Health + Hospitals—the largest public health care system in the U.S. He practices primary care at Bellevue Hospital and is a Clinical Associate Professor of Population Health and Medicine at the NYU School of Medicine.

We talk about what population health is, how it is distinct from public health, and what value it adds to our healthcare system. We also talk about how in some ways it might contribute to the erosion of relationships between primary care providers and patients, how that can be remedied, and how the small 1 or 2 doctor practice may fit into a population health management vision. We talk about a piece he wrote with Neil Calman and Diane Hauser about what they call the “expanded denominator,” and how that may further goals of public health and accountable care. Lastly, we talk about population health approaches in urban and rural settings, and how we should think about the opioid epidemic from a population health vantage point.

We reference a few articles throughout our conversation: Christine Sinsky’s already classic Annals paper detailing that physicians spend two hours on administrative tasks for every hour they see patients, and our journal club on that paper. Robin Williams’ and colleagues Health Affairs blog on utilizing the HIV cascade of care to battle the opioid epidemic, and Lawrence Casalino and colleagues work calculating what we spend measuring the care we provide. In addition, we reference the Surgeon General Vivek Murthy’s landmark report on addiction.

A quick note about a word we use frequently but didn’t pause to define for listeners – attribution. Attribution is the assignment of a specific patient to a specific primary care physician in a health system. Once a patient is attributed to a PCP or health system, that PCP and health system is held accountable for the patient’s quality measures and healthcare costs within ACOs or other alternative payment contracts. This still applies patients who do not frequently access the healthcare system through traditional channels or most frequently see specialists, who perhaps have never seen the assigned PCP, and is therefore at times controversial.

A little more background on Dr. Dave Chokshi: He was Assistant Vice President of Ambulatory Care Transformation at NYC Health + Hospitals and director of Population Health Improvement at NYU School of Medicine. In 2012-13, he served as a White House Fellow at the U.S. Dept. of Veterans Affairs, where he was the principal health advisor in the Office of the Secretary. His prior work experience spans the public, private, and nonprofit sectors, including positions with the New York City and State Departments of Health, the Louisiana Department of Health, a startup clinical software company, and the nonprofit Universities Allied for Essential Medicines, where he was a founding member of the Board of Directors.

If you enjoy the show, please rate and review us wherever you listen, and share us on social media. Tweet us your thoughts @rospodcast and check out our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audreyATrospod.org. We’d love to hear from you, and thanks for listening.

Reprise – How does architectural design influence c-section rates? With Mass Design & Ariadne Labs

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This episode starts with a question: “what if the architectural design of an obstetric unit influenced the c-section rate in that unit?”

That question occurred to obstetrician/gynecologist Neel Shah when he attended a presentation by Michael Murphy, the co-founder and executive director of Mass Design, an architectural design and research firm that focuses particularly on healthcare architecture. Neel thinks about c-section rates all the time and is a leading researcher in the field of maternal health. C-section rates vary widely throughout the US – from 7 to 70%, and where a woman delivers better predicts whether she will get a c-section than her own personal risk factors. So, Michael Murphy’s contention that “Architecture is never neutral. It either heals or hurts” stayed with Neel and inspired him to pursue a research initiative between Mass Design and his research group, Ariadne Labs.

Neel Shah and two of his collaborators, Amie Shao and Deb Rosenberg, researchers and architects with Mass Design, join us to talk about their collaboration and the report they produced.

Amie Shao is a director with MASS Design Group, where she oversees research focusing on health infrastructure planning and evaluation. In addition to guiding impact research for MASS built projects, she coordinated the production of National Health Infrastructure Standards for the Liberian Ministry of Health and has been involved in the design and evaluation of healthcare facilities in Haiti, Africa, and the United States. Deb Rosenberg joined MASS in 2015, with a unique background in healthcare and architecture. Throughout her career in nursing and architecture is a common ambition to promote health and well-being, and she believes that the spaces where people live, work and heal have the capacity to greatly support or restrict our human potential. Neel Shah, MD, MPP, is Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School, and director of the Delivery Decisions Initiative at Ariadne Labs. His team is currently collaborating with hospitals across the United States, and using methods from design, systems engineering, and management to reduce the epidemic of avoidable c-sections.

If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and check out our facebook page at www.facebook.com/reviewofsystems. Or, you can email us at audreyATrospod.org. We’d love to hear from you, and thanks for listening.

This interview has been lightly edited for length and clarity.

Understanding how to return joy to practice with Christine Sinsky

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In order to make primary care better, we have to understand what is working and what isn’t – and not just in broad strokes, but in granular detail. Dr. Christine Sinsky is on the cutting edge of this type of research, and publishes prolifically on what is driving burnout in primary care, what specific steps we can take to fix it, and how to return joy to practice. Dr. Sinsky is the VP of Professional Satisfaction at the AMA and has practiced as a general internist for 30 years in Dubuque, Iowa. We talk about her landmark work with Tom Bodenheimer, which introduced the idea of the quadruple aim in 2013, how new EHR metrics can improve how we deliver care and improve the experience of caregivers and patients, and the extent of the burnout crisis in medicine at large, not just primary care. You can find the call for research that Dr. Sinksy referenced and collaborated on with Dr. Lotte Dyrbye and other leaders in this field here. We previously featured one of Dr. Sinksy’s publications, which showed that physicians spend about 2 hours doing clerical work for every 1 hour they see patients in a journal club, which you can find here.

If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

This interview has been lightly edited for length and clarity. Photo courtesy of Christine Sinsky.

Journal Club: Lightning Round! Primary care vs Specialty care, Doorknob moments & Cost effectiveness of buprenorphine initiation in the ED

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This week Thomas Kim, David Rosenthal, and Audrey Provenzano talk about three recently published manuscripts for a lightning round edition of Journal Club. Thomas shares a paper by Bynum et al, Outcomes in Older Adults with Multimorbidity Associated with Predominant Provider of Care Specialty, examining outcomes among patients primarily cared for by specialists vs primary care providers. David shares a paper describing a novel technology for agenda setting and evaluation of social determinants of health by Wittink et al, entitled Patient priorities and the doorknob phenomenon in primary care: Can technology improve disclosure of patient stressors? (H/T Primary Care Progress for tweeting it!). Lastly, Audrey shares a paper entitled Cost effectiveness of emergency department initiated treatment for opioid dependence by Susan Busch et al, which is a cost-effectiveness analysis of an RCT of ED-initiated buprenorphine performed at Yale, previously featured on the podcast in an interview with Gail D’Onofrio

If you enjoy the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

How do we improve the value of care delivered in primary care? with John Mafi

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All of us like to think that we provide high-value care for our patients; but the truth is, just like the rest of the health care system, primary care provides a lot of low value care too – and we drive a lot of overuse. John Mafi joins us this week to talk about his leading research into these thorny, complex issues.

We talk about the definitions of high-value and low value care, his 2016 study in Annals of Internal Medicine examining rates of high and low value care among physicians, NPs, and PAs in the primary care setting, how practice setting may affect the delivery of high and low value care, and the essential truth that there is no free lunch in trying to solve some of the challenges in fixing primary care in the US. You can find Shah et al, which John referenced here; a recent study relevant to our conversation by Hong et al looking at clinician characteristics and frequent ordering of low-value imaging studies; and an extremely important new paper that John published recently in Health Affairs looking at the the impact of low-cost, high-volume studies on unnecessary health spending.

A little bit more about our guest:  John N. Mafi, MD, MPH is an assistant professor of medicine in the Division of General Internal Medicine and Health Services Research at the David Geffen School of Medicine at UCLA where he also practices and teaches. He also serves as an Affiliated Natural Scientist in Health Policy at RAND Corporation. Dr. Mafi trained in internal medicine at Beth Israel Deaconess Medical Center in 2012, where he also served as Chief Medical Resident and completed the Harvard Medical School Fellowship in General Internal Medicine and Primary Care in 2015. Dr. Mafi’s research focuses on quality and value measurement and how electronic health records can improve the value of care.

If you enjoy the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

 This interview has been lightly edited for length and clarity.

Lori Tishler of Commonwealth Care Alliance – Caring for the Most Vulnerable Patients

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Have you ever felt lonely and overwhelmed in a clinic room with a patient whose needs are far beyond your skills and ability to meet? I have, many times, and so has our guest this week, Dr. Lori Tishler. Dr. Tishler is the Vice President of Medical Affairs at Commonwealth Care Alliance, a not-for-profit organization that cares for more than 20,000 of the most vulnerable patients in Massachusetts, duals, or individuals who have both Medicare and Medicaid.

We talk about how CCA’s member-centered approach (as opposed to a physician-centered approach) has helped her feel more effective in caring for these vulnerable patients. We talk about the range of services that CCA offers, the role of their care partners, and the freedom that their financial model permits – for example, they provide 90% of care to patients in their homes.

You can find the Atlantic Magazine article we referenced featuring CCA here, and find a few Health Affairs blogs featuring CCA here, and a blog post focusing on building the business case for a community paramedicine program here.

A bit more about our guest: Lori Tishler is the Vice President of Medical Affairs at Commonwealth Care Alliance, a not-for-profit organization that cares for more than 20,000 of the most vulnerable patients in Massachusetts, people who have both Medicare and Medicaid.  She oversees CCA’s physicians and is involved with clinical aspects of quality, utilization, and pharmacy.  In addition, she is an Assistant Professor at Harvard Medical School and an active member of the General Medicine Faculty at Brigham and Women’s Hospital, As a caring and connected physician leader, mentor, and educator, Dr. Tishler’s passion has been providing care for the medically and socially vulnerable and making a difference in health systems for all.   Tishler has found that the most rewarding way to help change and grow our health care systems is to mentor learners who are interested in clinical care, leadership, and innovation.

Her leadership roles have extended outside of the clinic and outside of primary care.  She served on the Partners Healthcare Board of Directors, the Board of Directors for the Office for Women’s Careers, and the Board of the Schwartz Rounds while at the Brigham.  At Commonwealth Care Alliance, she teaches and presents nationally about our care model and innovations.

In addition to her leadership work, she continues to provide clinical care  Tishler feels that working as a clinician informs her choices and decisions as a leader.  Outside of work, Dr. Tishler loves to spend time with her husband and teenaged daughter, to travel, read, and knit.  She is honored to have been interviewed on Review of Systems.

If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @rospodcast and check out our facebook page at www.facebook.com/reviewofsystems. Or, you can email us at audreyATrospod.org. We’d love to hear from you, and thanks for listening.

Tom Bodenheimer – Building Blocks of High-Performing Primary Care and the Quadruple Aim

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Dr. Tom Bodenheimer is one of the world’s foremost experts in primary care re-design, having recently written about high-performing primary care clinics and the Quadruple Aim, which are articles consistently in the most-read list for the Annals of Family Medicine and among his most cited work.  We focused much of our conversation on his work visiting 23 high-performing primary care practices, what he and co-authors learned, how resident teaching sites can also be high-performing, and why we should be seeking a fourth aim in addition to IHI’s famed Triple Aim.

A general internist who received his medical degree at Harvard and completed his residency at the University of California-San Francisco, Dr. Tom Bodenheimer spent 32 years in primary care practice in San Francisco’s Mission District, a primarily low-income, Latino community—ten years in community health centers and 22 years in private practice.  He is currently Professor of Family and Community Medicine at UCSF and Founder and Co-Director of the Center for Excellence in Primary Care.  He has written extensively in journals such as the New England Journal of Medicine, JAMA, Annals of Family Medicine, and Health Affairs, on health policy and health care delivery for chronic disease management, including patient self-management, health coaching, and team-based care. He is also co-author of the books Improving Primary Care: Strategies and Tools for a Better Practice, and the health policy text book Understanding Health Policy.

Listen at the end of the episode for a promo code to receive 15% off registration fees for an upcoming conference from the Harvard Center for Primary Care: Primary Care in 2020 – Future Challenges, Tips for Today.

This interview has been lightly edited for length and clarity.