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.

Andrew Bazemore – Community Vital Signs: Achieving Equity through Primary Care Means Checking More than Blood Pressure

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“How do we get the data and the information necessary to address health?”

In this episode, another in a series with speakers from the 2017 second Starfield Summit, we talked with Dr. Andrew Bazemore about how primary care occupies the juncture between public health and health care. Andrew believes achieving health equity necessarily involves harnessing the democratization of data by pairing aggregated population health data to patient data in EHRs. We talked about his vision of Community Vital Signs and the challenges to getting there; the legacy of Sidney Kark, H. Jack Geiger, Gene Farley, and Curtis Hames and how they would drool at modern geographic information systems; how Community Vital Signs could help triage patients and help them achieve better health; and the potential for ecological fallacy in the work.

Andrew Bazemore is a practicing family physician and the Director of the Robert Graham Center, which he joined in 2005. He oversees and participates in the Center’s research with a particular interest in access to care for underserved populations, health workforce & training, and spatial analysis. He has authored over 150 peer-reviewed publications, while leading the Center’s emphasis on developing tools that empower primary care providers, leaders, and policymakers.  He also serves on the faculties of the Departments of Family Medicine at Georgetown University and Virginia Commonwealth University, and in the Department of Health Policy at George Washington University School of Public Health. He is an elected member of the National Academy of Medicine(NAM), and appointed member of the federal Council on Graduate Medical Education (COGME).

The Starfield Summit brought together leaders in primary care, clinicians, experts, advocates, patients, and community members in 2017 to collaborate in paving paths towards health equity and social accountability. The Summit was primarily sponsored by FMAHealth, OH&SU, and OCHIN.  Stay tuned in upcoming weeks for more speakers from the Starfield Summit.

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 thomasATrospod.org. We’d love to hear from you, and thanks for listening.

This interview was edited lightly for length and clarity.

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.

Nwando Olayiwola – primary care, tech, and leadership

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How can we use tech to make healthcare better and more accessible? Dr. Nwando Olayiwola, a family physician, faculty member at UCSF, and Chief Clinical Transformation Officer for RubiconMD, a leading provider of electronic consultations between primary care and specialty care providers, has spent many years thinking about that question. She joins us this week to tell us about her career in primary care, tech, and leadership. We also discuss her powerful essay, Racism in Medicine: Shifting the Power, and her research looking at various aspects of tech and care delivery.

Thank you to the Harvard Center for primary care for helping to facilitate this interview. I did make a few recording snafus on this interview – so my apologies for the sub-optimal audio quality in a few sections.

A little more about our guest: Dr. Nwando Olayiwola is a family physician and the inaugural Chief Clinical Transformation Officer for RubiconMD, a leading provider of electronic consultations between primary care and specialty care providers. She is also currently an Associate Clinical Professor in the Department of Family and Community Medicine at University of California, San Francisco. She served as the Director of the UCSF Center for Excellence in Primary Care until February 2017. In that role, she supported the Center in achieving strategic objectives around primary care transformation and systems redesign regionally, nationally and internationally. Prior to her work at UCSF, Dr. Olayiwola served as the Chief Medical Officer of the largest Federally Qualified Health Center system in Connecticut, Community Health Center, Inc. (CHCI), where she developed expertise in medical administration, translational and implementation research, professional development, systems based and quality improvement and practice transformation of twelve primary care practices into Patient-Centered Medical Homes. Her work led to CHCI being one of the first organizations in the United States to receive both the NCQA Level 3 PCMH and Joint Commission PCMH Recognitions. She has been a leader in harnessing technology to increase access to care for underserved and disenfranchised populations and is an expert in the areas of health systems reform, practice transformation, health information technology and primary care redesign. She is on the advisory board of Primary Care Progress and the Robert Graham Center for Family Medicine and Primary Care Policy.

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 audreyATrospod.org. We’d love to hear from you, and thanks for listening.

This interview has been edited for length and clarity.

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.

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.

How does architectural design impact c-section rates? Mass Design & Ariadne Labs

Play

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.

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.

Dave Chokshi – Population Health Management

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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.