Day 2 – Achieving Health Equity in Preventive Services

Day 2  - Achieving Health Equity in Preventive Services



THANKS, EVERYBODY, FOR COMING BACK TO DAY 2 OF OUR PATHWAYS TO PREVENTION CONFERENCE ON REDUCING DISPARITIES IN UTILIZATION AND OUTCOMES FROM PREVENTIVE INTERVENTIONS. IT'S A SERIOUS TOPIC BUT WE HAVE A LOT TO DO IN THE NEXT FIVE OR SO HOURS. A LOT OF LITERATURE TO DISCUSS AND WE HAVE GREAT SPEAKER PANELS AND GREAT KEYNOTE SPEAKER TO CLOSE. I'M TIM CAREY. GOOD MORNING. HOPE EVERYBODY GOT A GOOD NIGHT'S SLEEP. JUST TO REPRISE THE GROUND RULES, SO WE WILL HAVE TWO KEY QUESTIONS FOR DISCUSSION TODAY. ONE ON HIT AND ITS ROLE IN REDUCING DISPARITIES, ANOTHER IN THE ROLE OF HEALTH SYSTEMS AND SYSTEMS INTERVENTION IN REDUCING HEALTH DISPARITIES. WE WILL HEAR FROM COLLEAGUES AT OHSU WHO CONDUCTED SYSTEMATIC REVIEW AT THE BEGINNING OF EACH COMPONENT AND HAVE SEVERAL SPEAKERS TO GIVE A FEEL FOR WHAT ARE THE RESEARCH GAPS AND WHAT IS THE RESEARCH CONTEXT FOR THESE ISSUES AS WE DISCUSS FUTURE RESEARCH NEEDS IN THIS AREA. SO, FOR THOSE LOOKING ON, ONLINE, THIS IS BIG TELECONFERENCED, WE'RE INTERESTED IN YOUR VIEWS, OTHER RESEARCHERS, THOSE NOT HERE, PUBLIC, PATIENTS AND ADVOCATES. IF YOU COULD SEND VIA E-MAIL OR TWITTER, FOR THE ON LINE FOLK, WE'LL ADDRESS QUESTIONS AS WE CAN. SIMILAR TO YESTERDAY AFTER EACH COMPONENT IS DONE LINE UP — THE PANEL WILL ASK QUESTIONS FIRST, EVIDENCE PANEL, AND WE'LL GO TO LEFT MIC, RIGHT MIC, OR RIGHT AND LEFT MIC AND ANSWER QUESTIONS IN CORNER, LIMITED TO TWO MINUTES EACH. I HAVE TO BE STRICT SO WE CAN KEEP TO TIME. THANK YOU. I THINK THAT'S THE GROUND RULES. AND OUR NEXT UP WILL BE A VIDEO VIGNETTE AND MENTAL ON THE IMPORTANCE OF HEALTH EQUITY AND PREVENTIVE SERVICES TO NCI FROM DR. CROYLE, DIRECTOR OF DIVISION OF CANCER CONTROLAT NCI. DR. CROYLE. >> HEALTH EQUITY IS IMPORTANT TO THE NATIONAL CANCER INSTITUTE, BECAUSE THE RESEARCH THAT WE LEAD, SUPPORT AND CONDUCT IS REALLY DESIGNED TO INFORM STRATEGIES TO REDUCE THE INCIDENCE AND MORTALITY DUE TO CANCER IN OUR POPULATION. TO THE DEGREE THAT SOME POPULATIONS HAVE DISPROPORTIONATE BURDEN BECAUSE THAT EVIDENCE ISN'T REACHING THEM, EITHER THROUGH POLICY OR CLINICAL PRACTICE, WE WANT TO MAKE SURE THAT WE'RE PROVIDING THE RIGHT EVIDENCE THROUGH THE BEST RESEARCH TO REDUCE THOSE DISPARITIES. AS NIH'S LARGEST INSTITUTE WE HAVE A SPECIAL RESPONSIBILITY TO ADDRESS ISSUES OF HEALTH INEQUITY AND WE DO THIS THROUGH APPLICATIONS RESEARCH, BUT ALSO THROUGH THE UTILIZATION OF OUR EXTENSIVE RESEARCH INFRASTRUCTURE, 70 NCI DESIGNATEED CANCER CENTERS, A MAJOR NATIONAL CLINICAL TRIALS PROGRAM, A BREADTH OF EPIDEMIOLOGICAL COHORTS AND INTERVENTION STUDIES, BY BRINGING RESOURCES AND TOOLS TO BEAR CAN MAKE SIGNIFICANT PROGRESS ON REDUCING HEALTH INEQUITIES BY THE GENERATION OF NEW EVIDENCE BUT ALSO BY IMPLEMENTING THE BEST EVIDENCE WE CURRENTLY HAVE AVAILABLE. IN THE AREA OF CANCER CONTROL, WE HAVE INCREDIBLE OPPORTUNITIES TO SIGNIFICANTLY REDUCE THE BURDEN OF CANCER IN UNDERSERVED COMMUNITIES. AND THERE'S SOME REALLY COMPELLING EXAMPLES OF THIS. CERVICAL CANCER IS A GREAT EXAMPLE. THERE'S SIGNIFICANT DIFFERENCE, BUT THERE'S THE HPV VACCINE. IF WE CAN GET PEOPLE VACCINATED, WE CAN PREVENT CERVICAL CANCER. SIMILARLY IN COLORECTAL CANCER WE KNOW THAT WE HAVE THE TOOLS, AGAIN, SCREENING MODALITIES, THAT CAN ALLOW US TO DETECT COLORECTAL CANCER EARLY BUT ALSO TO PREVENT THE PROGRESSION OF CONTROL OH RECTAL CANCER. THAT'S REALLY ESSENTIAL. IF WE CAN IMPROVE THE DELIVERY AND UPTAKE OF THESE PREVENTIVE SERVICES, WE KNOW WE CAN HAVE A SIGNIFICANT IMPACT ON REDUCING CANCER MORTALITY. WE CAN MAKE TREMENDOUS PROGRESS REDUCING THE MOST COMMON CANCERS BY FOCUSING ON THE BIGGEST RISK FACTORS AND DRIVES OF CANCER IN AMERICA. THAT INCLUDES TOBACCO USE, WHICH STILL ACCOUNTS FOR A THIRD OF ALL CANCER DEATHS IN THE UNITED STATES. THAT INCLUDES COLORECTAL CANCER WHERE WE HAVE EFFECTIVE SCREENING STRATEGIES, AND THAT ALSO APPLIES TO CANCERS LIKE CERVICAL CANCER WHERE WE HAVE AN EFFECTIVE CANCER PREVENTION VACCINE. BY EMPLOYING THE BEST EVIDENCE, BY CONDUCTING ADDITIONAL RESEARCH AND DEVELOPING MORE EFFECTIVE STRATEGIES, WE CAN HAVE A SIGNIFICANT IMPACT ON REDUCING HEALTH INEQUITY IN THE UNITED STATES. I'M AMY CANTOR. I'M FROM THE EVIDENCE BASED PRACTICE CENTER. I WANTED TO INTRODUCE MYSELF, ASSOCIATE PROFESSOR OF MEDICAL INFORMATICS AND CLINICAL EPIDEMIOLOGY AS WELL AS FAMILY MEDICINE AND OBSTETRICS AND GYNECOLOGY. I'M GOING TO TALK ABOUT KEY QUESTION 4, FOCUSING ON HELD INFORMATION TECHNOLOGY INTERVENTIONS. SO LET'S SEE WHERE THE POINTER IS. HERE WE GO. I HAVE NOTHING TO DISCLOSE. AND, AGAIN, WANTED TO REINTRODUCE THE EVIDENCE-BASED PRACTICE CENTER TEAM. A FEW OF OUR MEMBERS OF OUR TEAM ARE HERE TODAY. AND THE OTHERS ARE TUNING IN. SO TO START WITH KEY QUESTION 4, I'LL READ IT OUT LOUD TO BE CLEAR FOR THIS QUESTION. KEY QUESTION 4 IS LOOKING AT THE EFFECTIVENESS OF HEALTH INFORMATION TECHNOLOGY AND DIGITAL ENTERPRISES TO IMPROVE ADOPTION IMPLEMENTATION AND DISSEMINATION OF EVIDENCE-BASED PREVENTIVE SERVICES IN SETTINGS THAT SERVE POPULATIONS ADVERSELY AFFECTED BY DISPARITIES. IMPORTANT TO UNDERSTAND FOR THIS PARTICULAR QUESTION IS LOOKING AT THE CRITERIA THAT ARE UNIQUE TO THE KEY QUESTION. AS WITH THE ENTIRE REVIEW WE'RE LOOKING AT POPULATIONS WHO ARE ADVERSELY AFFECTED BY DISPARITIES AND PROVIDERS SERVING THOSE POPULATIONS. INTERVENTIONS FOR THIS KEY QUESTION ARE LOOKING AT TYPES OF INTERVENTIONS THAT USE FORM OF TECHNOLOGY TO AUTOMATICALLY IDENTIFY OR DIRECTLY INTERACT WITH PATIENTS TO IMPROVE PREVENTIVE SERVICES. OUR COMPARISONS ARE THE TYPES OF STUDIES IN A LOOK AT INTERVENTION COMPARED WITH NO INTERVENTION, OR USUAL CARE, OR LOOK AT POPULATIONS WHO ARE ADVERSELY AFFECTED BY DISPARITIES VERSUS THOSE WHO ARE NOT. THE OUTCOMES INCLUDE INTERMEDIATE OUTCOMES, ACCESS TO PREVENTIVE SERVICES LIKE SCREENING RATES, AND CLINICAL OUTCOMES INCLUDES INCIDENCE, MORBIDITY, MORTALITY, BURDEN OF DISEASE AND OTHERS THAT ARE RELEVANT TO THOSE CLINICAL HEALTH OUTCOMES. THE STUDY DESIGNED FOR KEY QUESTION 4 INCLUDE CONTROLLED CLINICAL TRIALS AND COHORT STUDIES. SO WHAT ARE HEALTH INFORMATION TECHNOLOGY INTERVENTIONS? WHAT WE MEAN HERE, WANTEDDED TO GIVE SOME EXAMPLE OF TYPES OF INTERVENTIONS INCLUDED ARE AUTOMATED TEXT MESSAGE REMINDERS, INTERACTIVE ELECTRONIC KIOSKS TO DELIVER INTERVENTIONS WHERE THE PATIENT WOULD POTENTIALLY WALK UP TO AN INTERACTIVE TOOL OR UTILIZE THAT OR MULTI-MODAL INTERVENTIONS THAT MIGHT INCLUDE TECHNOLOGICAL COMPONENT. WHAT I MEAN BY THAT IS THAT IT COULD BE A WEBSITE OR INTERACTIVE VOICE RESPONSE SYSTEM AS PART OF AN INTERVENTION, AND SOME OF THE OTHER ELEMENTS OF THE INTERVENTION MAY NOT BE TECHNOLOGY BASED BUT IN ORDER TO BE INCLUDED IN THIS PARTICULAR QUESTION THERE HAS TO BE A TECHNOLOGY COMPONENT. WE LOOK AT STUDIES IN A UTILIZE ELECTRONIC HEALTH RECORDS BUT THEY HAVE TO BE USED TO AUTOMATE OR TRIGGER MESSAGES. IT DOESN'T INCLUDE INTERVENTIONS THAT USE H.R. TO REVIEW OR MANUALLY IDENTIFY PATIENTS. THERE ARE ALSO STUDIES IN A LOOK AT TELEMEDICINE VERSUS TELEPHONE COUNSELING, SO THAT DIGITAL INTERFACE BETWEEN PROVIDERS AND PATIENTS AS WELL, AND FOR KEY QUESTION 4, THERE ARE SEVEN RANDOMIZED CONTROLLED TRIALS INCLUDED. PREVENTIVE SERVICES, MAJORITY COVER CANCER SCREENING, THREE OF COLORECTAL, TWO BREAST CANCER, ONE FOR CERVICAL CANCER, THERE'S ONE STUDY OF SMOKING CESSATION AND ONE MORE MANAGEMENT OF OBESITY. POPULATIONS INCLUDED VULNERABLE, LOW INCOME, SAFETY NET CLINIC PATIENTS, RURAL, NATIVE ALASKA, AMERICAN INDIAN, LATINA WOMEN AND SOME OTHER MINORITIES AS WELL. AS A REMINDER AS WE MOVE THROUGH THE EVIDENCE WE USE THIS FOR GRADES AND STRENGTH OF APPLICABILITY AND YOU'LL SEE THIS IN SUMMARY TABLES. HIGH GRADE FOR EVIDENCE MEANS WE'RE VERY CONFIDENT THERE'S A TRUE EFFECT FOR THE INTERVENTION, WHEREAS FOR LOW WE'RE MORE LIMITED IN THE WAY THAT WE IN OUR CONFIDENCE IN TERMS OF WHAT THE EVIDENCE SHOWS AND WE NEED MORE EVIDENCE FOR THOSE PARTICULAR OUTCOMES. WHERE THERE'S INSUFFICIENT EVIDENCE THERE'S NO EVIDENCE OR NO CONFIDENCE, MEANING MAYBE IT WAS A POOR QUALITY STUDY OR THAT THERE AREN'T ANY STUDIES FOR THAT PARTICULAR OUTCOME AND THEN APPLICABILITY HAS THE SAME LEVEL, HIGH, MODERATE AND LOW, LOOKING AT LOW APPLICABILITY WOULD MEAN MAYBE RESULTS TO APPLY TO SELECTED POPULATIONS OR STUDY WAS CONDUCTED IN A SMALL POPULATION NOT NECESSARILY REPRESENTATIVE OF THE LARGER COMMUNITY IN THE U.S. RATHER THAN SOMETHING THAT WOULD ACHIEVE HIGH APPLICABILITY, WOULD APPLY WIDELY TO U.S. PRACTICE. I'M GOING TO START WITH EVIDENCE FOR TECHNOLOGY INTERVENTIONS AROUND COLORECTAL CANCER SCREENING. THE FIRST STUDY UTILIZED AN AID WITH PATIENT-ORDERED TESTS AND FOLLOW-UP MESSAGES. THEY USED A MOBILE PATIENT TECHNOLOGY FOR HEALTH THAT WAS LIKE AN — THEY USED AN IPAD TO DELIVER A BRIEF DECISION AID, LET PATIENTS ORDER TESTS AND SEND ELECTRONIC MESSAGES TO HELP WITH SCREENING AND SUPPORT. THIS INCREASED SCREENING RATES IN LOW INCOME PATIENTS. THE STRENGTH OF THE EVIDENCE AS WELL AS APPLICABILITY WAS LOW. THIS WAS A STUDY IN A SPECIFIC POPULATION AND COMMUNITY-BASED PRIMARY CARE PRACTICE IN NORTH CAROLINA. BUT CERTAINLY DEMONSTRATED FOR THIS GROUP OF VULNERABLE PATIENTS DESCRIBED BY THE STUDY AS LOW INCOME THIS WAS AN EFFECTIVE INTERVENTION. THE NEXT STUDY WAS ALSO A TRIAL THAT USED EHR TO IDENTIFY PATIENTS AND THEN AUTOMATE TELEPHONE CALLS, AND THIS INCREASED SCREENING RATES AS WELL IN LOW INCOME PATIENTS. THE EHR WAS USED TO IDENTIFY PATIENTS PAST DUE FOR SCREENING, THE INTERVENTION OCCURRD OVER THE COURSE OF SIX MONTHS, INCLUDED LETTERS, FOUR AUTOMATED TELEPHONE CALLS OVER THE INTERVENTION PERIOD. THERE WERE SOME OTHER MULTI-MODAL INTERVENTIONS BUT THE TECHNOLOGY PIECE WAS THE AUTOMATED TELEPHONE CALL AND THIS INCREASED SCREENING AT A YEAR FOR COLORECTAL CANCER, INCLUDING FOR COLONOSCOPY, FIT, OR FOBT IN THIS GROUP OF LOW INCOME PATIENTS. THE LAST STUDY THAT EVALUATED AN INTERVENTION FOR COLORECTAL CANCER SCREENING USED TEXT MESSAGES, IN ADDITION TO USUAL PHONE CALLS AND MAILINGS. AND NO DIFFERENCES WERE SEEN WHEN THEY COMPARED USUAL CALLS VERSUS AUTOMATED TEXT MESSAGES. THERE WERE THREE TEXT MESSAGE REMINDERS SENT ABOUT A MONTH APART TO A POPULATION OF ALASKA NATIVE AND AMERICAN INDIAN PATIENTS AND THERE WAS NO EFFECT THERE. THE NEXT GROUP OF STUDIES EVALUATED THE EFFECTIVE TECHNOLOGY FOR BREAST AND CERVICAL CANCER SCREENING. OVERALL, NONE OF THESE STUDIES WERE PARTICULARLY EFFECTIVE BUT I'LL WALK THROUGH EACH OF THE COMPONEENTS TO GET A SENSE OF WHAT THEY WERE DOING. BREAST CANCER SCREENING, EHR USED TO IDENTIFY PATIENTS PAST DUE FOR SCREENING AND THIS IS — IT'S THE SAME STUDY BUT ALSO DONE FOR COLORECTAL CANCER AND BREAST CANCER SCREENING IN THE SAME POPULATION OF PATIENTS. AND THEY USED THE AUTOMATED TELEPHONE CALLS, FOUR CALLS FOR THAT, AND THIS WAS NOT BE A EFFECTIVE INTERVENTION IN TERMS OF GETTING PATIENTS TO INCREASE SCREENING RATES. ANOTHER STUDY, ANOTHER TRIAL USED EHR-TRIGGERED REMINDER LETTERS FOR DIRECT REFERRAL TO SCREENING. AND THIS WAS DONE IN DETROIT, MICHIGAN, IN A LOW INCOME POPULATION, AND THE EHR TRIGGERED A LETTER TO VISIT THE PRIMARY CARE PHYSICIAN FOR MAMMOGRAPHY GETTING ANOTHER ARRANGEMENT THAT WAS NOT ELECTRONIC BASED. AND AFTER LOOKING AT SCREENING AT ONE YEAR THERE WAS NO EFFECT AMONG THIS POPULATION OF LOW INCOME PATIENTS. FOR CERVICAL CANCER SCREENING, THERE WERE ELECTRONIC EDUCATION MODELS, AND SO THERE WAS A ONE-TIME INTERACTIVE MODEL, AT A TOUCH SCREEN KIOSK TO EDUCATE PATIENTS ABOUT CERVICAL CANCER SCREENING WHICH INCLUDED KNOWLEDGE AND RISK FACTORS, SCREENING PROCEDURES, INFORMATION ABOUT THE TEST ITSELF. AND THE OUTCOME WAS WITHIN SIX MONTHS OF RECEIVING THE INTERVENTION, NO EFFECT FOR THOSE RECEIVING THE INTERVENTION VERSUS THOSE WHO DIDN'T. THIS TRIAL WAS DONE AMONG LOW INCOME LATINA WOMEN IN CALIFORNIA. NEXT WAS SMOKING CESSATION AND OBESITY MANAGEMENT. ONE STUDY OF SMOKING CESSATION AMONG RURAL LOW INCOME PATIENTS, HOW TELEMEDICINE WOULD WORK FOR COUNSEL. SO PATIENTS RECEIVED COUNSELING SESSIONS THROUGH THE CLINIC, MOVED INTO A SEPARATE SPACE AND THERE WAS A CONNECTION TO A TELEMEDICINE COUNSELOR. SO IT WAS LIKE A VIRTUAL VISIT ESSENTIALLY. THEY FOUND THERE WAS NO DIFFERENCE IN QUIT RATES AMONG THIS LOW INCOME RURAL PATIENT AND SO THEY HOOKED AT SMOKING CESSATION AT SIX MONTHS FOR TELEMEDICINE VERSUS TELEPHONE ENCOUNTERS AND THERE NO DIFFERENCE IN QUIT RATES FOR THAT PARTICULAR POPULATION. THE ONE STUDY OF OBESITY MANAGEMENT LOOKED AT BEHAVIORAL CHANGE COUNSELING WITH A WEB OR TELEPHONE-BASED PATIENT SELF MONITORING AND PROGRESS, AND THE POPULATION INCLUDED AS DESCRIBED BY THE STUDY RACIAL ANDETHNIC MINORITIES IN THREE CENTERS IN BOSTON, TWO-YEAR MULTI-MODAL INTERVENTION INCLUDING EDUCATION ABOUT BEHAVIOR CHANGE GOALS, PATIENT SELF MONITORING, FEEDSBACK AND THE REALTIME FEEDBACK CAME THROUGH A WEBSITE OR INTERACTIVE VOICE RESPONSE SYSTEM. COUNSELING AND CALLS DELIVERED BY COMMUNITY HELD EDUCATORS, OPTIONAL GROUP SESSIONS, A LOT OF COMPONENTS THERE, BUT THE TECHNOLOGY PIECE WAS USING THE WEBSITE AND INTERACTIVE VOICE RESPONSE SYSTEM. THEY DID FIND MODESTLY DECREASED BMI IN THE INTERVENTION GROUP OVER 24 MONTHS. IT WAS ABOUT .38 WAS THE DIFFERENCE THERE. AND THAT WAS STATISTICALLY SIGNIFICANT. AND THERE BE WAS DECREASED BMI FOR THE INTERVENTION GROUP OVER THE 24-MONTH PERIOD IN THIS GROUP OF ETHNIC AND RACIAL MINORITIES. SO TO SUMMARIZE ALL OF THE SEVEN HEALTH TECHNOLOGY INTERVENTIONS, OVERALL THERE WAS SOME MIXED RESULTS BUT THE MAJORITY OF THEM WERE NOT EFFECTIVE. FOR THE INTERVENTION USING ELECTRONIC DECISION AID FOLLOW-UP REMINDERS AND SELF ORDERED TEST THIS WAS EFFECTIVE FOR COLORECTAL CANCER SCREENING. AUTOMATED TEXT MESSAGE REMINDERS WERE NOT EFFECTIVE FOR COLORECTAL CANCER OR BREAST CANCER SCREENING. MULTI-MODAL INTERVENTION WAS EFFECT INCH FOR EFFECTIVE FOR COLORECTAL CANCER BUT NOT BREAST CANCER SCREENING. AUTOMAED LETTERS WERE NOT EFFECTIVE FOR BREAST CANCER SCREENING. UTILIZATION OF INTERACTIVE TOUCH SCREEN KIOSK WAS NOT EFFECTIVE FOR CERVICAL. TELEMEDICINE-DELIVERED COUNSELING INEFFECTIVE FOR SMOKING CESSATION, AND MULTI-MODAL INTERVENTION USING WEB PLATFORM OR INTERACTIVE VOICE RESPONSE SYSTEM TO MONITOR PROGRESS AND RECEIVE REALTIME FEEDBACK WAS EFFECTIVE FOR OBESITY MANAGEMENT. THERE ARE SOME LIMITATIONS OF OUR RESULTS HERE. THE NUMBER, QUALITY AND APPLICABILITY OF STUDIES VARIED. THERE WERE SEVEN STUDIES OF HEALTH INFORMATION TECHNOLOGY. AND MANY OF THE PATIENT POPULATIONS THAT WE KNOW ABOUT THAT WOULD BE INCLUDED AND CONSIDERED AT RISK FOR DISPARITIES WERE NOT STUDIED IN THESE STUDIES. PATIENT POPULATIONS MAY NOT HAVE BEEN CLEARLY DEFINED, JUST AN OVERARCHING DESCRIPTION OF LOW INCOME BUT MAYBE WE DIDN'T KNOW OTHER NUANCE FOR THOSE POPULATIONS. THERE WERE LACK OF STANDARDIZED INTERVENTIONS ACROSS ALL OF THE INTERVENTIONS SO THEY WERE ESSENTIALLY SOMEONE ELSEWHERE WE SAW HOW AN INTERVENTION WORKED IN ONE POPULATION BUT THAT DOESN'T MEAN IT MAY NOT WORK IN ANOTHER OR THAT IT WOULD WORK IN A DIFFERENT POPULATION. SO WE WANT TO BE CAUTIOUS THERE. IT'S UNCLEAR HOW TECHNOLOGY COMPONENTS IMPACTED OUTCOME WHEN WE HAVE SOME MULTI-MODAL INTERVENTIONS SO IF WE COULD DRILL DOWN ON HOW THAT PARTICULAR INTERVENTION AFFECTED WHEN WE HAVE A MULTILEVEL INTERVENTION. A LACK OF STUDIES AND SMALL NUMBERS OF PARTICIPANTS IN MANY OF THEM. FUTURE RESEARCH NEEDS FOR HEALTH INFORMATION TECHNOLOGY, STUDIES THAT INCORPORATE HEALTH INFORMATION TECHNOLOGY TO IMPROVE ACCESS AND EXPAND PREVENTIVE SERVICES AND TARGET POPULATIONS WE STARTED TO TALK ABOUT THIS A BIT YESTERDAY WHEN WE WERE THINKING ABOUT IMPLEMENTING TECHNOLOGY AND UTILIZING EHRs, AND THERE'S CERTAINLY MANY OPPORTUNITIES TO KIND OF PLACES WHERE WE COULD LOOK AT ELEMENTS OF EHR USING THEM IN AN AUTOMATED WAY, TELEMEDICINE IS INTERESTING AS PATIENTS WHEN WE'RE THINKING ABOUT RURAL POPULATIONS, THINKING ABOUT THE EFFECT OF REACHING HARD TO REACH POPULATIONS BY WAY OF INTERACTIVE VIRTUAL VISITS, COULD THOSE BE EFFECTIVE IN DIFFERENT SITUATIONS. THEY WEREN'T EFFECTIVE FOR THIS PARTICULAR GROUP OF STUDIES BUT CERTAINLY THERE ARE LOTS OF OPPORTUNITIES TO STUDY TECHNOLOGY AND SOME OF THAT'S IN THE WORKS. STUDIES OF ADDITIONAL PREVENTIVE SERVICES, THOSE NOT EVALUATED BY THE SEVEN STUDIES WE INCLUDED, INCLUDED LUNG CANCER SCREENING, HIGH BLOOD PRESSURE, TYPE 2 DIABETES SCREENING, ASPIRIN USE FOR CARDIOVASCULAR DISEASE AND COLORECTAL CANCER, AND HELPFUL DIET AND PHYSICAL ACTIVITY FOR CARDIOVASCULAR DISEASE PREVENTION. SO KEY MESSAGES FOR KEY QUESTION 4, THESE HEALTH INFORMATION TECHNOLOGY INTERVENTIONS VARIED WIDELY IN THEIR APPROACH AND COMPONENTS, SOME WERE REALLY SIMPLE, SOME USED AUTOMATED MESSAGING, SOME USED TEXT MESSAGE REMINDERS AND MULTI-MODAL INTERVENTIONS AND SOME OF THE WAYS THAT WE COULD SORT OUT HOW EFFECTIVE HEALTH INFORMATION TECHNOLOGY WAS IN THOSE MULTI-MODAL INTERVENTIONS. MOST OF THE INTERVENTIONSES WERE INEFFECTIVE, ALTHOUGH MOST STUDIES WERE SMALL AND INCONCLUSIVE SO THAT'S IMPORTANT TO CONSIDER WHEN WE'RE LOOKING AT SOME OF THE NUMBER OF PATIENTS INCLUDED, TYPES OF POPULATIONS AND ELEMENTS OF THE TECHNOLOGY, AS THOSE NEW TECHNOLOGIES EMERGE WE CAN THINK OF DIFFERENT WAYS TO EVALUATE THEM. AND IN GENERAL, FEW STUDIES HAVE BEEN DONE. WE'RE AT THIS PRECIPICE ESSENTIALLY OF WHEN WE'RE — THERE'S SO MANY WAYS THAT TECHNOLOGY IS BEING UTILIZED IN SOCIETY, SAND HOW CAN WE OPTIMIZE THAT IN MEDICINE, AND IN COMMUNITY HEALTH AND PUBLIC HEALTH. AND SEEMS LIKE THERE'S MANY OPPORTUNITIES, BUT CERTAINLY WE NEED TO EVALUATE THEM ON THE PATIENT CARE LEVEL, SO THAT WOULD BE AN IMPORTANT MESSAGE. AND THEN LIMITED APPLICATION TO OTHER POPULATIONS OR CLINICAL SETTINGS, SO REALLY LOOKING TO EVALUATE HOW THIS CAN BE ADOPTED IN MULTIPLE SETTINGS AND DIFFERENT TYPES OF POPULATIONS, AND FOR DIFFERENT PURPOSES. SO THOSE ARE GENERALLY THE MAIN MESSAGES FOR THE HEALTH INFORMATION TECHNOLOGY. OUR FULL EVIDENCE REPORT IS AVAILABLE CURRENTLY ONLINE AND WE WELCOME COMMENTS FOR THAT AND SUGGESTIONS CERTAINLY. WE'RE DOING AN UPDATED SEARCH, OUR SEARCH FROM THIS PARTICULAR DRAFT OF THE REPORT WENT THROUGH AUGUST OF 2018, WE'RE UPDATING AND LOOKING FOR STUDIES COMING OUT ABOUT HEALTH INFORMATION TECHNOLOGY AND HOW THAT RELATES TO PREVENTIVE SERVICES. SO THANK YOU. >> I'M GARY BENNETT FROM DUKE, A RESEARCH CENTER LOOKING AT THE IMPACT OF DIGITAL HEALTH TECHNOLOGY. MOST OF OUR WORK, MY DISCLOSURES, I WORK WITH WEIGHT WATCHERS AND INTERACTIVE HEALTH, SCIENCE ADVISORY BOARDS, A NON-PROFIT ORGANIZATION, INVESTED IN PHYSICAL ACTIVITY PROMOTION AMONG BLACK WOMEN. ONE OF THE DOWN SIDE RISKS OF HAVING BEEN SUBJECT TO LOTS OF MEDIA ATTENTION ABOUT OBESITY EPIDEMIC IS YOU CAN HABITUATE TO ITS MAGNITUDE AND THE FACT IS WE HAVE 93 MILLION AMERICANS WITH OBESITY, AND VERY FEW TREATMENT SOLUTIONS THAT ARE AVAILABLE TO THEM TODAY. THE PROBLEM IS PARTICULARLY DAUNTING I WOULD SAY MEDICALLY VULNERABLE COMMUNITIES, 7 OUT OF 10 HAVE THE CONDITION. IT'S NOT JUST THAT, FOLKS IN MEDICALLY VULNERABILITIER IN COMMUNITIES MORE LIKELY TO HAVE OBESITY AND CHRONIC DISEASES THAT TRAVEL WITH IT, THIS DRIVE HEALTH COSTS AND ARE LESS LIKELY TO RECEIVE TREATMENT. MOST AMERICANS DON'T RECEIVE TREATMENT IN PRIMARY CARE AND THOSE WHO HAVE THE
HIGHESTT,- RISK OF OBESITY ARE THE LEAST LIKELY TO RECEIVE THAT TREATMENT. AND SO THE ADDITIONAL PROBLEM, THE ONE WE SPEND MOST OF OUR TIME CONTENDING WITH IS THAT EVEN WHEN TREATED, PATIENTS WHO ARE MEDICALLY VULNERABLE ARE LESS LIKELY TO BE SUCCESSFUL. THIS IS WHAT OBESITY TREATMENT LOOKS LIKE, GENERALLY THIS IS OFTEN REFERRED TO AS GOLD STANDARD OBESITY TREATMENT, AND SO WHAT WE CAN TAKE AWAY FROM THIS IF YOU'RE NOT A BEHAVIORAL SCIENTIST, IT'S A LOT, EXTRAORDINARILY INTENSIVE COURSE OF TREATMENT THAT TAKES A LOT OF TIME AND REQUIRES — IT'S EXPENSIVE AND REQUIRES A LOT OF PATIENTS. IT'S NO SURPRISE THAT OVER SEVERAL GENERATIONS THE ONE CONSISTENT FINDING IN BEAST TREATMENT LITERATURE IS DISPARATE OUTCOMES. IN GENERAL, YOU SEE SOMEWHERE BETWEEN A THIRD AND TWO-THIRDS OF WEIGHT LOSS EFFECTS YOU SEE IN MAJORITY POPULATIONS, THE PROBLEM IS WEIGHT LOSSES BELOW THE LEVEL OF WEIGHT LOSS WE BELIEVE TO BE CLINICAL MEANINGFUL, PRODUCES POSITIVE CHANGES. WE LACK SOLUTIONS FOR THOSE AT HIGHEST RISK. WE AND OTHERS HAVE BEEN INTERESTED IN IMPACT DIGITAL TREATMENTS TO HELP CONTEND WITH THE PROBLEM BECAUSE WE CAN DO A BETTER JOB PERSONALIZING THEM AND BECAUSE OF THE INHERENT DISSEMINATION POTENTIAL OF DIGITAL TECHNOLOGIES. AND WHAT WE KNOW ABOUT THESE STRATEGIES, I'D ARGUE THESE ARE THE BEST STUDIED TECHNOLOGIES IN THE HEALTH SPACE, YOU SEE MOST OF THE DATA FOR WEIGHT LOSS, IN ALL POPULATIONS YOU SEE 5 KILOS AT SIX MONTHS. HOWEVER, WHEN YOU LOOK IN THE PRIMARY CARE SETTING WHERE WE SPEND OUR TIME YOU SEE SOMEWHAT LESS, SMALL ARE OUTCOMES. THIS WAS AT HOPKINS A FEW YEARS AGO, U01 NETWORK OF TRIALS, 4-KILOS, CLINICALLY MEANINGFUL, AT ONE YEAR,S MAXIMUM YOU'RE LIKELY TO DETECT. HE HAD TWO ACTIVE TREATMENT CONDITIONS, ONE OF THOSE USED DIGITAL MODALITIES. WHEN WE SEE THE OPPORTUNITY HERE IS THAT IN MANY MEDICALLY VULNERABILITIER IN COMMUNITIES IN WHICH WE WORK, YOU CERTAINLY SEE THIS NATIONWIDE, WE REALLY HAVE NEW DIGITAL DIVIDES. THERE'S A TEMPTATION TO TALK ABOUT THE LACK OF ACCESS TO DIGITAL TECHNOLOGIES IN THESE POPULATIONS, BUT INDEED THEY ARE MOBILE FIRST, THEY ARE MOBILE ONLY, AND FOR SOME GROUPS YOU ACTUALLY SEE REVERSE DIVIDES IN AS MUCH AS BLACKS AND HISPANICS ARE MORE LIKELY TO OWN MOBILE PHONES, BUT MORE IMPORTANTLY TO USE THEM FOR A WHOLE HOST OF DATA-RELATED PURPOSES, THOSE OF WHICH YOU SEE HERE. NO SURPRISE PLATFORMS LIKE TWITTER AND FACEBOOK ARE DISPROPORTIONATELY BLACK
AND LATINO, AN OPPORTUNITY TO CONTEND WITH DISPARITIES PARTICULARLY WE OBSERVE IN OBESITY TREATMENT. I'M NOT GOING TO SPEND TIME ON THIS BUT JUST NOTE THERE'S A SIZEABLE LITERATURE ABOUT HOW TO MAXIMIZE TREATMENT OUTCOMES USING DIGITAL MODALITIES, YOU CAN SUMMARIZE THIS WAY. SO WE TRIED TO INCORPORATE MANY OF THESE STRATEGIES IN OUR TOOLS. I WILL SPEND A SECOND TELLING YOU ABOUT OUR APPROACH BECAUSE IT WAS DESIGNED SPECIFICALLY WITH MEDICALLY VULNERABLE POPULATIONS IN MIND, BASIS FOR WHAT I'M ABOUT TO TELL YOU NEXT. SO WE CREATED THIS APPROACH CALLED IOTA. IN ORDER TO LOSE A POUND OR TWO A WEEK, A HEALTHY AMOUNT OF WEIGHT LOSS, ONE MUST CREATE A 500-CALORIE DEFICIT EACH DAY. THERE'S VARIABILITY BUT IT'S ABOUT THAT. YOU CAN GET THERE IN A VARIETY OF WAYS. ONE IS BY HAVING PEOPLE DO COMMON SENSE BEHAVIORS THEY ALREADY KNOW HOW TO DO, EACH OF THESE THINGS HAS A CALORIE DEFICIT, AND IF YOU SUM THEM YOU CAN GET TO THE MAGIC 500 CALORIES PER DAY. THE TRICK IS HOW YOU PRESCRIBE THIS FOR PATIENTS WHO ARE DIFFERENT — – HAVE DIFFERENT CHARACTERISTICS. WOMAN MID-30s MIGHT HAVE GOALS LIKE THIS, MAN OLDER MIGHT NEED GOALS LIKE THAT. DIGITAL APPROACHES WORK WELL. WHAT WE DO WITH IOTA IS TO ADMINISTER SURVEYS, ASSESS A RANGE OF FACTORS THAT PERTAIN TO A PATIENT'S LIKELIHOOD OF ENGAGING IN TREATMENT OVER THE LONG TERM SO WE HAVE THEM FILL OUT A SURVEY IN THE CLINIC, USUALLY ON AN IPAD, ALMOST NONE OF OUR PATIENTS HAVE USED A KEYBOARD OR MOUSE. AND THEN WE SEND THOSE DATA INTO THE SKY WHERE ESSENTIALLY THEY RUN AGAINST ALGORITHMS, WHERE WE THEN REACH DEEP INTO LIBRARIES, GIVE THEM GOALS AND SELF MONITOR ADHERENCE OVER AN EXTENDED TIME HORIZON. WE ASK THEM TO SELF MONITOR EACH DAY IN SOME TRIALS, WEEKLY IN OTHERS, VARYING OUTCOMES, I CAN TALK ABOUT THOSE IF YOU'RE INTERESTED. WE PUT DEVICES IN PEOPLE'S HOMES, CONNECT TO CELLULAR NETWORK IN RURAL AREAS IN NORTH CAROLINA, AND THEN EVERY TIME THEY TRACK WE PROVIDE PERSONALIZED FEEDBACK, YOU SEE AN EXAMPLE OF FEEDBACK HERE. I WON'T SPEND TIME ON THIS. WE USE A.I.-STYLE STRATEGIES ESSENTIALLY TO PUT TOGETHER SNIPPETS OF FEEDBACK USING INTERACTIVE VOICE RESPONSE OR TEXT MESSAGES. AMAZON ECHO NOW, THE IDEA TO PIECE THESE TOGETHER IN ORDER TO PROVIDE SOMETHING LIKE THE KIND OF FEEDBACK YOU MIGHT RECEIVE IN COUNSELING ENCOUNTER. DIGITAL HEALTH WORKS BETTER WITH A HUMAN INVOLVED SO WHAT WE PROVIDE SUPPORT OF ALL TYPES, ONCE WE HAVE THE DATA WE CAN PRESENT TO THE CARE PROVIDERS IN A WAY CARE PROVIDERS CAN BEST USE THEM. REGISTERED DIETITIANS IN CLINIC WE LIKE TO SEE A LOT OF DATA, DEEP DASHBOARDS, BUT FOR OUR PHYSICIAN COLLEAGUES WHO ARE GOING TO BE PROVIDING COUNSELING, IN SHORT AMOUNT OF TIME, COMPLEX PATIENTS, WE GIVE THEM EXACTLY WHAT WE NEED, THIS IS HARD FOR YOU TO SEE BUT IT'S A SCRIPT THAT SAYS TELL YOUR PATIENT WHO IS IN THIS STUDY SHE'S LOST X AMOUNT OF POUNDS, REINFORCE SHE'S DONE WELL AND SAY THAT. AND SO OVER THE LAST DECADE AND A HALF WE'VE DONE ABOUT A HALF DOZEN RANDOMIZED CONTROLS MOSTLY IN OBESITY SPACE, YOU HEARD ABOUT ONE. AND WE'VE TESTED THIS APPROACH AND IT WORKS FOR A RANGE OF OUTCOMES THAT YOU SEE HERE. I THOUGHT I WOULD IN THE SPIRIT OF THE QUESTION TALK ABOUT ONE OF THOSE STUDIES, WHICH IS CALLED TRACK. I DO THINK THIS ILLUSTRATES THE POTENTIAL OF UTILIZING ADVANCED TECHNOLOGY IN PRIMARY CARE SETTINGS THAT SERVE MEDICALLY VULNERABLE PATIENTS. WE CREATED TACK. THE BEAUTY OF THE HEALTH SYSTEM, THEY HAVE A ROBUST HEALTH RECORD NOT LINKED WITH A MAJOR CENTER, JUST THEIR OWN HEALTH RECORD. THE ADVANTAGE HERE IS THAT — WE CREATED TRACK AS TECHNOLOGY TO INTEGRATE WITH EXISTING HEALTH RECORD, ALREADY SINGLE SOURCE OF TRUTH BETWEEN PROVIDERS, MEANING THEIR PHYSICIAN PROVIDERS AND ANCILLARY CARE PROVIDERS. THEY HAD NOT HAD STRATEGIES THAT ALLOWED PATIENTS TO PROVIDE DATA. THE TRACK TRIAL WE COMPLETE THE LAST YEAR, PREDOMINANTLY WOMEN, ABOUT HALF BLACK, I'LL NOTE THAT THIS IS REALLY A GROUP OF FOLKS WHO WERE IN THE WORKING POOR, AND SO THAT PUTS A HOST OF CONSTRAINTS ON YOUR ABILITY TO ENGAGE IN THE CARE SETTINGS TO GET TO THE CARE SETTINGS SO UTILIZING TECHNOLOGY OFFERS A GREAT OPPORTUNITY TO ENGAGE THEM AT A DISTANCE. JUST TO FAST FORWARD TO THE END, WE SEE ABOUT 4-KILOS WEIGHT LOSS AT 12 MONTHS IN COMPARISON TO WHAT YOU'D SEE AS A GOLD STANDARD, WE GET CLOSE TO THAT, I WANT TO HIGHLIGHT THESE CAN WORK AND CAN WORK AT LEVELS THAT APPROXIMATE WHAT YOU'D SEE IN OTHER POPULATIONS. NOTABLY WE SEE HIGH RATES OF ENGAGEMENT USING THESE TECHNOLOGIES, WE'RE ASKING PATIENTS TO USE THESE TOOLS EACH AND EVERY WEEK OVER THE COURSE OF A YEAR OR TWO. IF YOU ASK ME HOW OFTEN THEY DO IT, THEY DO IT A LOT. WE SEE HIGH RATES OF ENGAGEMENT. IF WE LOOK AT OBSERVED, HOW OFTEN ARE THEY USING TECHNOLOGY, �RECOMMENDATION.ERENCE TO THAT IF THEY TRACK MORE, IF THEY ARE USING TECHNOLOGIES MORE, WE SEE LARGER OUTCOMES, ABOUT A THIRD OF PATIENTS TRACK MORE THAN 80% OF THE WEEKS AND IF THEY DO THAT THEY LOSE AN EXTRA 5 KILOS. IF THEY WEIGH THEMSELVES DAILY, WE HAVE NETWORK-CONNECTED SCALES IN HOMES, IF THEY ARE WEIGHING DAILY, WE COUNT THIS AS SIX OUT OF SEVEN DAYS, 40%, THEY LOSE AN EXTRA 7 1/ 1/2 KILOS. IF THEY ARE DOING EVERYTHING, ESSENTIALLY THEY LOSE ALMOST 8-KILOS MORE. AS WE GET BETTER AS PRODUCING ENGAGEMENT WE MIGHT IMAGINE OUTCOMES WILL GET BETTER. WE SEE WEIGHT LOSS SIMILAR TO OTHER PRIMARY CARE TRIALS, FROM THE APPLE TRIAL EARLIER TO NOTE THAT WE CAN ACHIEVE OUTCOMES THAT ARE SIMILAR, AS WE SEE IN OTHER POPULATIONS. BUT NOTABLY, IMPROVING CLINICIANS HELPS, AND THIS HAS BEEN SOMETHING THAT FOLKS IN MY FIELD STRUGGLED WITH FOR SOME TIME. MANY STUDIES INCLUDING THE ONE YOU HEARD ABOUT EARLIER THAT WE'VE DONE DON'T INCLUDE PHYSICIAN PROVIDERS, MOSTLY BECAUSE THEY HAVE SO MUCH TO DO IN THESE SETTINGS SO WE THINK ABOUT THE TECHNOLOGIES AS OFFLOADING CLINICAL RESPONSIBILITY FROM THEM BUT INCLUDING PROVIDERS IS EXTRAORDINARILY POWERFUL, IN FACT. AT THE END OF THE TRIAL, A PAPER THAT JUST CAME OUT WE ASK PATIENTS DID OUR DOC COUNSEL YOU ON DIET, EXERCISE, WEIGHT LOSS, YOUR INVOLVEMENT IN THE TRIAL? WE SEE NO EFFECT IF A PATIENT SAID HER DOCTOR COUNSELED HER IN A GENERIC WAY BUT IF A PATIENT NOTES HER DOCTOR DID WHAT WE ASKED THE DOCTOR TO DO, READ THIS SNIPPET AND REINFORCE PARTICIPATION, THEY LOSE AN EXTRA 4 1/2 KILOS, IT POINTS TO PATIENT CENTEREDNESS, IMPORTANCE OF ACCOUNTABILITY, PROVIDING PROVIDERS WITH DATA THAT WILL ALLOW THEM TO BE ABLE TO DO A VERY SMALL INTERVENTION, TINY DOSE AND HAVE A REASONABLE SIZEABLE EFFECT. AND I THINK MY KEY POINT IS THESE DIGITAL THERAPEUTICS HAVE POSSIBILITY OF WORKING FOR EVERYONE. THE QUESTION I WAS REALLY ASKED TO ANSWER IS WHAT CAN PROVIDERS DO TO INCORPORATE THESE KINDS OF TECHNOLOGIES INTO THEIR PRACTICE. AND THE ANSWER IS VERY, VERY LITTLE. THAT IS BECAUSE DIGITAL TECHNOLOGY REQUIRES INFRASTRUCTURE. THERE IS AN OFT NOTED KIND OF NOTION THAT THE ADVANTAGE OF DIGITAL HEALTH TECHNOLOGIES IS IN THEIR SCALABILITY. THAT'S TRUE. BUT THEY ARE ONLY SCALABLE ONCE THEY HAVE A FOUNDATION, THAT IS COSTLY AND THAT REQUIRES A SIGNIFICANT AMOUNT OF THOUGHT. ANY KIND OF DIGITAL TECHNOLOGY, WHETHER VOICE RESPONSE, TEXT MESSAGING, WEB, MOBILE, APP, AMAZON, USER INTERFACE TOOLS REQUIRES TECHNOLOGY, MAINTENANCE A STARTUP THAT ESSENTIALLY RECRUITED 10,000 NEW USERS WITHIN THE FIRST MONTH AND WITHIN THAT FIRST MONTH THIS IS A TECHNOLOGY THAT REQUIRED NO USE OF WI-FI THERE WERE HUNDREDS AND HUNDREDS OF TELEPHONE CALLS ASKING ABOUT HOW TO FIND THE WI-FI PASSWORD. ONE HAS TO PREPARE WHEN YOU LAUNCH FOR AN ONSLAUGHT OF TECH SUPPORT AND CUSTOMER SERVICE OUT OF BOUNDS FOR MOST CARE SETTINGS, IN LARGE PART MANY ACADEMIC CARE CENTERS DON'T HAVE ROBUST DIGITAL HEALTH TOOLS JUST YET. WE WILL HAVE TO THINK ABOUT HOW TO HANDLE SOME OF THESE CONCERNS TO SEE WIDESPREAD IMELEMENTATION OF TECHNOLOGIES IN CARE SETTINGS. WE TALK ABOUT DISSEMINATION ABOUT IMPACT OF DOCTORS, PEOPLE WHO ULTIMATELY USE THESE TECHNOLOGIES. IN THE DIGITAL WORLD ADOPTERS ARE UNLIKELY TO BE THE SETTING IN WHICH TECHNOLOGIES ARE BEING TESTED. THAT IS TO SAY VERY FEW COMMUNITY HEALTH CENTERS, VERY FEW ACADEMIC MEDICAL CENTERS, VERY FEW HELD SYSTEM ACTORS OF ANY TYPE WILL BE THE PRIMARY ADOPTERS OF THE TECHNOLOGIES THAT I TEST IN MY RESEARCH TRIALS. IT'S FAR MORE LIKELY THE TRUE ADOPTERS ARE GOING TO BE FOLKS LIKE THESE. MANY OF THESE VENDORS WHO SELL EHR TOOLS OR PORTAL VENDORS OR HRA TOOLS OR WEIGHT LOSS STARTUPS, WELLNESS, DEVICE MAKERS ARE PRIMARY ADOPTERS OF THE TECHNOLOGY AND ESSENTIALLY SELL THEIR FOUNDATION, THE PLATFORMS, INTO THE HEALTH SYSTEMS WHERE TECHNOLOGIES ARE ULTIMATELY ADOPTED. IF WE DON'T UNDERSTAND THE ADOPTION CONSIDERATIONS OF THIS GROUP, IT WILL BECOME VERY CHALLENGING TO DISSEMINATE EVIDENCE-BASED TECHNOLOGIES INTO ANY CARE SETTING PARTICULARLY THOSE THAT SERVE MEDICALLY VULNERABLE PATIENTS. BY WAY OF EXAMPLE WE CONDUCTED A TRIAL THAT UNIDENTIFIED ON A OUR IOTA SYSTEM SEVERAL YEARS, CALLED SHAPE, I WON'T SPEND TIME BUT NOTE IT WAS AN INTERACTIVE VOICE RESPONSE SYSTEM, VERY INEXPENSIVE, WE PUBLISHED A COST EFFECTIVENESS PAPER A FEW DAYS AGO THAT ESSENTIALLY ASKED PEOPLE TO TRACK ALL THOSE IOTA GOALS VIA TELEPHONE AND PROVIDED PERSONALIZED FEEDBACK EACH WEEK. ESSENTIALLY WE SHOWED YOU CAN PREVENT WEIGHT GAIN FOR UP TO FOUR YEARS. SO IT WAS SUCCESSFUL, BUT YOU SEE IN THE PURPLE BOX THE WAY WE TEST THE ESSENTIALLY INTERVENTION COMPONENTS AS TESTED IN OUR TRIAL. I CAN TELL YOU QUITE CLEARLY THERE'S NO PAYER IN THE COUNTRY WHO WOULD IMPLEMENT THE WAY WE TESTED, THAT'S DOUBLY TRUE FOR VENDORS, ULTIMATE ADOPTERS OF THE TRIALS. IT'S NOT JUST THAT THEY ARE MORE LIKELY TO USE DIFFERENT TYPES OF COACHES AND DIFFERENCE TYPES OF TECHNOLOGIES, THEY MAY HAVE DIFFERENT EXPECTATIONS ABOUT PROVIDER INVOLVEMENT, IT'S ALSO THE OUTCOMES OF INTEREST THAT DRIVE ADOPTION CONSIDERATIONS ARE QUITE DIFFERENT, FOR VENDORS THEY MAY BE FOCUSED ON RETURN ON INVESTMENT AND COST CONSIDERATIONS MAY BE MORE DRAMATIC FOR PAYERS. SO I THINK THIS IS IMPORTANT AS WE BEGIN TO MOVE BEYOND THE EFFICACY STAGE IN DIGITAL HEALTH SPACE AND MOVE DOWN THE TRANSLATION CONTINUUM. WE HAVE TO GET MORE SOPHISTICATED AS A FIELD THINKING ABOUT HOW TOOLS ARE ULTIMATELY ADOPTED AND ARE IMPLEMENTED IN PRACTICE. SO IN CONCLUSION LET ME SAY I THINK THESE DIGITAL TREATMENTS CAN COMPLEMENT CARE IN A SIGNIFICANT WAY, THEY CAN ENGAGE PATIENTS OVER THE LONG TERM. WHEN I'M ON THE WEST COAST AND TALK ABOUT ENGAGEMENT WITH THESE TECHNOLOGIES IN LOW INCOME POPULATIONS PEOPLE FIND IT HARD TO BELIEVE. EVERYONE USES IT FOR 30 DAYS AND STOPS, THEY WILL USE IT FOR A LONG TIME HORIZON. THEY DON'T COST MUCH, THEY SCALE BUT HAVE TO BE DESIGNED WELL. TO GET DISSEMINATION PIECE REQUIRES SERIOUS PARTNERSHIP. MY RECOMMENDATION AS RELATE TO THIS QUESTION WE NEED TO THINK MORE ABOUT MOVING TRIALS PARTICULARLY HYBRID EFFECTIVE EFFICACY TRIALS TO HEALTH CARE PARTICULARLY IN THE DIGITAL SPACE. IT'S THERE WHERE WE'RE GOING TO FIND THE NEXUS OF ANCILLARY AND HAVE THE GREATEST OPPORTUNITIES. WE DO NEED TO TALK TO VENDORS AND PAYERS ABOUT THEIR ADOPTION CONSIDERATIONS AND ACTUAL OUTCOMES THEY ARE FOCUSED ON, MOST OF OUR PAYER COLLEAGUES AND MANY VENDOR COLLEAGUES ARE NOT INTERESTED IN SINGLE OUTCOME TRIALS. THEY ARE FAR MORE INTERESTED IN LOOKING IT'S A — AT A MORE PERSON APPROACH TO OUR PATIENTS. I THINK YOU CAN USE THE SBIR MECHANISM AS A MODEL TO THINK ABOUT DISSEMINATION AND IMPLEMENTATION TRIALS THAT INCLUDE INDUSTRY PARTNERS. WE NEED TO PUSH TOWARD GREATER MOBILE ADOPTION, INTERFACE, WHERE MEDICALLY VULNERABLE POPULATIONS ARE. IT'S NOT THAT YOU JUST CAN REACH MEDICALLY VULNERABLE COMMUNITIES USING MOBILE DEVICES, IT'S THE BEST WAY IN HARD TO REACH POPULATIONS SO WE NEED TO THINK MORE ABOUT MOBILE ADOPTION GETTING MORE SOPHISTICATED WITH THE TECHNOLOGIES WE'RE USING THERE. THANK YOU VERY MUCH. I'M JESSICA ANCKER, FACULTY MEMBER AT WEILL CORNELL IN NEW YORK CITY, THE WORK IS AT OUR ACADEMIC MEDICAL CENTER AND ALSO WORK DONE IN COLLABORATION WITH INSTITUTE FOR FAMILY HEALTH, WHICH IS A FEDERALLY QUALIFIED HEALTH CENTER ALSO IN NEW YORK. OOPS, SORRY. I DON'T HAVE ANY CONFLICTS TO DISCLOSE. AND I WANT TO START WITH A LITTLE BIT OF A CAUTIONARY TALE. WE'RE ALL FAMILIAR WITH THE FACT THAT SMOKING RATES HAVE DROPPED DRAMATICALLY IN THIS COUNTRY, IN 1953 ALMOST HALF OF AMERICANS SMOKED, AND IN 2017 THIS WAS WAY DOWN, SO THIS IS CLEARLY A PUBLIC HEALTH SUCCESS STORY. HOWEVER, I'D LIKE TO POINT OUT AT THE SAME TIME WE INADVERTENTLY CREATED A NEW KIND OF PROBLEM. IN 1953, THERE WAS REALLY NO DISCREPANCY BETWEEN MORE EDUCATED AND LESS EDUCATED INDIVIDUALS IN TERMS OF SMOKING RATE. HOWEVER, MORE RECENTLY, WE SEE THAT PEOPLE WITH COLLEGE EDUCATION AND ABOVE HARDLY ANY OF THEM ACTUALLY SMOKE, AS OPPOSED TO MORE THAN A THIRD OF PEOPLE WITH HIGH SCHOOL EDUCATION OR BELOW. SO, THE SUCCESS STORY OF SMOKING CESSATION IS ONE IN WHICH WE INADVERTENTLY CREATED HEALTH DISPARITY. THE REASON I'M HERE IN THE INFORMATION TECHNOLOGY PANEL IS THAT MANY OF US WORKING IN THIS SPACE ARE A BIT WORRIED THAT INFORMATION TECHNOLOGY COULD IN FACT BE A NEW EXAMPLE OF GOOD INTENTIONS BUT ONES THAT CREATE DISPARITY WHEN THERE WAS NONE BEFORE. SO, I DON'T NEED TO TELL THIS AUDIENCE THAT WE KNOW PEOPLE WITH FEWER RESOURCES DEFINITELY HAVE WORSE HEALTH. BUT I DO WANT TO POINT OUT THAT THOSE WITH LESS RESOURCES ARE ALSO SLOWER TO ADOPT NEW TECHNOLOGIES. THIS IS SOMETHING THAT'S BEEN KNOWN SINCE THE MID-20TH CENTURY WHEN EVERETT ROGERS STUDIED FARMING COMMUNITIES AND WHO WAS LIKELY TO ADOPT NO ADOPT — NEW STRAINS OF CORN. EARLY ADOPTERS ARE LIKELY TO BE THE BEST EDUCATED AND AFLUENT THAT CAN TAKE A RISK WITHOUT CAUSING A DISASTER. LATER ADOPTERS TEND TO BE LESS AFFLUENT, DON'T HAVE THAT FINANCIAL ABILITY TO TAKE A RISK ON SOMETHING NEW. THEY ALSO TEND TO BE SLOWER TO LEARN ABOUT NEW TECHNOLOGIES BECAUSE OF SMALLER SOCIAL NETWORKS AND LOWER EDUCATION. THIS IS NOT SOMETHING THAT DISAPPEARED IN THE 20th CENTURY. WE STILL SEE THAT OLDER AND LESS AFFLUENT AND LESS EDUCATED PEOPLE ARE LESS LIKELY TO USE INTERNET. MOST RECENT DATA FROM THE PEW DEMONSTRATES THAT THE OVER 65s, ONLY 3/4 OF PEOPLE ARE USING INTERNET IN ANY FORM, WHETHER BY SMARTPHONE OR COMPUTER. WE SEE THE LOWEST INCOME BRACKETS ARE LESS LIKELY TO USE THE INTERNET AND WE ALSO SEE PEOPLE WITH HIGH SCHOOL EDUCATION AND LESS ALSO, AGAIN, ONLY ABOUT 3/4 OF THEM ARE ON THE INTERNET IN ANY FORM. AND THIS IS THE BROADEST QUESTION. THIS IS INCORPORATING SMART PHONE AS WELL AS COMPUTER ACCESS. NOW, AS DR. BENNETT DID POINT OUT, WE DO SEE VERY INTERESTING SWAP IN SMARTPHONE-ONLY INTERNET, ENTIRE GENERATIONS OF AMERICANS WHO SKIPPED COMPUTERS AND HAVE GONE DIRECTLY TO SMARTPHONES. THIS IS A VERY INTERESTING POPULATION WE CAN ACTUALLY REACH PEOPLE WITH LOWER EDUCATION LEVELS WHO DO HAVE SMARTPHONE-ONLY ACCESS, BUT IT MATTERS WHICH POPULATION YOU'RE LOOKING AT. IT'S STILL — THAT DOES NOT, FOR EXAMPLE, HELP US NECESSARILY REACH THE OVER 65s WHO ARE — WHO REMAIN LESS LIKELY TO BE, FOR EXAMPLE, SMARTPHONE-ONLY INTERNET USERS. SO THESE PATTERNS HAVE AFFECTED ADOPTION OF ELECTRONIC PATIENT PORTALS. WE HEARD OVER TWO DAYS A LOT OF OPTIMISM WILL ELECTRONIC MEDICAL RECORDS, PARTICULARLY ELECTRONIC PATIENT PORTALS, HOW MANY PEOPLE IN ANY ROOM HAVE A PATIENT PORTAL ACCOUNT WHERE YOU CAN LOG ON AND SEE YOUR MEDICAL RECORD? MOST PEOPLE, YES. SO, THIS IS A TECHNOLOGY THAT ALLOWS YOU TO SEE YOUR LAB TEST RESULTS, IT ALLOWS YOU TO BUILD YOUR RELATIONSHIP WITH YOUR HEALTH CARE PROVIDER BY MESSAGING, COLLECTING PATIENT-REPORTED OUTCOMES IS ANOTHER OPPORTUNITY HERE. I THINK WE ARE PARTICULARLY EXCITED ABOUT THE OPPORTUNITY FOR REMINDING OR INVITING PATIENTS TO ENGAGE IN CLINICAL PREVENTIVE SERVICES BECAUSE WE CAN SEND REMINDES, YOU HAVEN'T HAD A MAMMOGRAM IN TWO YEARS, OR IT'S TIME FOR YOUR ANNUAL FLU SHOT. ELECTRONIC PATIENT PORTALS HAVE DEMONSTRATED THE SAME SLOWER ADOPTION RATE AMONG MORE DISADVANTAGED POPULATIONS THAT WE'VE SEEN PARTICULARLY IT'S BEEN A BIT OF A BARRIER WITH THE LOWER INCOME PATIENT POPULATIONS. SO, THIS IS WHY IN INFORMATICS WE'RE WORRIED ABOUT THIS. WE KNOW THAT LOW RESOURCES ARE ASSOCIATED WITH WORSE HEALTH AND ARE LESS LIKELY TO BE REACHED BY INTERVENTIONS. WE'RE CONCERNED THAT WE COULD BE CREATING A NEW SET OF INTERVENTIONS THAT DISPROPORTIONATELY REACHES PEOPLE ALREADY IN BETTER HELD AND A SITUATION WHERE WE HAVE A DIVIDE BETWEEN HAVES AND HAVE NOTS. WE'VE SEEN INTERESTING INNOVATION IN THIS AREA AS WELL. LET ME GIVE A COUPLE EXAMPLES. I CAN'T SAY I'VE GOT THE SOLUTION BUT WE'VE DIRECTION. I DO A LOT OF MY WORK WITH INSTITUTE FOR FAMILY HEALTH. THEY ARE A NEW YORK CITY-BASED FQHC, THEY HAVE 24 SITES IN AROUND NEW YORK CITY FROM SCHOOL HEALTH CLINICS TO MENTAL HEALTH TO COMMUNITY CENTERS. AND THEY ARE 20 TO 30% UNINSURED AND 25% MEDICAID, EARLY ADOPTER OF INTERNET TECHNOLOGY, ROLLED OUT A PORTAL IN 2008, AND IN 2011 WE DID THE FIRST RETROSPECTIVE ANALYSIS OF USERS AND FOUND THAT NOT SURPRISINGLY THE POOREST AND THE MINORITY PATIENTS WERE LESS LIKELY TO JUMP ON BOARD WITH THE PORTAL. HOWEVER, WE DIDN'T STOP THERE. WE STARTED TO SAY, OKAY, WHY. AND SOMEWHAT UNEXPECTEDLY WHEN WE TRACED HOW THOSE PATIENT PORTAL ACCOUNTS WERE CREATED, WE DISCOVERED IT WAS THE PHYSICIANS WHO WERE DISPROPORTIONATELY OFFERING THE PORTAL TO WHITE PATIENTS AND INSURED PATIENTS. I DON'T KNOW IF THIS IS AN ISSUE OF IMPLICIT BIAS, I DON'T KNOW IF THIS IS AN ISSUE OF THOSE ARE THE PATIENTS MOST LIKELY TO ASK ABOUT IT. I DON'T KNOW IF THE CLINICIANS WERE EXERCISING CLINICAL JUDGMENT SAYING THIS IS WHO WE THINK WILL USE IT, BUT EFFECT WAS VERY CLEAR THAT DIFFERENT POPULATIONS WERE MORE — LESS LIKELY TO GET ACCESS TO THIS IN THE FIRST PLACE. TO THEIR CREDIT, INSTITUTE FOR FAMILY HEALTH IMMEDIATELY DECIDED TO TAKE ACTION ON THIS AND IN 2011, AS SOON AS WE PUBLISHED THIS FINDING, THEY CHANGED THEIR POLICY. THEY TOOK THAT RESPONSIBILITY ESSENTIALLY OUT OF THE HANDS OF THE PHYSICIANS, AND THEY PUT IT IN THE FRONT DESK SO REORGANIZED WORK FLOW AND THE CHECK-IN PROCESS, SO AS SOON AS YOU WALKED IN FOR YOUR APPOINTMENT YOU WOULD BE CHECKED TO SEE IF YOU HAD A PATIENT PORTAL ACCOUNT, IF NOT IT WAS GENERATED THERE, YOUR PASSWORD GIVEN WITH A FLIER HOW TO USE IT AND COULD ASK WHAT IS THIS NEW THING THAT I HAVE. SO NOT SURPRISINGLY, THE RACE DISPARITY OFFERS ALMOST IMMEDIATELY DISAPPEARED BUT WHAT WAS MORE EXCITING WAS OVER THE SUBSEQUENT YEARS THE RACE DISPARITY AND USAGE ALSO DISAPPEARED. THE BLACK-WHITE DIFFERENCES DISAPPEARED OVER FOUR YEARS AND LATINO/NON-LATINO DIFFERENCES ALSO DISAPPEARED. ONE DIFFERENCE THAT DID NOT FULLY DISAPPEAR WAS MEDICAID VERSUS PRIVATELY INSURED, THERE REMAIN FINANCIAL BARRIERS OUTSIDE OF OUR CONTROL THAT PROBABLY WERE CREATING AN ADDITIONAL HURDLE TO PORTAL USE. BUT I THINK THAT'S ONE EXAMPLE OF HOW THE — IN FACT IT'S THE ORGANIZATION OF THE CLINICAL SETTING THAT WAS CREATING THE DISPARITY IN THE FIRST PLACE. AND REMOVING THAT BARRIER TOOK US A LONG WAY TOWARD WHERE WE WANTED TO BE. ANOTHER INNOVATION THAT INSTITUTE FOR FAMILY HEALTH WORKED ON WAS THIS PROBLEM OF BY DEFINITION ELECTRONIC PATIENT PORTAL IS FULL OF MEDICAL JARGON. YOU LOG ON AND SEE TERMS, NUMBERS WITH NO CONTEXT. AND IN ORDER FOR ANY PATIENT TO BENEFIT FROM THIS, PARTICULARLY A PATIENT WITH LOW LITERACY OR LOW HEALTH LITERACY THERE NEEDS TO BE SOME HELP TO INTERPRET THIS. INSTITUTE FOR FAMILY HEALTH PARTNERED WITH THE NATIONAL LIBRARY OF MEDICINE AND AS WELL AS EPIC SOFTWARE TO DEVELOP A HYPERLINK SYSTEM SO THAT ANY TERM THAT APPEARED IN THE ELECTRONIC MEDICAL RECORD VISIBLE TO THE PATIENT WAS AUTOMATICALLY HYPERLINKED TO A MEDICAL ENCYCLOPEDIA WRITTEN AT THE 8th GREAT READING LEVEL, PRETTY GOOD THERE. THIS IS A FREE RESOURCE, I HIGHLY RECOMMEND IT FROM THE NATIONAL LIBRARY OF MEDICINE. SO THIS IS SORT OF HOW IT LOOKS, IF YOU'RE A PATIENT IN THE EHR THE PHYSICIANS FACING SIDE OF THINGS YOU WOULD SEE ICD, THIS IS THE ICD-9, 34.0 FOR STREPTOCOCCAL SORE THROAT, TRANSLATED TO THE PATIENT AS STREP THROAT, YOU HAVE AN IMMEDIATE POP-UP WINDOW WITH THE DEFINITION, THE TREATMENT, AND THE RISK FACTORS. WHEN THIS WAS DEPLOYED AND WE STARTED ANALYZING USE, REALLY EXCITING THING HAPPENED. THIS NEVER HAPPENS. THIS ENCYCLOPEDIA, HYPERLINKS WERE USED MORE BY BLACK THAN WHITE,MORE BY LATINO AND MORE BY RESIDENTS OF THE BRONX, POOREST AND MOST DIVERSE BOROUGH. THIS ALMOST NEVER HAPPENS, IT'S USED MOST OFTEN BY THE DISPARITY POPULATIONS THAT WE WANT IT TO BE USED BY. I THINK THIS IS ANOTHER EXAMPLE OF ADAPTING TECHNOLOGY TO THE NEEDS OF THE PATIENTS. WE RECENTLY COMPLETED A SMALLER SYSTEMATIC REVIEW OF PATIENT PORTAL RESEARCH AND FOUND MORE THAN 100 STUDIES DOCUMENTING DISPARITIES IN ADOPTION OF PATIENT PORTALS. YOU CAN STOP NOW. WE DON'T NEED ANY MORE STUDIES SHOWING THAT. WE DID FIND A SMALL NUMBER OF STUDIES TRYING TO DO SOMETHING TO ADDRESS THOSE DISPARITIES, AND I THINK THAT'S WHAT IS MORE INTERESTING. A NUMBER OF THESE PROVIDED SOME SORT OF TRAINING FOR PATIENTS. TRAINING THEM IN HOW TO USE EITHER TECHNOLOGY OR THE PORTAL IN PARTICULAR. SOME OF THEM PROVIDED TECHNICAL HELP FOR PATIENT NAVIGATORS. WE'VE HEARD ABOUT THAT EARLIER TODAY. SITTING DOWN WITH PATIENT HELPING THEM SET UP THE ACCOUNT OR NAVIGATE THROUGH IT. ALERTS OR REMINDERS, �DOCTOR OR HEALTHCARE SYSTEM TO LOG IN AND PERHAPS REMINDER THERE'S NEW INFORMATION THERE YOU MIGHT WANT TO FIND, YOU MIGHT WANT TO READ. PROVIDING PATIENTS WITH EITHER DEVICES SUCH AS TABLETS OR PHONES OR BROADBAND ACCESS. AS I MENTIONED REDESIGNING WORK FLOW TO MAKE SURE PATIENTS HAVE ACCESS TO THIS. A CLEAR WIN IS TO PROVIDE MOBILE ACCESS TO THAT WEBSITE. TO REDESIGN THIS TECHNOLOGY FOR IMPROVED USABILITY, RELATIVELY MINOR USABILITY BARRIERS THAT PROBABLY EVERYONE IN THIS ROOM WOULD FIND TRIVIAL THAT WE WOULD OVERCOME WITH A LITTLE BIT OF TRIAL AND ERROR CAN BE A MAJOR DETERRENT TO SOMEONE NOT FAMILIAR WITH COMPUTERS, SOMEONE USING COMPUTERS RARELY OR FOR THE FIRST TIME. SO USABILITY CAN BE A SERIOUS BARRIER. AND THEN A NUMBER OF EFFORTS TO PROVIDE BETTER CONTEND AND FEATURES THAT PATIENTS ACTUALLY THINK THEY WOULD BENEFIT FROM, AND THAT THEREFORE IT'S A DRAW THEY WOULD COME TO THE PORTAL SO, FOR EXAMPLE, DEFINITIONS, PATIENT EDUCATION RESOURCES, AND DISEASE-SPECIFIC CONTENT THEY MIGHT WANT. SO, IN SUMMARY THIS PARTICULAR SYSTEMATIC REVIEW SUGGESTS TRAINING PATIENTS IS EFFECTIVE. IT IS A LITTLE BIT HARD TO SCALE. IT'S LABOR INTENSIVE. YOU NEED TO ASSIGN AN EXPERT TO SIT DOWN WITH THE PATIENT. IT'S PRETTY COSTLY. SO I THINK I ALSO HAVE A LITTLE BIT OF A CONCERN THAT IT HAS A CENTRAL ASSUMPTION WHICH IS THAT THE PATIENT IS NOT WELL ADAPTED TO THE HEALTHCARE SYSTEM. WE NEED TO CHANGE THE PATIENT. SO, I'M MORE EXCITED ABOUT OPPORTUNITIES TO REDESIGN THE SYSTEM FOR THE PATIENT RATHER THAN THE PATIENT FOR THE SYSTEM. THAT'S HARDER TO DO. SO, WHEN WE LOOK AT ALL THESE INTERVENTIONS THAT HAVE BEEN TESTED, THE ONE SORT OF HIGHLIGHTED IN GRAY ARE ONES THAT HAVE MORE TO DO WITH REDESIGNING EITHER THE TECHNOLOGY SYSTEM OR HEALTHCARE SYSTEM FOR THE BENEFIT OF THE PATIENT RATHER THAN THE PATIENT FOR THE SYSTEM. SO MY RECOMMENDATIONS ON THE BASIS OF THIS IS THAT WE STILL SEE A TREMENDOUS OPPORTUNITY FOR PORTALS TO PROMOTE THE ADOPTION OF PREVENTIVE SERVICES TO ENGAGE PATIENTS WITH THE HEALTHCARE SYSTEM, BUT WE HAVE TO RECOGNIZE THAT THE EARLIEST ADOPTERS OF ANY NEW TECHNOLOGY ARE LIKELY TO BE THE MOST AFFLUENT AND MOST EDUCATED. THIS IS NOT GOING TO GO AWAY JUST BECAUSE ADOPTION OF PATIENT PORTALS IS NOW AT 30 TO 40% ACROSS THE NATION. WHEN WE MOVE FROM 4G TO 5G WE'LL SEE A SIMILAR DISPART ARISE WHERE THE MORE AFFLUENT AND MORE EDUCATED PEOPLE WILL BE THE QUICKEST TO SWITCH. SO EVERY TIME WE CHANGE TECHNOLOGIES, THIS SHOULD BE A CONCERN OF HOW DO WE ADAPT THESE TECHNOLOGIES TO THE PEOPLE WHO ACTUALLY NEED THEM THE MOST. WE DO SEE THAT TRAINING PATIENTS TO USE INFORMATION TECHNOLOGY IS PROBABLY NECESSARY. WE HAVE EVIDENCE THAT IT IS EFFECTIVE. BUT WE KNOW IT IS CHALLENGING TO DELIVER TO EVERYBODY WHO NEEDS IT. AND SO WE — THIS IS AN OPPORTUNITY FOR US TO TAKE A LOOK AT THE SYSTEMIC BARRIERS THAT ARE CREATING BARRIERS TO TECHNOLOGY USE. ENSURE ALL PATIENTS ACTUALLY ARE OFFERED ACCESS. SEEMS TRIVIAL BUT THAT MEANS, FOR EXAMPLE, THE FLYERS IN THE WAITING ROOM HAVE TO BE IN THE PATIENT'S LANGUAGE, THEY CAN'T ONLY BE ENGLISH. OFFERS HAVE TO BE MADE TO EVERY SINGLE PATIENT. I'LL QUICKLY SAY NATIONAL DATA CURRENTLY IN NATIONAL SURVEYS ONLY 50% OF PATIENTS SAY THEY HAVE BEEN OFFERED ACCESS TO THEIR MEDICAL RECORDS. IT PROBABLY ACTUALLY IS HIGHER BUT ONLY 50% OF PATIENTS REMEMBER OR RECOGNIZE THAT'S WHAT THEY WERE OFFERED. PROVIDING — SOME ARE UNSEXY AND ON THE GROUND INTERVENTIONS. DR. BENNETT HAD A GREAT EXAMPLE HOW YOU NEED A TON OF TECH SUPPORT PARTICULARLY FOR NEW COMPUTER OR PHONE USERS. IMPROVING USABILITY, USING PLAIN LANGUAGE, INTERPRETS MEDICAL LANGUAGE, ADAPTING TO PATIENTS' HEALTH LITERACY, TO WHAT PATIENTS BRING TO US. PROVIDING CONTENT THAT PATIENTS WANT AND NEED, DEFINITELY OFFER EVERYTHING ON MOBILE, AS LEAST AS GOOD AS THE WEBSITE. WE SEE DISPARITIES WHERE THE WEBSITE HAS MORE CONTENT THAN THE MOBILE DEVICE VERSION. DEFINITELY OFFER IN SPANISH OR THE LANGUAGE OF YOUR PATIENT POPULATION, AND WE UNFORTUNATELY SEE THAT A LOT OF STUFF IS TRANSLATED INTO SPANISH AND THE TRANSLATION IS NOT THAT GREAT. OR SOMETHING THAT WE'VE STARTED NOTICING IS THAT THE FRONT PAGE IS TRANSLATED NICELY AND THEN THE DEEPER YOU GO, THE SHODDIER THE TRANSLATION GETS. SO IT LOOKS GOOD ON THE SURFACE. PROVIDE FREE ACCESS. IF YOU REALLY WANT LOW INCOME PATIENTS TO USE THESE TECHNOLOGIES AGAIN DR. BENNETT HAD GREAT EXAMPLES OF ACTUALLY PROVIDING WEARABLES TO THE PATIENTS, DO NOT ASSUME THEY WILL BRING THEIR OWN DEVICES AT ALL TIMES. FINALLY, I DON'T THINK WE NEED MORE STUDIES DEMONSTRATING THAT THE DISPARITY EXISTS. WE WOULD REALLY LIKE MORE STUDIES OF INNOVATIVE WAYS TO OVERCOME DISPARITIES, AND WAYS TO TRACK WHETHER THESE ACTUALLY PORTALS WHICH COULD BE A GREAT TOOL FOR PREVENTIVE SERVICES. THANKS VERY MUCH. [APPLAUSE] I'LL QUICKLY NOTE THAT WE HAD SORT OF TWO POTENTIAL DIRECTIONS FOR THESE TALKS, AND BOTH TIFFANY VEINOT AND I DECIDED TO GO WITH PATIENT PERSPECTIVE BUT DURING THE DISCUSSION IF THERE'S FURTHER — I'M ALSO EMBEDDED IN THE INFORMATICS GROUP IN MY MEDICAL CENTER AND WOULD BE HAPPY TO HAVE LARGER USE OF DISCUSSION OF MEDICAL RECORDS AND DATA BASES FOR DISPARITIES RESEARCH AS WELL. SO THANK YOU VERY MUCH. >> HELLO, EVERYBODY. I'M TIFFANY VEINOT FROM UNIVERSITY OF MICHIGAN SCHOOL OF INFORMATION AND SCHOOL OF PUBLIC HEALTH, I ALSO DIRECT OUR MASTERS OF HEALTH INFORMATICS PROGRAM. I'M HERE TO SPEAK TO YOU TODAY ABOUT INTEGRATING AND DISSEMINATING DIABETES PREVENTION INFORMATION INTO THE PRIMARY CARE SETTING. SO I HAVE NO INFORMATION TO DISCLOSE. MY AGENDA IS BEGIN BY SITUATIONING THIS PROBLEM OF DISPARITIES IN DIABETES PREVENTION, BUILDING ON SOME COMMENTS OF OTHERS IN THIS SESSION. I WILL TALK ABOUT HEALTH INFORMATION TECHNOLOGY INTERVENTION APPROACHES AND I'D LIKE TO EMPHASIZE TECHNOLOGIES AND HOW THEY ARE PURPORTED TO WORK, TALKING ABOUT UNIVERSAL VERSUS TARGETED TIMES OF INTERVENTIONS AS WELL AS POTENTIAL MECHANISMS FOR INTERVENTION IN THE HEALTH CARE SETTING. MY EMPHASIS WAS ON REVIEWING EXISTING RESEARCH AS WELL AS TALKING ABOUT SOME OF MY OWN. I AM TALKING ABOUT EXAMPLES THAT ARE DRAWN FROM OUTSIDE OF DIABETES PREVENTION STRICTLY BECAUSE THERE'S VERY LITTLE WORK IN THAT PARTICULAR AREA AS WE'VE BEEN HEARING FROM A SYSTEMATIC REVIEW SO I'M GOING TO BE TALKING ABOUT THINGS LIKE SECONDARY PREVENTION IN DIABETES CARE, EXAMPLES OUTSIDE OF THE AREA, LIKE BLOOD PRESSURE CONTROL, SO LOOKING AT SORT OF THE PROMISE OF THE INTERVENTION STRATEGIES FOR DIFFERENT TYPES OF CLINICAL OUTCOMES. SO I BEGIN BY SHARING A MODEL OF AN EXTENSION OF THE WORLD HEALTH ORGANIZATION MODEL OF HEALTH DISPARITIES. AND THIS MODEL IS ONE THAT CAN BE READ TYPICALLY FROM RIGHT TO LEFT, WITH THE DARK BLUE BOX ON THE RIGHT INDICATING IMPACTS ON DISPARITIES IN HEALTH AND WELL BEING. SORT OF KEY POINTS TO TAKE AWAY FROM THIS PARTICULAR DIAGRAM IS THAT WE HAVE MICROLEVEL FACTORS WHICH ARE INDIVIDUAL LEVEL, THAT INFLUENCE HEALTH DISPARITIES, THOSE INCLUDE PSYCHOSOCIAL FACTORS, BEHAVIORAL AND BIOLOGICAL FACTORS. AND THOSE ARE WHERE THE MAJORITY OF OUR TECHNOLOGY AND OTHER TYPES OF INTERVENTIONS HAVE FOCUSED. WE HAVE UPSTREAM STUDENTS LIKE LIVING AND WORKING CONDITIONS, SOCIAL AND COMMUNITY NETWORKS AND HEALTH SYSTEM WHICH INFLUENCE DISPARITIES. MOVING FURTHER TO THE LEFT WE LOOK AT MACROLEVEL FACTORS THAT DRIVE DISPARITIES. IN PARTICULAR, EACH OF THE BLUE BOXES ON THIS MODEL RECOMMEND OR SUGGEST PLACES WHERE WE COULD TRY TO INTERVENE. SO WE COULD BE INTERVENING ON THINGS LIKE TRYING TO REDUCE SOCIAL HIERARCHIES, ON TRYING TO REDUCE HARMFUL EXPOSURES OR DECREASING VULNERABILITY, OR WE COULD ALSO BE LOOKING AT DIFFERENTIAL CONSEQUENCES WITH REGARDS TO HEALTH. WHAT I'M GOING TO TALK ABOUT IS FOCUS ON HEALTH SYSTEM BUT THE KEY POINT I'M TRYING TO MAKE IS THERE ARE OBVIOUSLY A NUMBER OF OTHER FACTORS AT PLAY SO WE'RE LOOKING AT ONE SLICE OF THIS PARTICULAR AREA. SHARING THE MODEL FROM GOMEZ AND DISPARITIES, SOURCES OF DISPARITIES AND HEALTHCARE QUALITY, A MODEL CREATED FOR MINORITIES AND MINORITY POPULATIONS BUT I THINK THAT IS VALUE BEYOND THAT PARTICULAR SETTING. WHAT THIS PRESENTS IN THE RED BOX IS KIND OF TYPOLOGY OF THE FACTORS THAT GO INTO DRIVING DISPARITIES IN HEALTHCARE QUALITY AS IT'S PROVIDED. SO WE SEE HERE THERE ARE DISCRIMINATION BIASES, STEREOTYPING, CLINICAL UNCERTAINTY, MORE AT A PROVIDER LEVEL. THEN WE SEE ISSUES RELATED TO HOW THE OPERATION OF THE HEALTHCARE SYSTEM WORKS TO DIFFERENTIALLY AFFECT QUALITY OF CARE. WE SEE DIFFERENCES THAT ARE PATIENT RELATED, RELATED TO CLINICAL APPROPRIATENESS, NEEDS AND PREFERENCES. I'M GOING TO BE TALKING ABOUT EACH OF THESE PARTICULAR MECHANISMS BY WHICH DISPARITIES ARE PRODUCED IN HEALTH CARE AND CONTEXT OF INTERVENTION STRATEGIES. SO THIS IS A TYPOLOGY I'VE CREATED THAT OUTLINES CERTAIN STRATEGIES THAT MAP ONTO THESE MECHANISMS THAT DRIVE HEALTHCARE DISPARITIES. SO ON THE LEFT-HAND SIDE WE SEE THE DISTINCTION OF UNIVERSAL OR TARGETED APPROACHES. UNIVERSAL APPROACHES WOULD BE THOSE THAT ARE INTENDED TO BE FOR EVERYBODY WHO IS A PATIENT IN A PARTICULAR HEALTH SYSTEM. TARGETED APPROACHES WOULD BE MORE FOR SPECIFIC POPULATIONS AND WE'VE HEARD ABOUT TARGETED INTERVENTIONS BUT A BIT LESS I WOULD SAY ABOUT UNIVERSAL INTERVENTIONS SO I'M GOING TO TALK A LITTLE ABOUT THOSE AS WELL. SO THE NEXT COLUMN FROM THE LEFT, THE VARIOUS MECHANISMS I SHOWED IN THE GOMEZ MODEL. THEN IF WE LOOK AT INTERVENTION, WE'LL TALK ABOUT THOSE A LITTLE BIT. ONE OF THE MAIN INTERVENTION STRATEGIES THAT WE SEE IN TECHNOLOGY-BASED INTERVENTIONS TODAY IS IDEA OF STANDARDIZATION AND TRYING TO ACHIEVE GUIDELINE CARE THROUGH SOME FORM OF STANDARDIZATION. I'D SAY THERE ARE THREE CLASSES OF WAYS THAT HAPPENS, MAINLY IN TECHNOLOGY. ONE IS PROMPTING WHICH WE HEARD A BIT ABOUT YESTERDAY WHICH INVOLVES CLINICAL REMINDERS AND ALERTS, SO THAT'S TRYING TO GET A CLINICIAN TO DO SOMETHING AT A PARTICULAR TIME BY REMINDING THEM THEY SHOULD DO IT. THEN WE HAVE THE IDEA OF DEFAULT CARE PROCESSES, THOSE ARE REALLY ABOUT TRYING TO REDUCE DECISION MAKING BURDEN BY HAVING STANDARD ACTIONS THAT ARE GUIDELINE CONCORDANT. HERE WE SEE THINGS LIKE ORDER SETS, CARE PATHWAYS, CLINICAL ALGORITHMS, ET CETERA. THEN WE HAVE INTERVENTIONS THAT ARE MORE TARGETED TOWARDS HEALTH CARE PROVIDERS, SELF-REGULATION, SO YOU GIVE THEM FEEDBACK AND YOU'RE TRYING TO HAVE A HEALTH CARE PROVIDER TAKE THAT IN AND TRY TO ADJUST PERFORMANCE IN ORDER TO IMPROVE AND THOSE MAIN MECHANISMS ARE THINGS LIKE AUDIT AND FEEDBACK. THEN WE HAVE INTERVENTIONS THAT MIGHT BE MORE COMPLEXITY REDUCTION FOCUSED, SO THOSE ARE THINGS THAT TRY TO ADDRESS BARRIERS IN THE HEALTHCARE SYSTEM. YOU MIGHT SEE SIMPLIFICATION PROCESSES AND TOOLS. ONE OF THE MAIN APPROACHES I THINK IS REALLY EXCITING IN THIS AREA IS IDEA OF ONE-CLICK ACTIONS, SIMPLIFIED BY MAKING IT SO THAT THERE'S LESS COMPLEXITY FOR A PATIENT OR PROVIDER, AND INSTEAD TRANSFERRING THAT COMPLEXITY TO A TECHNOLOGY THAT CAN BEAR THAT BURDEN ON BEHALF OF INDIVIDUALS. WE ALSO CAN BE LOOKING AT UNIVERSAL LITERACY PRECAUTIONS WITHIN ORGANIZATIONS. I'M NOT GOING TO TALK ABOUT THAT BUT THAT'S ANOTHER STANDARD APPROACH. WE COULD BE LOOKING AT TARGETED INTERVENTIONS THAT ADDRESS DIFFERENCES IN CLINICAL AND SOCIAL NEEDS AMONGST PATIENTS. AND HERE WE TYPICALLY SEE INTERVENTIONS THAT TRY TO IDENTIFY NEEDS, AND TARGET RESOURCES TOWARDS ADDRESSING THEM. AND THE MAIN APPROACH THAT USES TECHNOLOGY THAT WE SEE IS POPULATION MANAGEMENT, TYPICALLY THAT INVOLVES SOME FORM OF RISK SCREENING OR EXTRACTION, SOME FORM OF RISK ALGORITHM OR APPROACH TO IDENTIFYING WHO IS AT RISK, AND THEN SOME KIND OF MATCHING TO SUPPLEMENTAL SERVICES. AND SO I'M GOING TO TALK ABOUT EACH OF THESE INTERVENTIONS, AND IN PARTICULAR DRAWING FROM SOME OF WHAT JESSICA JUST SPOKE ABOUT, I'M GOING TO TALK ABOUT SOME OF THE ISSUES RELATED TO POTENTIAL DIFFERENTIAL EFFECTS, OR HETEROGENEITY OF TREATMENT EFFECTS RELATED TO INTERVENTIONS. SO I'M STARTING BY TALKING ABOUT DISCRIMINATION. AND IN PARTICULAR, THOSE PROMPTING ACTIONS, DEFAULT CARE PROCESS, PROVIDER SELF-REGULATION. ONE OF THE KEY POINTS IN THIS PARTICULAR AREA IS THAT FEW STUDIES HAVE EVER EXAMINED THE EQUITY EFFECTS OF UNIVERSAL STRATEGIES RELATED TO TECHNOLOGIES. AND THERE ARE FEWER STUDIES AS WELL THAT LOOK AT OUTCOMES OF TARGETED INTERVENTIONS FOR DISPARITY GROUPS BUT THERE IS A BIT MORE THERE. SO THIS IS A META-ANALYSIS FROM 2012 THAT LOOKED AT STANDARDIZATION, VARIOUS FORMS OF INTERVENTIONS IN DIABETES CARE. AND LOOKED AT THEIR NET TREATMENT EFFECT. AS YOU CAN SEE HERE THE IDEA OF CLINICIAN REMINDERS IS SOMETHING THAT IS SHOWN TO HAVE A NET BENEFIT WITH REGARDS TO REDUCTION IN HBA1C AND DIABETES CARE. SO, IF WE LOOK AT THAT PARTICULAR IDEA, THAT'S THE AVERAGE EFFECT, BUT THEY BE IF WE LOOK AT STUDIES THAT HAVE EXAMINED EXAMINE HETEROGENEITY, ONE STUDY SHOWED IT MIGHT FAVOR DISPARITY GROUPS, THAT WAS A STUDY LOOKING AT SMOKING-RELATED SCREENING INVOLVING NURSE PRACTITIONERS. AND THERE WERE TWO STUDIES THAT SHOWED NO EFFECT. STUDIES LOOKING AT TRYING TO PROMPT TREATMENT ACTIONS OF TWO STUDIES ABLE TO LOCATE, THEY HAD NEUTRAL OR MIXED EFFECTS WITH REGARDS TO EQUITY AND PROCESS OUTCOMES AND NO IMPACT ON INTERMEDIATE HEALTH OUTCOMES AT ALL. SO THE EVIDENCE IS QUITE MIXED WITH REGARDS TO THAT ASPECT OF STANDARDIZATION. WITH REGARDS TO DEFAULT CARE PROCESSES, THERE ARE TWO STUDIES THAT HAVE VERY RECENTLY BEEN PUBLISHED, THAT LOOK AT IMMIGRANT POPULATIONS AND TRYING TO STANDARDIZE RESPONSES TO COMMON HEALTH CONDITIONS IN THESE GROUPS, SO THERE WAS ONE STUDY THAT LOOKED AT ORDER SETS AND CULTURALLY TAILORED ACTIONS AROUND SOUTH ASIAN IMMIGRANTS AND BASICALLY COMMUNITY-BASED PRACTICES, AND THEY FOUND THAT THERE WAS AN IMPROVEMENT IN BLOOD PRESSURE CONTROL. THIS WAS A STEPPED WEDGE QUASI-EXPERIMENT AND ANOTHER STUDY FOUND WITH CAMBODIAN IMMIGRANTS THAT A SCREENING AND CARE PATHWAY WAS EFFECTIVE WITH REGARDS TO INCREASING DEPRESSION AND SYMPTOMS AND DIAGNOSIS. SO IF WE LOOK AT IDEA OF AUDIT AND FEEDBACK, THAT IDEA OF TRYING TO PROMPT PROVIDER SELF-REGULATION, WE SEE THAT, AGAIN, PATIENT REGISTRIES ARE COMMONLY PART OF THESE INTERVENTIONS AND TYPICALLY HAVE AUDIT AND FEEDBACK AND THERE IS ON AVERAGE A NET BENEFIT WITH REGARDS TO TRYING TO IMPROVE HBA1C AND DIABETES CARE BUT IF WE LOOK AT STUDIES THAT LOOKED AT HETEROGENEITY OF TREATMENT EFFECT, I WAS ONLY ABLE TO LOCATE ONE, THIS WAS A DESCRIPTIVE STUDY, LONGITUDINAL, 198 PRIMARY CARE PRACTICES, FAVORED ADVANTAGED GROUPS, SO FAVORED WHITES, FAVORED NON-HISPANICs AND PEOPLE WITH HIGHER SES WITH REGARDS TO BLOOD PRESSURE CONTROL. SO I'M GOING TO MOVE TO OPERATION OF HEALTH CARE SYSTEMS, THE LEGAL AND REGULATORY CLIMATE. SO HERE THE IDEA OF PROCESS SIMPLIFICATION AND REDUCTION THROUGH ONE-CLICK ACTION IS FOCUS. HERE I WAS ABLE TO LOCATE TWO STUDIES THAT FOCUSED ON TRYING TO CHANGE CARE PROCESSES WITHIN HEALTH CARE. AND THESE WERE REALLY ABOUT TRYING TO MAKE SURE THAT NEEDS WERE MET, THAT PATIENTS HAD. ONE WAS A CASE STUDY THAT LOOKED AT A MEDICAL LEGAL PARTNERSHIP, IN WHICH AUTOMATED SHUT-OFF PREVENTION LETTERS INTEGRATED INTO THE H.R. WERE USED, AND THEY ACTUALLY INCREASED NUMBER OF LETTERS THAT WERE ABLE TO BE PRODUCED, AND REDUCED AMOUNT OF TIME FROM 30 MINUTES TO 30 SECONDS TO PRODUCE THESE LETTERS. ANOTHER STUDY LOOKED AT TRYING TO REFER — TRYING TO ENGAGE — HAVE CLINICIANS ENGAGE INTERPRETERS FOR PATIENTS WITH LIMITED ENGLISH PROFICIENCY IN URGENT CARE CANCER SETTING, FOUND IT INCREASED CLINICIAN CALLS TO FREQUENCY — FREQUENCY OF CLINICIAN CALLS TO INTERPRETER SERVICES SO THESE WERE TWO THAT SHOWED IMPROVEMENTS IN HEALTHCARE PROCESSES WITH REGARDS TO MEETING PATIENT NEEDS. WE HAVE THE IDEA OF POPULATION MANAGEMENT. AND AS I MENTIONED, THERE ARE THREE PARTS TO THESE TYPICAL INTERVENTIONS, THEY ARE ABOUT TRYING TO ADDRESS DIFFERENCES IN CLINICAL AND SOCIAL NEEDS AMONGST DIVERSE PATIENTS. SO IT'S THIS PART OF THE MODEL. AND SO HERE WE'RE STARTING TO SEE MORE TYPES OF INTERVENTIONS THAT ARE TRYING TO HAVE THIS HEALTHCARE SYSTEM ACT IN SOME WAY ON THESE OTHER DETERMINANTS OF HEALTH. WE SEE EFFORTS TO TRY TO ADDRESS THINGS LIKE PSYCHOSOCIAL FACTORS THAT ARE FACING PATIENTS, LIKE THEIR FINANCIAL STATE, WE SEE THINGS LIKE LIVING AND WORKING CONDITIONS, ADDRESSING HOMELESSNESS, TRYING TO INCREASE OR ADAPT PEOPLE'S SOCIAL SUPPORT, ET CETERA. SO HERE WE'VE SEEN QUITE A LOT OF EFFORT THAT'S BEEN ALLOCATED TOWARDS POPULATION MANAGEMENT, ESPECIALLY RELATED TO SOCIAL RISK OR WHAT'S OFTEN CALLED SOCIAL DETERMINANTS OF HEALTH-RELATED SCREENING OR DATA EXTRACTION. THERE'S A LOT OF DATA THAT IS HISTORICALLY COLLECTED THAT'S OF THE NATURE THAT'S BEEN MOSTLY VERBAL OR RECORDED IN SOME FORM OF CLINICAL NOTES. WHAT WE'VE SEEN IS A MASSIVE SHIFT TOWARDS MORE STRUCTURED DATA COLLECTION, AND IMPLEMENTATION OF VARIOUS KINDS OF STRUCTURED TOOLS AND ELECTRONIC HEALTH RECORD. WE'VE ALSO SEEN EFFORTS TO TRY TO USE NATURAL LANGUAGE PROCESSING TO EXTRACT SOME DETAILS FROM NOTES. AND MORE ATTENTION TO COMMERCIALLY AVAILABLE DATASETS. WITH REGARDS TO RISK ALGORITHMS, SO THERE IS SOME WORK TRYING TO USE THESE SOCIAL DETERMINANTS OF HEALTH DATA TO TRY TO IMPROVE PERFORMANCE, AND MOST OF THAT WORK TO DATE HAS LOOKED AT HOSPITAL-RELATED READMISSIONS BUT SOME STUDIES HAVE SHOWN IMPROVEMENTS IN PERFORMANCE OF PREDICTIVE ALGORITHMS WHEN TRYING TO USE THESE KINDS OF DATA, SOME HAVE NOT NECESSARILY. AND IF WE LOOK AT THIS PHENOMENON OF MATCHING PEOPLE TO SUPPLEMENTAL SERVICES, SO THIS IS — I'M SHOWING STUDIES WITH REGARDS TO THEIR INTERVENTION EFFECTS, AND WE SEE THAT TWO THAT I'M TALKING ABOUT HERE HAD POSITIVE EFFECTS, ONE A TARGETED INTERVENTION FOR LOW SES POPULATIONS, ANOTHER FAVORED DISADVANTAGED GROUPS RAPID THESE WERE — ONE WAS A CHRONIC CARE MODEL, COMPLEX INTERVENTION, BUT HAD EHR CHANGES AS PART OF IT. AND THIS STUDY HAD AN IMPROVEMENT IN THE PATIENTS THAT HAD CONTROLLED BLOOD PRESSURE. THE OTHER STUDY WAS FOCUSED ON COLORECTAL CANCER SCREENING AND FOUND IT INCREASED RATES OF COLORECTAL CANCER SCREENING WITH AN APPROACH THAT INVOLVED IDENTIFYING PEOPLE WHO HAD OVERDUE COLORECTAL CANCER SCREENS AND THAT FACILITATING CONTACT THROUGH A SCHEDULER OR LETTERS, AND SOME KIND OF INTENSIVE FOLLOW-UP WITH A NAVIGATOR FOR PEOPLE AT HIGH RISK. THERE WAS ALSO A STUDY HERE THAT LOOKED AT PROVIDING CLINICIANS WITH FEEDBACK AND THEN ALSO MATCHING IT WITH POPULATION HEALTH COORDINATOR, NEUTRAL EFFECTS WITH REGARDS TO EQUITY. AND FOR ANOTHER THERE WAS A POSITIVE EFFECT, THIS FOCUSED ON TRYING TO GIVE COMMUNITY HEALTH WORKERS TECHNOLOGIES FOR DECISION SUPPORT RELATED TO DIABETES TREATMENT. AND THIS ONE DID IMPROVE SOME PSYCHOSOCIAL MEASURES LIKE SATISFACTION, INFORMATION AND DIABETES DISTRESS. THERE'S ALSO SOME EMERGING WORK THAT'S IN THE AREA OF REFERRAL-BASED SYSTEMS, ESPECIALLY EFFORTS TO TRY TO LINK PEOPLE TO SERVICES THAT ARE OUTSIDE OF CARE. AND SOMETIMES THOSE OUTCOMES CAN BE BENEFICIAL, THERE WAS A STUDY THAT SHOWED THAT IN A CLUSTER RANDOMIZED CONTROL TRIAL. BUT ONE OF THE THINGS I THINK IS AN AREA WHICH FUTURE WORK IS REALLY NEEDED IS THE IDEA OF TRYING TO ACTUALLY USE THESE DATA TO INFORM CLINICAL DECISIONS OR INFORM CARE IN SOME WAY. AND THIS IS THE RESULT OF SOME OBSERVATIONAL WORK THAT I'VE DONE WITH COLLEAGUES THAT LOOKS AT HOW CLINICIANS ARE USING PSYCHOSOCIAL INFORMATION IN ORDER TO MAKE CLINICAL DECISIONS, AND THIS IS IN THE CONTEXT OF DIABETES CARE BUT THE MAIN POINT ABOUT THIS MODEL IS REALLY THAT THE INFORMATION IS BEING USED, AND IT'S BEING USED TO MAKE ASSESSMENTS ABOUT THE PATIENT AND ABOUT HOW — ABOUT VARIOUS ASPECTS OF TREATMENT LIKE RISK AND FEASIBILITY OF OPTIONS, IN TURN INFLUENCING DECISIONS, HAPPENING BUT NOT NECESSARILY TECHNOLOGYINGS TO SUPPORT IT AND I SUGGEST THIS MAY BE AN AREA FOR ATTENTIONING WITH REGARDS TO PREVENTIVE SERVICES. TO CONCLUDE, THERE'S VERY FEW STUDIES THAT LOOK AT EQUITY EFFECTS RELATED TO UNIVERSAL INTERVENTIONS RELATED TO HEALTH INFORMATION TECHNOLOGY, AND EVEN MORE SO THERE'S NOT A GREAT DEAL THAT LOOKS AT UNDERLYING MECHANISM ALSO WHEN THINGS DO WORK OR WHEN THEY ARE NOT — WHEN THEY ARE OR ARE NOT EQUITY POSITIVE. THERE'S ALSO PROMISE WITH REGARDS TO HIT-BASED COMPLEXITY INTERVENTION AS BASIS FOR INTERVENTION ESPECIALLY GIVEN COMPLEXITY OF SOME PREVENTIVE SERVICES, A NEED FOR GREATER INVESTIGATION IN THAT AREA. ALSO A NEED TO SUPPORT RESEARCH REGARDING USE OF THAT SOCIAL RISK DATA THAT'S INCREASINGLY BEING COLLECTED IN DIABETES PREVENTION INTERVENTION AND DECISIONS. WE NEED TO COMPARE EFFECTIVENESS OF DIFFERENT APPROACHES, FOR EXAMPLE WHAT IS UNIVERSAL VERSUS TARGETED APPROACH BEST, WHO IS IT BEST FOR, WHEN IS IT MOST EFFECTIVE. WE ALSO NEED TO LOOK AT WHETHER CERTAIN KINDS OF APPROACHES ARE BETTER SO IS COMPLEXITY REDUCTION BETTER THAN SUPPLEMENTAL SERVICES, OR IS IT BETTER TO HAVE STANDARDIZATION OF THIS TYPE OR THAT TYPE. SO I DON'T THINK WE REALLY KNOW ANY OF THOSE THINGS, AND I THINK WE REALLY NEED TO GO A LONG WAY TO OPEN THE BLACK BOXES OF MANY OF OUR TECHNOLOGY-BASED INTERVENTIONS, AND REALLY UNDERSTAND HOW THEY WORK AND ALSO WHOM THEY WORK FOR, AND WHEN THEY WORK, WHY THEY WORK. THANK YOU. [APPLAUSE] >> I WANT TO THANK THE SPEAKERS, THAT WAS EXCITING AND INNOVATIVE AND FORWARD LOOKING. WE'RE GOING TO START WITH QUESTIONS AND COMMENTS FROM OUR PANEL. >> THANKS FOR SOME GREAT PRESENTATIONS. GARY, IN PARTICULAR YOU TALKED ABOUT COST IMPLICATIONS OF THESE TECHNOLOGIES, WHICH PRESUMABLY HAVE A FAIRLY HIGH UPFRONT COST, AND THEN HOPEFULLY SOME SCALEUP VALUE. CAN YOU GIVE US SOME IDEAS ABOUT WHAT THAT LOOKS LIKE AND PARTICULARLY HOW IT COMPARES TO SOME OF THE OTHER STRATEGIES THAT — I DON'T KNOW IF YOU'VE BEEN HERE THE LAST COUPLE DAYS BUT HAVING COMPARED SOME OF THE OTHER NON-HIT ORIENTED KINDS OF THINGS? >> SURE. I CAN GIVE YOU MAYBE LESS ON THE COMPARATIVE SIDE, BUT JUST A SENSE OF THIS, FROM THE TEXTING SPACE. SO THE — LET'S SAY FOR ME TO SCALE AN INTERVENTION FROM 100 USERS TO 10,000 USERS IS — WOULD ROUGHLY BE ONCE A SYSTEM IS BUILT, WOULD BE MAYBE DELTA OF ABOUT $50 PER MONTH, IN TERMS OF PAYING THE SORT OF OPERATING COST, SENDING THAT MANY MORE TEXT MESSAGES, INCREMENTAL COST SAVINGS ARE TINY. WHERE YOU EXPERIENCE MOST OF THE COST IS AREA OF THE INITIAL BUILD AND THEN TECHNICAL SUPPORT, CUSTOMER SERVICE SPACE. BUT THE ACTUAL COST OF DELIVERING THESE TECHNOLOGIES IS VERY, VERY TINY. THAT'S FOR, SAY, INTERACTIVE VOICE RESPONSE, TEXT MESSAGING. ONCE YOU WALK INTO THE MOBILE CASE. THERE'S OFTEN MORE ITERATION, PARTICULARLY AS YOU TEND TO USE ITERATION, THAT IS PROGRAMMING THE APP MANY TIMES OVER IN ORDER TO MAXIMIZE OUTCOMES OF INTEREST. SO IF I WANT SOMEONE TO HIT THAT BUTTON I MIGHT CHANGE ITS SHAPE AND COLOR AND SIZE AND THE WAY IT'S NESTING, OVER MULTIPLE ITERATIONS. EVEN THAT KIND OF COST IS DRAMATICALLY LESS THAN WHAT YOU WOULD PAY FTE TO DELIVER A SERVICE IN A CLINIC. >> COMMENTS FROM OTHER FOLKS? >> I THINK I WAS GOING TO QUICKLY SAY ONE OF THE THINGS YOU SAID TOWARD THE END OF YOUR TALK WAS WHY MANY OF THESE THINGS ARE OUTSIDE THE MEDICAL SYSTEM. AND THIS GETS BACK YESTERDAY I ASKED ABOUT LARGER INCENTIVES. MEDICAL ORGANIZATIONS ARE RESPONDING TO A NETWORK OF FEDERAL INCENTIVES AS WELL AS REIMBURSEMENT STRATEGIES, AND THIS INITIAL COST OF SETTING UP SOMETHING NEW, EVEN IF THE INCEMENTAL COST AFTERWARDS IS SCALING TO MORE PATIENTS MAY BE MEDICAL ACADEMIC CENTER UNLESS IT IS GRANT FUNDING. WHAT ARE WE PAYING MEDICAL CENTERS TO DO, NOT TO KEEP PEOPLE HEALTHY, WHICH WOULD BE GREAT. >> I THINK THAT'S RIGHT. I TEND TO THINK MEDICAL CENTERS DON'T BUILD THEIR MEDICAL DEVICES, THEIR OWN MEDICATIONS. THEY BUY THOSE THINGS. THEY PURCHASE SERVICES, SO IS DIGITAL APP. >> THANK YOU. >> SO THIS CONVERSATION, THIS QUESTION AND RESPONSE JUST GOT ME THINKING. SO, AS YOU ARE THINKING ABOUT THE COST OF THESE TECHNOLOGIES PER, YOU KNOW, INTERACTION, ET CETERA, RELATIVE TO, SAY, FTE OF A PERSON, ET CETERA, NOW YESTERDAY THERE WAS A LOT OF EMPHASIS THROUGHOUT THE DAY ON HIGH TOUCH, ON RELATIONSHIP BUILDING, ON HAVING THAT PERSONAL CONNECTION WITH PEOPLE. AND THEN THAT IS REALLY IMPORTANT FOR ADDRESSING THIS DISPARITY GAP, IMPROVING EQUITY. ONE COULD ARGUE BOTH WAYS, RIGHT? WHAT YOU ALL ARE DESCRIBING INCREASES THAT CONNECTION. NOW, WE ALSO WILL OFTEN ARGUE AT HOME THAT EVERYBODY'S ON THEIR iPHONEs NOW, NOT ACTUALLY TALKING, ET CETERA. SO CAN YOU GIVE US SOME OF THE PROS AND CONS OR DISCUSS THAT A LITTLE BIT, LIKE HOW IS THIS ACTUALLY RELATING TO THAT HIGH TOUCH DISCUSSION OF YESTERDAY, OR DOES IT EXACERBATE THAT DIVIDE? COULD YOU TALK A LITTLE BIT ABOUT THAT? >> SO I CAN START BY REFERRING TO THE HEISLER STUDY LOOKING AT COMMUNITY HEALTH WORKERS WITH A TABLET-BASED APPLICATION THEY BROUGHT TO PATIENTS' HOUSES, A VISIT FOR ONE TO TWO HOURS TO WALK THEM THROUGH IT. ONE THING THEY GOT IN TERMS OF FEEDBACK THAT PEOPLE LOVED THE MOST WAS THAT VISITOR. IT MIGHT HAVE BEEN CO-INTERVENTION, TO BE EFFECTED THEY NEEDED THIS MEDIATION AND CONTACT IN RELATIONSHIP. I THINK WE SEE THAT ACTUALLY OVER AND OVER AGAIN WITH REGARDS TO INTERVENTIONS THAT ESPECIALLY WITH VULNERABLE POPULATIONS THAT SOME KIND OF MIXTURE OF HUMAN CONTACT, SOME KIND OF RELATIONSHIP WITH PEOPLE WHO CARE ABOUT YOU, THAT THAT IS SOMETHING THAT IS IMPORTANT TO COMPLEMENT SOME OF THE THINGS TECHNOLOGY MAKES EASIER. I WILL HIGHLIGHTED FOR SOME POPULATIONS TECHNOLOGY USE IS VERY SOCIAL, THINGS LIKE PATIENT COMMUNITIES, AND FOR YOUNGER POPULATIONS THAT MIGHT BE ON SOCIAL MEDIA, TECHNOLOGY CAN BE VERY MUCH A PART OF THE SOCIALABILITY THAT WE SEE EVERY DAY AND SO I WOULD SAY THAT DEPENDING ON THE MARGINALIZED GROUP THAT WE'RE TALKING ABOUT, ONLINE FORMS OF SOCIALABILITY OR INTERACTION RELATING MAY BE VALUABLE AND SUFFICIENT. >> ONE APPLICATION OF THESE TECHNOLOGIES I THINK THAT IS A LITTLE TANGENTIAL BUT RELEVANT PATIENTS APPRECIATE THE OPPORTUNITY TO MAKE THEIR WORK BURDEN LESS. YOU KNOW YOU HAVE TO PAY YOUR BILL, REFILL YOUR MEDICATION. YOU MAY ALREADY HAVE A RELATIONSHIP WITH YOUR PHYSICIAN, BUT DOES THAT MEAN YOU WANT TO GO AND TAKE A HALF DAY OFF OF WORK WHICH MAY BE REALLY CHALLENGING TO GET MEDICATION RENEWED. PARTICULARLY THOSE ACCUSTOMED TO DOING BANKING ONLINE, EASING THEIR BURDEN OF THEIR DAILY LIFE THROUGH TECHNOLOGY, WE SEE THAT THEY ALSO LIKE TO USE, FOR EXAMPLE, PATIENT PORTALS AND TECHNOLOGIES IN THAT WAY. THAT SORT OF TRANSACTIONAL EVENT ISN'T NECESSARILY THERAPEUTIC SO IN PSYCHIATRIC INTERVENTION, COGNITIVE BEHAVIORAL THERAPY, WEIGHT LOSS INTERVENTIONS, YOU NEED THERAPEUTIC RELATIONSHIP WITH A HUMAN BEING. I THINK YOU MENTIONED THIS AS WELL, YOU LIKE THE TECHNOLOGY TO MEDIATE THAT BUT THERE'S ALSO THIS ROOM FOR SORT OF MAKING PEOPLE'S LIVES EASIER BY MAKING THE TRANSACTIONS THAT THEY'VE GOT TO DO ANYWAY SIMPLER. WE DO SEE BILL PAYING AND MEDICATION RENEWALS AS VERY POPULAR USES OF THE PATIENT PORTAL AMONG THOSE USERS. >> YEAH, I COULDN'T AGREE MORE. I'VE BEEN CODING MY WHOLE LIFE. I'M A CLINICAL PSYCHOLOGIST, I COME AS A SOFT CARE CODER. MY INTENTION WAS TO GET THE HUMANS OUT OF THE BUSINESS, TO TRY TO FIGURE OUT WAYS OF USING DIGITAL TO REPLICATION IN A CLINICAL ENCOUNTER. THAT'S FOLLY, THE LITERATURE SUGGESTS, NOTHING SHOWS A DIGITAL TREATMENT CAN PRODUCE CLINICALLY RELEVANT OUTCOMES. NO STUDIES IN BLOOD PRESSURE CONTROL THAT SUGGEST THE SAME. THEY ALL REQUIRES HUMANS OF SOME SORT TO MAXIMIZE TREATMENT OUTCOMES. I GUESS THE FIRST RESPONSE WOULD BE WE DON'T HAVE AN EVIDENCE-BASED, I THINK AT THIS POINT, THAT SUGGESTS THOSE OUTCOMES TO WHAT YOU WOULD DO TO LEVERAGE A WHOLLY DIGITAL APPROACH TO MAXIMIZE CLINICAL OUTCOMES. WHAT I'VE OBSERVED IN OUR TRIALS ANYWAY IS YOU CAN LEVERAGE DIGITAL IN THIS AS MIDDLEWARE SOLUTION TO HELP MAKE THE HUMANS BETTER AT THEIR JOBS AND HELP MAKE EFFICIENT CARE DELIVERY AND INFORMED CARE DELIVERY AND THE COMPLEX MORASS OF CLINICAL CARE DELIVERY WITH PATIENTS I TEND TO WORK WITH I THINK PHYSICIAN AND COLLEAGUES NEED ALL THE HELP THEY CAN GET TO TRIAGE AND FIGURE OUT WHAT THEY ARE GOING TO HANDLE WHEN AND THESE KINDS OF SOLUTIONS CAN BE VERY HELPFUL IN THAT REGARD. >> I THINK MY QUESTION MAY HAVE SORT OF BEEN ANSWERED. BUT THIS IDEA THAT CAME UP ABOUT TECHNOLOGY TO PRODUCE ENGAGEMENT WHICH MADE A LOT OF SENSE IN THE WEIGHT LOSS WHERE PEOPLE WHO WERE MORE ENGAGED SAW BETTER RESULTS, BUT I'M SORT OF THINKING A LOT OF OUR MANDATE IS RELATED TO THE SCREENING. AND SO HOW DO YOU — DOES TECHNOLOGY HAVE A ROLE IN PRODUCING ENGAGEMENT WITH THE IEA OF SCREENING? I'M STRUGGLING TO THINK WHERE THE APPLICATIONS MIGHT BE THERE AND CURIOUS WHAT YOUR PERSPECTIVES ON THAT WOULD BE. >> THERE HAVE BEEN A COUPLE OF STUDIES IN A VERY SPECIFIC POPULATION, AND THAT IS EMPLOYEES. SO EMPLOYEES OF A PARTICULAR COMPANY USING THAT ELECTRONIC PATIENT PORTAL, FOR EXAMPLE, AND THEY GET THE REMINDER FOR THE ANNUAL FLU SHOT. THEY KNEW THEY HAD TO DO IT ANYWAY. OH, RIGHT, IT'S FLU SEASON. AND YOU WILL SEE SOME UPTAKE BECAUSE OF THAT. AGAIN, ESPECIALLY IF THERE'S SOME COMPLEXITY REDUCTION PART OF IT WHERE NOT ONLY DO YOU GET THE REMINDER BUT THE — YOU KNOW, THE NURSING STAFF HAPPEN TO BE IN YOUR BUILDING ON THURSDAY, AND YOU CAN GO DOWN AND GET YOUR SHOT. SO, THE ALERTS AND REMINDERS FOR OTHER POPULATIONS I THINK THE EVIDENCE IS A LITTLE BIT MORE MIXED, I THINK YOU PRESENTED SOME OF THIS ABOUT WHETHER IF I GET, YOU KNOW, I LOG ONTO MY PATIENT PORTAL AND IT SAYS I'M DUE FOR MY MAMMOGRAPHY BUT I KNOW I GOT MY MAMMOGRAM ACROSS THE STREET IT THE OTHER MEDICAL CENTER AND MY PRIMARY CARE IS NOT UPDATED SO I KNOW TO DISREGARD THAT, THAT IS SORT OF THE HOPE AND I'M NOT SURE THAT WE'VE SEEN THAT DELIVERED ON YET. >> I'LL JUST MENTION THAT STUDY THAT I IDENTIFIED WITH REGARDS TO COLORECTAL CANCER SCREENING, THAT ONE WHERE THERE WERE REMINDERS SENT, BUT THERE WAS ALSO THE IDENTIFICATION OF PEOPLE WHO NEEDED MORE ASSISTANCE, INTENSIVE CASE MANAGEMENT. I THINK THAT PERHAPS I'M MORE OF A STRATIFIED APPROACH MIGHT BE MORE EFFECTIVE WITH REGARDS TO THOSE KINDS OF ACTIONS. >> CAN I JUST ARGUE QUICKLY THIS IS WHERE OUR APPROACH TO SINGLE OUTCOME SCIENCE HURTS US. SO, FOR EXAMPLE, IF YOU WOULD ASK ABOUT OUR WORK, RIGHT, I CAN TELL YOU THE THING WE'RE REASONABLY GOOD AT IS LONG-TERM ENGAGEMENT, MEDICALLY VULNERABLE POPULATIONS, WE CAN GET THEM TO USE OUR APPS FOR EXTENDED TIMES. ARE WE MAXIMIZING WEIGHT LOSS? BY NO MEANS. IF I HAVE SOMETHING USING MY APP A YEAR LATER THE QUESTION SHOULD BE WHAT ELSE CAN I DO WITH THAT TIME, WITH THOSE EYEBALLS. I SHOULD BE PROMPTING FLU SHOTS, PROMPTING REMINDERS FOR COLORECTAL CANCER SCREENING BUT THERE'S NO ABILITY FOR ME TO INVESTIGATE THOSE QUESTIONS. ON THIS POINT THE COMMERCIAL WORLD IS WAY AHEAD OF US AND GETS TO THE EMPLOYER PIECE. SPEAKING WITH AN EMPLOYER, A VENDOR WHO RUNS A PHYSICAL ACTIVITY PROMOTION APP FOR EMPLOYERS, AND CONVERSATION, I WAS INTERESTED FOR PHYSICAL ACTIVITY PURPOSES, HE REVEALED HE WASN'T. WHAT HE WAS REALLY INTERESTED IN WAS NOTIFYING EMPLOYEES ABOUT FLU SHOTS, BUT HE KNEW NOBODY WOULD SIGN UP FOR A FLU SHOT WE MINDER SERVICE, THEY WOULD HOWEVER SIGN UP FOR PHYSICAL ACTIVITY PROMOTION EVENT. AND THOSE ARE THE KINDS OF OPPORTUNITIES WE HAVE. >> SO, CAN YOU — SOMEBODY ADDRESS THE ISSUE OF PROVIDER REIMBURSEMENT IMPLICATIONS OF ALL THIS. SEEMS LIKE THIS BEGS FOR BUNDLED PAYMENT OF SOME KIND. BUT IS ANYBODY ADDRESSING THAT? >> DON'T ALL JUMP UP AT ONCE. >> YEAH, ARE YOU GOING TO VOTE IN NOVEMBER? SORRY. I DON'T KNOW IF YOU REMEMBER YESTERDAY I ACTUALLY ASKED A QUESTION ON THIS TOPIC. WE HAD BEEN TRYING TO — I'M STILL HOPEFUL WE'LL GET THERE, HOPING TO DEVELOP A MULTI-MODAL APPROACH WHERE WE DELIVERED DECISION SUPPORT TO THE PATIENTS VIA THE PORTAL. WE UPDATED THEIR SMOKING STATUS, THAT WOULD BE HELPFUL, AND SORT OF FACILITATED THROUGH THE SCREENING PROCESS, AND IT TURNS OUT THAT THE INCENTIVES ARE SUCH THAT RADIOLOGY WANTS MORE PEOPLE TO GET SCREENED, THEY DON'T CARE IF THEY MEET THE GUIDELINES OR NOT. THEY WANT MORE OF THEM. WHICH WASN'T WHAT I WAS HOPING FOR. AND PROBABLY NOT — BUT THE MEDICAL CENTER IS INCENTIVIZED TO DO MORE SCREENINGS, NOT NECESSARILY TO FOLLOW BEST EVIDENCE. >> I WAS MORE INTERESTED YOU FACILITATE THINGS LIKE PRESCRIPTION REFILLS. OTHER LAB ORDERS, THINGS THAT USED TO REQUIRE VISIT, ACTION ON PROVIDER THEY COULD BILL FOR, AND NOW YOU'RE PROVIDING THIS CONVENIENCE, BUT HITTING THE BOTTOM LINE OF THE PROVIDERS. THAT'S WHAT I'M CONCERNED ABOUT IS PROVIDERS HAVE THE SAME TYPES OF INCENTIVES, INCENTIVES FOR OVERUSE OF TECHNOLOGY FOR LIKE RADIOLOGISTS BUT THERE'S INCENTIVE FOR UPDATE USE THAT CUTS INTO YOUR BILLING >> YES, WE ARE STARTING TO SEE MOVEMENT, THERE ARE NOW BILLABLE REMOTE VISITS, SO THAT PHYSICIANS CAN FREQUENTLY BILL FOR A TELEPHONE VISIT. THERE'S STARTING TO BE SOME INTEREST IN BILLING FOR TELEHEALTH VISITS. THAT'S A LITTLE BIT — THERE'S A CPT CODE NOW FOR THAT BUT MOST INSURERS ARE NOT NECESSARILY COVERING THAT. THERE'S A FLIP SLIDE TO THIS WHICH IS THAT IF THEY ARE NOT BILLING FOR THE VISIT, YET THEY HAVE TO APPROVE THE — THEY HAVE TO READ THEIR E-MAIL, RESPOND TO THE SECURE MESSAGE, THEY HAVE TO AUTHORIZE THE MEDICATION REFILL ANYWAY, WE MAY IN FACT BE CREATIN MORE NON-BILLABLE WORK FOR THE PHYSICIANS. >> AND MY FINAL COMMENT IS IT SEEMS LIKE WHEN YOU THEN SET UP THE BILLING MECHANISM YOU CREATED IMMENSE POTENTIAL FOR FRAUD. YOU KNOW, ELECTRONICS MAGNIFIES POTENTIAL FOR EVERYTHING. EVERYTHING GOOD, EVERYTHING BAD. AND TO ME THERE'S NOT INTENDED CONSEQUENCES IN ALL OF THIS, AND ONE OF THEM IS, OH, WE CAN START BILLING FOR ELECTRONIC VISITS, LESS START INVENTING ELECTRONIC VISITS. I ENVISION THIS IS A HUGE HEADACHE FOR PAYERS. >> HOPEFULLY QUICK QUESTION AND WE'LL GET TO THE AUDIENCE. THIS IS CLEARLY AN ENGAGED — A LOT OF INTEREST. WE DIDN'T HEAR THE WORDS NEURAL NETWORK, DEEP LEARNING YET. THERE'S BEEN PRESENTATIONS AND DISCUSSION FROM FOLKS ON WE CAN USE THESE VERY LARGE DATABASES TO PROFILE THE MOST IMPORTANT TESTS FOR THE PATIENTS, IN REDUCING DISPARITIES ARE THERE ADVANTAGES TO PURSUING THAT AND COULD THERE BE UNINTENDED CONSEQUENCES, WEAPONS OF MASS DISTRACTION AND ALL OF THAT. >> ABSOLUTELY. I THINK UNINTENDED CONSEQUENCES WITH REGARDS TO MACHINE LEARNING-BASED APPROACHES ARE A SIGNIFICANT CONCERN. ONE AREA THAT DRIVES THAT IS THE FACT PEOPLE WHO — THERE'S CERTAIN PEOPLE WITH DIFFERENTIAL AMOUNTS OF DATA ABOUT THEM, AND SPECIFICALLY PEOPLE WHO ARE MORE DIGITALLY CONNECTED, THERE'S GOING TO BE A LOT MORE DATA ABOUT THEM AVAILABLE FOR LEARNING. AND OFTEN WE'LL SEE BIAS IN TRAINING SETS THAT ARE USED IN ORDER TO DEVELOP VARIOUS FORMS OF ALGORITHMS. I THINK THAT WE ALSO — BASICALLY EVERY STAGE OF DEVELOPING AND TESTING ALGORITHMS, THERE'S THE POSSIBILITY FOR BIAS, AND EXTENSIVE WORK THAT SHOWS THAT THERE IS HUMAN BIAS WITH REGARDS TO THE WAY THAT MANY OF THESE TYPES OF ALGORITHMS MIGHT FUNCTION. SO I THINK THAT IT'S IMPORTANT TO BE EXTREMELY CAREFUL AND TO BE EVALUATING BIAS AS WE MOV FORWARD. I DON'T THINK THAT WE CAN JUST SAY, OH, THIS IS WONDERFUL, LOOK HOW GREAT THE PERFORMANCE IS. >> LET'S START WITH TWITTER QUESTION. >> ONLINE QUESTIONS, A COUPLE. >> SPEAK UP. >> YEAH. IF TIME ALLOWS I'LL ASK BOTH. FIRST IS FOR DR. BENNETT. IT SAYS, HOW, IF AT ALL, DOES YOUR TOOL THAT IDENTIFIED ACTIVITIES TO ACHIEVE A 500-CALORIE DEFICIT ACCOUNT FOR CHANGES IN BEHAVIOR THAT MIGHT COUNTERACT THE PRESCRIBED BEHAVIORS? FOR EXAMPLE I WENT FOR A WALK, NOW I EARNED A PIECE OF CAKE, DID THIS COME UP AS A CHALLENGE AT ALL? >> SOUNDS KIND OF GOOD TO ME. NO, WE CHANGED THE GOALS ON A REGULAR BASIS. SO WE HAVE — I ONLY SPOKE ABOUT OUR GOAL PRESCRIPTION ALGORITHM BUT WE HAVE GOAL REASSIGNMENT ALGORITHMS THAT ARE DELIVERED INTERMITTENTLY OVER THE COURSE OF TREATMENT IN ORDER TO UPDATE THOSE GOALS TO REFLECT CHANGES IN BEHAVIORS AND SO THAT'S HOW WE CAN ACCOMMODATE SOME OF THOSE THINGS >> NEXT QUESTION, CAN ANY PRESENTERS SPEAK ON THE CONCEPT OF TRUST OF I.T. AND NON-MAJORITY POPULATIONS? >> I'LL START. YES. THERE IS — THERE ARE SURVEY DATA, CLEARLY SHOWS DIFFERENTIAL LEVELS OF TRUST IN INFORMATION TECHNOLOGY BROADLY, SPECIFICALLY IN THE MAJOR TECH COMPANIES. AND ALSO EVEN MORE SPECIFICALLY IN THE PRICE INSECURITY FOR MEDICAL DATA. SO WE SEE PARTICULARLY LESS EDUCATED POPULATIONS ARE MORE SKEPTICAL ABOUT THE SECURITY OF, FOR EXAMPLE, ONLINE PORTAL ACCOUNT. AND THAT WILL BE A REASON PEOPLE GIVE FOR NOT ACTUALLY TURNING ON THEIR ACCOUNT. WE DO — THERE'S A SMALLER — THERE'S ALSO SOME PEOPLE WHO HAVE MORE TRUST IN THE ELECTRONIC DATA THAN THEY DID IN THE PAPER MEDICAL RECORDS. IT'S A SMALLER GROUP OF PEOPLE. I'M ASSUMING THEY ARE PEOPLE WHO MAYBE GOT BURNED IN THE PAPER WORLD, YOU KNOW, SOMEBODY DID LOOK AT THEIR MEDICAL RECORD. AND THEY HAD SOME ADVERSE EXPERIENCE WITH THAT ONE. BUT YES, THAT HAS BEEN ONE OF THE CITED BARRIERS TO CERTAIN PEOPLE USING SOME OF THESE TECHNOLOGIES. IT TENDS TO ALSO BE MORE FREQUENT AMONG OLDER PEOPLE. SO YOUNGER PEOPLE ARE MORE COMFORTABLE IN THE DIGITAL WORLD BROADLY, AND HAVE BROKEN DOWN PRIVACY BARRIERS ANYWAY. SO WE DON'T SEE THAT LEVEL OF CONCERN AS MUCH AMONG YOUNGER PATIENTS. >> THANK YOU. >> YES, THIS SIDE. >> THANK YOU. MY NAME IS LEE YOUNG. YOU MENTIONED A LOT, AND THAT'S REALLY IMPORTANT, THAT RESOURCES AND SKILL AND I THINK PROBLEM IS ESPECIALLY IN RURAL AREA IT'S HARD TO FIND PHYSICIAN OR HEALTH SERVICES BUT IF THEY HAVE NO CAR AND THEY ARE HOMELESS, WHETHER IT'S URBAN OR RURAL AREA, IT'S VERY DIFFICULT. I FIND IN THE LIBRARY NOW PEOPLE ARE MORE AND MORE GETTING LIBRARY SERVICES BECAUSE THEIR COMPUTER IS STOLEN OR VIRUSES AND REALLY UNABLE TO DO SOME THINGS, OR YOU SEE LIBRARY SERVICES NOW GETTING MORE IMPORTANT. BUT PEOPLE — LIBRARY SERVICES ARE LIMITED, ONLY VERY FEW COMPUTER AVAILABLE SO I THINK WE GOT TO THINK ABOUT THIS AVAILABILITY OF EQUIPMENT TO THEM AND SERVICE TO THEM SO THEY CAN BE EDUCATED SO I WONDER IF WE CAN PAY ATTENTION TO THIS REALLY AVAILABLE FOR ALL THOSE SERVICES ESPECIALLY THOSE HOMELESSNESS, THEY REALLY NEED SOME HYGIENE AND GO TO LIBRARY, A LOT OF PEOPLE THERE IS NOT REALLY DESIRABLE SO THEY ARE — THEY WILL BE HESITANT TO GO TO LIBRARY ANYWAY. SO WE GOT TO PAY ATTENTION TO OUR SOCIAL PROBLEM AND REDUCE HOMELESSNESS AND BECAUSE OF HOMELESSNESS THEY ARE NOT REALLY — THERE WILL BE HOMELESSNESS. >> THANK YOU. IF YOU COULD FOCUS ON THERE IS SOME LITERATURE ON DIGITAL ACCESS AMONG HOMELESS POPULATIONS, I KNOW THERE'S SOME EXPERTISE HERE. >> I WILL JUST AGREE WITH YOU THAT I DO THINK THAT PUBLIC LIBRARIES ARE AN IMPORTANT SOURCE OF ACCESS TO TECHNOLOGY FOR POPULATIONS THAT DON'T HAVE IT OTHERWISE. SO IN RURAL COMMUNITIES, OFTEN WE SEE THAT LIBRARIES MAY BE THE ONLY NON-RELIGIOUS INSTITUTIONS TO WHICH THE PUBLIC HAS ACCESS, SO THAT'S A REALLY IMPORTANT THING. WE ALSO SEE THAT THERE ARE IMPORTANT PLACES FOR HOMELESS PEOPLE TO GAIN ACCESS TO TECHNOLOGY AS WELL AS PEOPLE WHO ARE LOW INCOME. I KNOW LIBRARIES ALSO TYPICALLY OFFER — MAY BE THE ONLY SOURCE OF FREE INTERNET IN A COMMUNITY AND TYPICALLY HAVE PEOPLE AVAILABLE THERE WHO CAN ACTUALLY PROVIDE HELP TO PEOPLE IN USING TECHNOLOGIES. ACTUALLY A PAPER THAT JESSICA AND I WROTE WITH REGARDS TO INTERVENTION GENERATING INEQUALITY ONE THING WE TALK ABOUT IS PROBLEMS OF ACCESS TO TECHNOLOGY AND PROMISE OF PUBLIC LIBRARIES AS ONE OF THE AREAS OR WAYS TO TRY TO CLOSE THAT GAP. >> THANK YOU. YES, SIR. >> YES, THANK YOU. AS SOMEONE WHO WORKS ON A PERSONAL HEALTH REPORT, I'M SORRY, PATIENT PORTAL, I WAS RELIEVED TO SEE MUCH MORE DISCUSSION, YESTERDAY I WAS AFRAID WE WEREN'T GOING TO HEAR PATIENT PORTALS DISCUSSED, THIS IS A GREAT DISCUSSION TO HEAR. I WORK ON THE DEEP OF VETERANS AFFAIRS PATIENT PORTAL FOR VETERAN PATIENTS, RURAL VETERANS AND VETERANS WITH LOWER INCOME AND HOMELESS ARE A BIG CONCERN FOR US. WE FOUND THAT THE SMART SMARTPHONE HAS BEEN A HUGE BOON FOR PEOPLE IN THOSE POPULATIONS, DIGITAL ENGAGEMENT FOR THE FACE-TO-FACE ENCOUNTER HAS BEEN TREATMENT. I WANTED TO MENTION SECURE MESSAGING. BECAUSE I'M NOT WHAT YOU CALL A HEALTHCARE PROFESSIONAL MYSELF, I'M NOT ALWAYS SURE WHEN YOU TALK ABOUT BILLABLE HOURS, BUT WITH SECURE MESSAGING WE INTRODUCED THIS AND FOUND THE EARLY ADOPTERS EMBRACED IT, AND THEN WE HIT A WALL, UNTIL THEY DEVELOPED — THEY INCLUDED USE OF SECURE MESSAGING BY PROVIDERS, CLINICIANS AND OTHERS, TO ACCOUNT FOR THEIR TIME IN WHAT'S CALLED THE WORK LOAD CREDIT WITHIN THE V.A. IT TOOK OFF, BECAUSE PHYSICIANS, PROVIDERS, KNEW THEIR TIME WAS GOING TO BE ACCOUNTED FOR. AND HAVING THAT HAS MEANT THAT SECURE MESSAGING IS THE MOST POPULAR FEATURE, AND WE'VE SEEN A 10-POINT INCREASE, UP TO 40%, SOME WEEKS 50% OF USAGE ON PATIENT PORTAL IS THE USE OF SMARTPHONES AND TABLETS. AND SINCE OUR AVERAGE USER IS 66 YEARS OLD, AND OUR VETERAN POPULATION IS AT OR BELOW THE AVERAGE INCOME LEVEL IN THE UNITED STATES, WE FEEL LIKE WE ARE MAKING PROGRESS IN REACHING THESE KINDS OF POPULATIONS. THANK YOU FOR BRINGING PHRs. >> I WILL SAY MY HEALTHY VET, THE V.A. TOOL. >> THAT'S THE WORD. >> HAS BEEN A LEADER, RECOGNIZED AS A LEADER. THE POINT ABOUT FINANCIAL INCENTIVES THAT ARE EXTERNAL TO THE TECHNOLOGY YOU'RE NOT BILLING FOR HOURS THE WAY THE REST OF US ARE. >> YOU ABOUT PROVIDERS WERE CONCERNED. >> ACCOMMODATING THAT YOU ACCOMPLISH A CHANGE. I DON'T KNOW IF THERE'S ANYONE HERE FROM KAISER, I'M SURE THERE'S SOMEBODY. KAISER IS INSURANCE AND HEALTH CARE AND MADE A MAJOR PUSH FIVE YEARS AGO TO TRY TO PROMOTE ADOPTION OF SECURE MESSAGING AND REMOTE VISITS BECAUSE THEY ARE INVENT ADVISED TO NOT HAVE THE PATIENT COME IN FOR LOW URGENCY VISITS BECAUSE THEY ARE GOING TO GET PAID, THEY HAVE MORE OF A PER CAPITA SYSTEM. THEY PUBLISHED PAPERS TO SEE WERE THAT REDUCED EMERGENCY DEPARTMENT USE >> I'M KEVIN GAVELY, BEEN HERE THE PAST COUPLE DAYS. FIRST, I WAS LOOKING AT THE MISSION OF NIH, IT SAYS SEEK FUNDAMENTAL KNOWLEDGE TO ENHANCE HEALTH AND REDUCE ILLNESS AND DISABILITY. UNITED STATES ONE OF THE MOST WEALTHY COUNTRIES HAPPEN TO BE RANKED 26th AMONG OECD FOR AVERAGE LIFESPAN, WHICH I WANT TO PUSH BACK ON JUST BEING LOW INCOME OR AS BEING A DISPARATE PROBLEM. I FEEL THOUGH CANCER HAS SURVIVAL RATES HAVE DOUBLED IN THE LAST 40 YEARS, THE LIFETIME RISK HAS GONE FROM 1 IN 3 TO 1 IN 2, DIABETES UP FROM .93% IN 1958 TO 7.4% IN 2015. A LOT OF THIS IS DUE TO OUR DIET. I'M IN THE FOOD INDUSTRY, HEALTH AND NUTRITION, I'M 40 YEARS OLD, PERFECT HEALTH. MY FAMILY HAS A LONG HISTORY OF LIVING, GREAT GRANDMOTHER IS 99, HER MOTHER LIVED TO OVER 100. A LOT OF ISSUES ARE WE INGEST, ALUMINUM CAUSES ALZHEIMER'S, FOR EXAMPLE. CHLORINE IN OUR WATER. I KNOW THAT OBESITY, A LOT OF PROBLEMS WITH THAT IS BECAUSE OF THE HYPOTHALAMUS BEING DAMAGED DUE TO MSG, IN A LOT OF OUR FOOD, HIDDEN, NOT JUST CHINESE FOOD, IT'S CALLED NATURAL FLAVORS, SOY PROTEIN ISOLATE. THERE ARE A LOT OF ISSUES THAT WE HAVE TO DEAL WITH AS AMERICANS, AND IT'S A THORN IN MY SIDE HEARING THESE GROUPS. NUMBER ONE, THESE GROUPS ARE NOT — THEY ARE TARGETED. THEY ARE ADDICTED TO THINGS LIKE SUGAR, MSG, BUT IT'S NOT JUST THOSE GROUPS. IT'S US AS AMERICANS. AND THERE'S SO MUCH IN OUR DIETS THAT CAUSE US TO HAVE A SHORTER LIFESPAN THAN, SAY, JAPAN WHO LIVES TO 84, SO WE NEED TO LOOK HOLISTICALLY AT THE ISSUES IN THIS COUNTRY THAT ARE AFFECTING US DUE TO COMPANIES LIKE MONSANTO, CARGO, KRAFT, PHARMACEUTICAL INDUSTRIES LIKE MERCK, AND DIFFERENT THINGS THAT ARE AFFECTING US ALL. >> THANK YOU. >> WHEN WE TRY TO SEPARATE OURSELVES AND LOOK AT INDIVIDUAL SMALL GROUPS WE MISS THE BIGGER PICTURE OF WHAT'S REALLY HAPPENING IN OUR COUNTRY AND TO ALL OF US, 7 IN 10 AMERICANS ON PRESCRPTION DRUGS, NOT JUST LOW INCOME OR MARGINALIZED PEOPLE. IT'S AMERICANS. >> MAYBE COMMENT A BIT ON USE OF TECHNOLOGY RATHER THAN CALORIE REDUCTION TO FOOD TYPE AND IS THERE PROGRESS TO BE MADE THERE, BROADER AGENDA. >> YEAH, SO THE WORK — MY WORK, MY COLLEAGUE STEINBERG AT DUKE IS DOING EXCELLENT WORK RIGHT NOW, ONE OF THE MOST IMPORTANT ADVANCES I THINK IN THE LAST SEVERAL GENERATIONS WAS THE DASH DIET TRIALS. SIMPLE ADOPTION OF A RELATIVELY STRAIGHTFORWARD EASILY ACCESSIBLE DIETARY PATTERN HAS THE ABILITY TO IMPACT BLOOD PRESSURE, AT THE SAME LEVEL AS ANTI-HYPER HYPERTENSIVE IN A WEEK. IT'S STUNNING. IF YOU LOOK AT NATIONAL ADHERENCE IT'S LESS THAN 1%, WITH THE 40-SOME-ODD MILLION PEOPLE NEWLY DIAGNOSED WITH HIGH BLOOD PRESSURE, YOU COULD REALLY MITIGATE THAT DRAMATICALLY WITH WIDESPREAD ENGAGEMENT OF ADHERENCE TO THE DASH DIET, FOCUSING ON THAT QUESTION. SHE HAS A TRIAL RIGHT NOW ESSENTIALLY REPURPOSING EXISTING COMMERCIAL MOBILE APPS DOWNLOADED ALMOST A BILLION TIMES BY AMERICANS IN THE LAST FIVE TO TEN YEARS, YOU HAVE MOST ALL OF YOU HAVE ONE OF THE COMMERCIAL APPS ON YOUR PHONE RIGHT NOW FOR DIET TRACKING, I'M A WEIGHT LOSS RESEARCHER AND CAN KEEP UP FOR TWO WEEKS. SHE'S WRITTEN TECHNOLOGIES THAT REPURPOSES APPS TO HELP PEOPLE TO GET MOR ADHERENT, IT WORKS, NEXT STEP IS AMAZON ALEXIS IN YOUR HOME AND THAT WORKS AS WELL. THOSE KINDS OF STRATEGIES WILL BE EASILY AFFORDABLE TO POPULATIONS OF ALL TYPES. >> THANK YOU. A COMMENT FROM THE WEB? >> YES. A BIT OF A TWO-PART QUESTION. WHAT EXPLAINS THE DIFFERENCES SEEN IN THE USE OF HIT IN REGARDS TO DIFFERENT DIAGNOSES, PARTICULARLY AS DISCUSSED FOR CANCER PREVENTION, DO WE UNDERSTAND WHY IT WORKED FOR SOME CANCERS BUT NOT OTHERS AND PIGGYBACKING WHAT IMPACT DO YOU SEE WITH USE OF HIT ON MENTAL HEALTH? >> AMY, MAYBE YOU COULD START WITH SOME CANCERS AND NOT OTHERS. WHAT WOULD EXPLAIN WHY I.T. WORKED SOME OF THE TIME AND NOT OTHERS, COULD YOU GAIN INSIGHT FROM THAT LITERATURE? >> I THINK IT'S INTERESTING TO TRY TO CHARACTERIZE WHY IT WORKED FOR A CANCER VERSUS ANOTHER BECAUSE SEVEN STUDIES ADDRESSED DIFFERENT POPULATIONS, DIFFERENT CANCERS, I FEEL LIKE IT WOULD BE HELPFUL TO HAVE MORE DATA THAT WOULD DRILL DOWN ON THAT. FOR EXAMPLE, USING THE SAME INTERVENTION IN DIFFERENT POPULATIONS FOR DIFFERENT TYPES OF SCREENINGS. I THINK THAT WOULD BE MORE INFORMATIVE THAN THE INDIVIDUAL STUDIES IN DIFFERENT SUBPOPULATIONS OF DIFFERENT TECHNOLOGY TIMES. — TYPES. I'M HEARING A LOT OF OPPORTUNITY TO EXPLORE EHR OR EXPLORE MOBILE APPS OR EXPLORE ANY ONE OF THESE INTERVENTIONS BUT TO IMPLEMENT THEM IN DIFFERENT POPULATIONS USING THE SAME INTERVENTION AND THEN WE REALLY COULD HAVE COMPARATIVE INFORMATION AND WITHOUT THAT IT'S REALLY HARD TO DRAW CLEAR CONCLUSION JUST BASED ON ONE INTERVENTION AND ONE SUBPOPULATION IN A PARTICULAR LOCATION SO I THINK IT WILL BECOME MORE MEANINGFUL IF WE CAN SCREENING USING X INTERVENTION IN MULTIPLE POPULATIONS AND SPEAKING TO THE WAY WE'RE MEASURING OUTCOMES IF YOU'RE JUST LOOKING AT ONE OUTCOME YOU'RE LOOKING AT ONE INTERVENTION, WE HAVE TO BE ABLE TO ADAPT THEM APPROPRIATELY AND CULTURALLY, IN MULTIPLE SETTINGS. AND THEN WE MIGHT BE ABLE TO GAIN A LITTLE MORE INSIGHT ABOUT HOW EFFECTIVE THEY ACTUALLY ARE SO HOPEFULLY THAT ANSWERS THE QUESTION. >> AND MENTAL HEALTH ISSUES. >> COULD YOU REPEAT PART TWO OF THE QUESTION? >> SURE. WHAT IMPACT DO YOU SEE WITH THE USE OF HIT ON MENTAL HEALTH? >> SO I'D SAY THAT IT'S A MIXED BAG. I DO KNOW THAT THERE ARE — I SPOKE ABOUT ONE STUDY WHERE IT WAS BEING — TECHNOLOGY WAS USED TO HELP CLINICIANS DIAGNOSE PTSD AND DEPRESSION AMONGST CAMBODIAN IMMIGRANTS, AND IT LED TO MORE GUIDELINE CONCORDANT CARE AND THERE WAS A VERY STRONG KIND OF CULTURAL COMPETENCE COMPONENT TO THAT INTERVENTION AS WELL. THAT WAS ONE THAT HELPED PEOPLE GET BETTER CARE. BUT I THINK THAT THERE'S — WITH REGARDS TO OTHER KINDS OF INTERVENTIONS, THERE'S A LOT OF WORK THAT'S COMMERCIAL NOW THAT'S LOOKING AT TRYING TO PROVIDE PEOPLE WITH MENTAL HEALTH INTERVENTIONS, REMOTELY, USING VARIOUS KINDS OF COMMERCIAL PLATFORMS. I'D SAY THAT'S — – THERE'S A LOTS OF QUESTIONS WITH REGARDS TO REGULATIONS SURROUNDING THEM. AND SO I'D SAY THAT'S KIND OF A NEW EMERGING SPACE THAT'S FAIRLY UNKNOWN. >> I CONCUR COMPLETELY. I THINK THE POTENTIAL IS GREAT, A SIMPLE ALGORITHM THAT CAN ASSESS WHERE YOU ARE AND WHETHER YOU MOVE CAN DO ANALYSIS ON TEXT MESSAGES YOU'RE SENDING, CAN LOOK AT YOUR POSTURAL DETECTION, PRETTY GOOD INDICATION WHETHER OR NOT SOMEBODY'S IN A DEPRESSIVE EPISODE, MUCH MORE CONCERN ON THE TREATMENT SIDE IF THERE'S AN AREA WE KNOWED HUMAN CONNECTION MATTERS IT'S THERE. AND NOTING REGULATORY ISSUES. I'LL JUST SAY BROADLY WE SAW CALIFORNIA ANNOUNCE THEY ARE GOING TO DO A LARGE SCALE TRIAL, TWO COMMERCIAL MENTAL HEALTH TREATMENTS, IN THEIR POPULATION I BELIEVE THEIR EMPLOYED POPULATION, I'M REALLY CONCERNED ABOUT THAT. WE CERTAINLY WOULD NOT ALLOW DRUG TREATMENT — I'M SORRY, THESE ARE COMMERCIAL TREATMENTS THAT HAVE NOT HAD EFFICACY TESTING YET SO INITIAL TESTING WILL BE IN THE WILD, FOR LACK OF BETTER WAY OF DESCRIBING IT. I'M CONCERNED WHEN WE HAVE INNOVATIONS THAT EMERGE LIKE THIS THAT SEEM EXCITING IN THE COMMERCIAL SPACE WE'RE LESS LIKELY TO MOVE THEM THROUGH THE REGULATORY PATHWAYS WHEN TALKING ABOUT DIGITAL TREATMENTS AS COMPARED TO OTHER TYPES OF TREATMENTS. >> I'D LIKE TO THE LAST TWO FOLKS TO KEEP QUESTIONS BRIEF. >> PAMELA THORN, NIDDK. THANK YOU FOR PRESENTATIONS. I WANT TO REVISIT A TOPIC, INTEREST IN SCIENCE OF ENGAGEMENT. AND MY QUESTION IS SPECIFICALLY FOR DR. BENNETT BUT OTHERS MAY HAVE FEEDBACK. BECAUSE YOUR STUDY AROUND — YOUR FINDINGS AROUND SUSTAINED ENGAGEMENT WERE PARTICULARLY IMPRESSIVE, DO YOU HAVE SOME TIPS FOR WHAT YOU'RE DOING IN HYBRID APPROACHES TO SUSTAIN INITIALIZE, IS THERE AN INTERIM STAGE AND FOR THE TOUCH PART IS THERE A SPECIFIC CHARACTERISTIC OF THE STAFF OR CHARACTERISTICS, TIPS TO GIVE US. >> THAT'S LIKE A SOAP BOX YOU JUST GAVE ME. I'LL TRY HARD NOT TO STAND ON IT. LET ME JUST SAY, YEAH, SCIENCE OF ENGAGEMENT ONE THING WE NEED TO INVEST IN, ALL THAT WE WANT TO ACCOMPLISH IN PATIENT-FACING TECHNOLOGIES IS BOUND UP IN THIS. I'LL TELL YOU A COUPLE THINGS THAT WE DO. ONE IS WE DO A LOT OF TESTING, AND YOU DON'T — STEVE JOBS ONCE SAID PEOPLE DON'T KNOW WHAT THEY WANT, AND HE MEANT THAT IN A COMMERCIAL SENSE BUT IN A DIGITAL SENSE HE'S RIGHT ABOUT THAT. QUALITATIVE WORK WHERE YOU ASK PATIENTS WHAT THEY WANT TO SEE IS NOT AS USEFUL, IN MY VIEW, AS ITERATING THROUGH DESIGN OF TREATMENTS, MAXIMIZE BEHAVIORAL CHANGES YOU'RE TRYING TO CREATE. A COUPLE PRINCIPLES YOU NEVER ASK A PATIENT FOR DATA WITHOUT PROVIDING FEEDBACK. THAT'S AN ABSOLUTE. THE WE TESTED THIS, OTHERS HAVEST ITED THIS. WE ALWAYS PROVIDE FEEDBACK. WE PROVIDE FEEDBACK THAT'S HIGHLY PERSONALIZED, AND PERSONALIZATION MAY TAKE A VARIETY OF FORMS. AND THEN SORT OF THE NOTION OF ACCOUNTABILITY, THE IDEA SOMEONE IS ALWAYS LOOKING AT MY DATA CAN BE ESSENTIALLY MAXIMIZED IN FEEDBACK YOU'RE PROVIDING AND DIRECTING FEEDBACK TO OTHER CARE PROVIDERS WHO ARE THEN ALSO REINFORCING THE ACCOUNTABILITY IN THEIR INTERACTIONS WITH PROVIDERS. I HAVE A LOT TO SAY ABOUT THAT. I'M HAPPY TO DO THAT OFFLINE. I SAW THE ONE MINUTE MARK, THAT WAS MOSTLY FOR ME. >> COMING UP ON BREAK. LAST QUESTION. >> DR. ANCKER, SEVERAL YEARS AGO THE PRIOR COMMISSIONER OF HEALTH IN NEW YORK STARTED A REMARKABLE AND REVOLUTIONARY PROGRAM WHERE SHE INSISTED EVERYBODY ON THE HEALTH DEPARTMENT BE EDUCATED ABOUT STRUCTURAL RACISM AND THAT INCORPORATED INTO THEIR DAILY WORK, IT WAS A REVOLUTIONARY THING TO DO. HAS THAT AFFECTED THE USE OF HEALTH INFORMATION TECHNOLOGY OR DO YOU SEE THAT EFFECTS OF IT ELSEWHERE IN YOUR WORK? >> THAT'S A GREAT POINT. THE STUDY THAT I PRESENTED FROM THE FEDERALLY QUALIFIED HEALTH CENTER RAISED THE QUESTION WHETHER PROVIDER — FOR EXAMPLE IMPLICIT BIAS WAS LEADING TO DIFFERENTIAL USE AMONG PATIENTS. IMPLICIT BIAS IS ONLY ONE OF THE ISSUES IN STRUCTURAL RACISM THAT THE DISADVANTAGED POPULATIONS ARE SUFFERING FROM A WIDE VARIETY OF OTHER SOCIETAL AS WELL AS HEALTH SYSTEM FACTORS HERE. THE DEPARTMENT OF HEALTH IN NEW YORK CITY IS FORWARD THINKING. THEY ARE NOT OFFERING PHRs DIRECTLY TO PATIENTS, SO THEY DO A LOT OF DIRECT COMMUNICATION TO THE PUBLIC. THEY BUY SUBWAY ADS, TELL US NOT TO DRINK SUGARY DRINKS. THEY HAVE A LOT OF RESOURCES ONLINE THAT PATIENTS CAN — I'M SORRY, ANYBODY IN THE PUBLIC CAN USE TO SEARCH ONLINE. I DON'T KNOW WHETHER THEY'VE GOT GOOD DATA ABOUT USAGE OF RESOURCES. THAT WOULD BE INTERESTING. THE ANSWER IS I DON'T KNOW. >> I WANT TO THANK OUR SPEAKERS, THANK THE AUDIENCE. GREAT DISCUSSION. [APPLAUSE] TEN-MINUTE BREAK. WE'LL COME BACK AND TALK ABOUT HEALTH SYSTEMS. IT WILL BE REALLY INTERESTING AND BUSY. SEE YOU IN TEN. THANK YOU. WE'RE HITTING INTO THE HOME STRETCH, A LOT TO DISCUSS YET INCLUDING REVIEW AND DISCUSSION OF HEALTH SYSTEMS INTERVENTIONS. WE'RE GOING TO START WITH A VIDEO VIGNETTE FROM THE DIRECTOR OF NIDDK FROM DR. GRIFFIN RODGERS. AND IF WE COULD HEAR FROM DR. ROGERS. * >> NIDDK, MANY DISEASES IN OUR RESEARCH MISSION EXHIBIT HEALTH DISPARITIES, INCLUDING OBESITY, TYPE 2 2 DIABETES, PLACING INDIVIDUALS AT RISK FOR KIDNEY DISEASE, INCREASING RISK FOR PREMATURE DEATH AND LOWER QUALITY OF LIFE. ABOUT A THIRD OF U.S. ADULTS HAVE OBESITY, AND RATES ARE SIGNIFICANTLY HIGHER AMONG HISPANICS, AFRICAN-AMERICANS, NATIVE AMERICAS, PACIFIC ISLANDERS, AND MANY MINORITY GROUPS. ABOUT 12% OF U.S. ADULTS, 30 MILLION PEOPLE, HAVE DIABETES. 90 TO 95% OF THESE ARE CAUSED BY CASES OF TYPE 2 DIABETES, WHICH AGAIN DISPROPORTIONATELY AFFECT CERTAIN RACIAL, ETHNIC AND SOCIALLY DISADVANTAGED GROUPS. 1 IN 3 ADULTS HAS PREDIABETES, DISPARITIES POINTING TO A NEED TO ACHIEVE HEALTH EQUITY AND PREVENTIVE IT SERVICES. WE ADDRESS BY FUNDING RESEARCH IN OUR STUDIES, STRIVING TO GET BROAD REPRESENTATION OF DIVERSE POPULATIONS, SO WE'RE MOVE CONFIDENT THAT RESEARCH FINDING AND RECOMMENDATIONS WILL HOLD TRUE FOR POPULATIONS THAT ARE MOST AFFECTED. FOR EXAMPLE, THE NIDDK-LED DIABETES PREVENTION PROGRAM, DPP, RECRUITED AMONG AFRICAN-AMERICANS, HISPANICS, AMERICAN INDIANS, AND ASIAN COMMUNITIES, AND SHOWED THAT STRUCTURED LIFESTYLE CHANGES DESIGNED TO PROMOTE MODEST WEIGHT LOSS CAN DELAY AND POTENTIALLY PREVENT ONSET OF TYPE 2 DIABETES IN THOSE AT HIGH RISK AND PEOPLE FROM THOSE BACKGROUNDS. NIDDK SUPPORTED TRANSLATIONAL RESEARCH, FORMING THE BASIS FOR CONGRESSIONALLY ESTABLISHED NATIONAL DIABETES PREVENTION PROGRAM, WHICH IS BEING DISSEMINATED BY THE CDC AND CMS. ACHIEVING HEALTH EQUITY WOULD IMPROVE HEALTH OF DISADVANTAGED COMMUNITIES WHERE RATES OF OBESITY AND DIABETES ARE HIGHEST. HEALTH EQUITY APPROACHES COULD TRANSFORM ACCESS TO EVIDENCE-BASED SERVICES, AFFORDABLE DIABETES SCREENING AND FEASIBLE TREATMENT OPTIONS THAT ALIGN WITH PEOPLE'S CULTURE AND VALUES. THIS REQUIRES STRONG COLLABORATION WITH COMMUNITY, HEALTHCARE SYSTEM AND RESEARCH, IT'S IMPERATIVE WE DEVELOP AND TEST NEW APPROACHES TO PREVENTION, ESPECIALLY INTERVENTIONS THAT CAN BE USED IN UNDERRESOURCED COMMUNITIES, INCLUDING THE INNOVATIVE USE OF TECHNOLOGIES. I BELIEVE ACHIEVING EQUITY AND PREVENTIVE SERVICES WILL REDUCE AND HELP PREVENT COMPLICATIONS, IMPROVING UPTAKE OF EVIDENCE-BASED SERVICES AND DIVERSE SETTINGS WILL IMPROVE MANY HEALTH OUTCOMES, SO PEOPLE HAVE A BETTER OPPORTUNITY TO LIVE LONGER AND HEALTHIER LIVES, REGARDLESS OF INCOME, WHERE THEY LIVE OR RACIAL AND ETHNIC BACKGROUND. THESE OUTCOMES ARE IMPORTANT FOR OUR NATION AND MOTIVATE THE WORK WE DO AT NIDDK. [APPLAUSE] >> GOOD MORNING. HOW'S THE SOUND? CAN YOU HEAR ME? YEAH? OKAY. I'LL WAIT FOR THE SLIDES. GREAT. HI, I'M HEIDI NELSON FROM THE PACIFIC NORTHWEST EVIDENCE-BASED PRACTICE CENTER AT THE OREGON HELD AND SCIENCE UNIVERSITY. AND WE'RE GOING TO TALK ABOUT QUESTION 5 BASED ON HEALTH SYSTEM INTERVENTIONS. I HAVE NO DISCLOSURES TO INFORM YOU OF TODAY, AND I ALSO BEFORE WE MOVE ON WANT TO ACKNOWLEDGE CONTRIBUTIONS OF THE FULL TEAM AT THE EVIDENCE-BASED PRACTICE CENTER LISTED HERE. KEY QUESTION 5, WE'RE AT THE LAST ONE OF THIS CONFERENCE, FOCUSING ON THE EFFECTIVENESS OF INTERVENTIONS THAT HEALTHCARE ORGANIZATIONS AND SYSTEMS IMPLEMENT TO REDUCE DISPARITIES AND PREVENTIVE SERVICES USE. THIS KEY QUESTION FOCUSES ON SYSTEMS, HEALTH SYSTEM INTERVENTIONS, BUT AS WE'VE SHOWN IN THE DIAGRAM A FEW TIMES ALREADY IN THE CONFERENCE WE'RE ALSO INCLUDING THOSE THAT ARE IN OTHER SETTINGS BUT ARE CONNECTED TO HEALTH SYSTEMS. AND SO THE HEALTH SYSTEM IS PROBABLY THE MOST EXPANSIVE PART OF THE REVIEW, WE INCLUDED THOSE TAKING PLACE IN CLINICIAN SETTINGS, AND IN COMMUNITY SETTINGS THAT HAVE LINKS TO THE HEALTH SYSTEM. SO, THE GOOD NEWS IS UNLIKE SOME OTHER QUESTIONS YOU'VE SEEN SO FAR WE HAVE MANY STUDIES THAT ADDRESS THIS QUESTION. 57 STUDIES IN 60 PUBLICATIONS MET INCLUSION CRITERIA, 46 RANDOMIZED CONTROL TRIALS. AS WITH THE OTHER QUESTIONS IN THIS REVIEW, MOST OF THEM FOCUSED ON CANCER SCREENING, FOR COAL COLORECTAL, BREAST OR CERVICAL CANCER, AND THREE INVOLVED OBESITY MANAGEMENT, AND ONE HIGH BLOOD PRESSURE SCREENING. INCLUDING LOW INCOME, RURAL, UNDERSERVED AFRICAN-AMERICAN, HISPANIC, ASIAN AND NATIVE HAWAIIAN POPULATINS. THE STUDIES GENERALLY COMPARED ENHANCED SCREENING INTERVENTIONS WITH USUAL CARE, OR ALTERNATIVE METHODS. AND MEASURED EFFECTIVENESS THROUGH IMPROVED SCREENING RATES. INTERVENTIONS FOCUSED ON THE PATIENT, OR MORE GENERALLY FOCUSED ON THE HEALTH SYSTEM, SO SYSTEM CHANGES VERSUS MORE DIRECT PATIENT CHANGES. THE PATIENT INTERVENTIONS INVOLVED NAVIGATION, EDUCATION, TELEPHONE CALLS AND PROMPTS, LAY HEALTH WORKERS AND HOME VISITS, AND THESE VARIED WIDELY. I'LL DESCRIBE THEM A LITTLE AS WE GO TODAY. INTERVENTIONS THAT FOCUS ON HEALTH SYSTEMS INVOLVED SCREENING CHECK LISTS, PROVIDER& TRAINING, PRACTICE CHANGES AND COMMUNITY ENGAGEMENT, THOSE TYPES OF INTERVENTIONS. WE FOUND THAT MANY DIFFERENT TYPES OF POPULATIONS WERE INCLUDED IN THESE STUDIES, AND FOR THE META-ANALYSES, PLOTS, TABLES, WE ADOPTED AN ABBREVIATION SYSTEM TO DRILL DOWN AND SEE WHICH POPULATIONS WERE INVOLVED BUT AS YOU CAN SEE THERE WERE MANY DIFFERENT PERMUTATIONS OF THE DIFFERENT TYPES OF POPULATIONS, AND MANY STUDIES WERE ONE-OFF INVOLVING ONLY A COUPLE — ONE OR A COUPLE STUDIES SO IT'S DIFFICULT TO PUT IT TOGETHER FOR SPECIFIC GROUPS BUT IT'S IMPORTANT TO UNDERSTAND WHO IS IN THE STUDY AS WE GO THROUGH THEM. JUST A REMINDER, THAT WE USE THE GRADE LEVELS FOR EVALUATING THE STRENGTH OF EVIDENCE AND APPLICABILITY, ANYONE GETTING A HIGH GRADE WOULD BE CONFIDENT THAT THE EFFECT IS TRUE, HIGH RATING MEANS RESULTS WOULD APPLY WIDELY IN PRACTICE. SO WE FIRST LOOK AT THE RESULTS FOR COLORECTAL CANCER SCREENING AND FOUND THERE WERE MANY TRIES AND STUDIES LOOKING AT PATIENT NAVIGATION, NAVIGATION IS A BROAD TERM THAT MEANT MANY THINGS TO DIFFERENT STUDIES AND IN EVIDENCE WE VIEW WE HAVE TABLES DESCRIBING MORE EXACTLY WHAT WAS INVOLVED IN NAVIGATION FOR DIFFERENT STUDIES. BUT SOME COMPONENTS INCLUDE DECISION AIDS, WE TALKED ABOUT DECISION AIDS YESTERDAY, BUT SOME OF THE NAVIGATION INTERVENTIONS INCLUDE DECISION AIDS. PERSONALIZED BARRIER ASSESSMENT, TAKING A PERSONALIZED VIEW OF IDENTIFYING WHAT PROHIBITS SCREENING, PROVIDING KITS FOR COLON CANCER SCREENING, MAILED MATERIALS, PERSONALIZED MESSAGES, ASSISTANCE, HANDS ON ASSISTANCE WITH PRESCRIPTION, APPOINTMENTS, TRANSPORTATION, PROMPT SHEETS FOR CLINICIANS AND CLINICS, AND FOR PATIENTS, DIFFERENT TYPES OF SCREENING. SO MANY VARIATINS OF THIS WERE REPRESENTED BY THE TERM " SCREENING" FOR USING NAVIGATION. FOR THE COMMUNITY NAVIGATION STUDIES, COMMUNITY WAS INVOLVED IN SOME VERY INTERESTING AND CREATIVE WAYS, RECRUITMENT FOR COLON CANCER SCREENING FOR INSTANCE HAPPENS IN BARBERSHOPS FOR AFRICAN-AMERICAN MEN, LAY HEALTH WORKERS FOR AMERICAN AND VIETNAMESE POPULATIONS, RECRUITMENT CENTERS IN TEXAS, AND CHURCHES FOR KOREAN AMERICANS IN LOS ANGELES, USING THOSE COMMUNITY RESOURCES BROUGHT THEM INTO A HEALTH SYSTEM. SO IN THE TABLE, IN EVIDENCE REVIEW, WE SEPARATE BECAUSE COMMUNITY RESOURCES WERE UNIQUE, IN ADDITION, BUT YOU SEE A FAIRLY ROBUST SET OF STUDIES AND WE ELEVATE THAT STRENGTH RATING TO STRONG OR HIGHEST RATING, BUT WE SPLIT THEM OUT TO BE MORE — PROVIDE MORE INFORMATION. SO, FOR PATIENT NAVIGATION IN HEALTH SYSTEM WE HAVE 12 RANDOMIZED TRIALS, 25,000 INDIVIDUALS ENROLLED, ESSENTIALLY ALL SHOWED INCREASED SCREENING RATES EXCEPT ONE TRIAL. PATIENT NAVIGATION USING COMMUNITY RESOURCES, FIVE NON-RANDOMIZED TRIAL, AND THAT ALSO SHOWED INCREASED SCREENING IN ALL STUDIES EXCEPT ONE TRIAL THAT SHOWED MULTIPLE ENHANCED SCREENING INTERVENTIONS SO ALL THE ARMS WERE ACTIVE ENHANGSED SCREENING AND NAVIGATION SHOWED NOT PARTICULARLY A BENEFIT, ABOVE AND BEYOND THE OTHERS. SO WE TOOK THIS TO THE NEXT LEVEL AND DID STATISTICAL META ANALYSIS PUTTING NAVIGATION STUDIES, WHETHER COMMUNITY OR NOT. FOR RANDOMIZED TRIALS COMBINED INTO AN ESTIMATE OF 1.67 TO INCREASE SCREENING FOR COLORECTAL CANCER. THE OBSERVATIONAL STUDIES WERE COMBINED SEPARATELY, ALSO SHOWED INCREASED SCREENING RATES. WE LOOKED AT VARIOUS TYPES OF SCREENING TESTS, SOME STUDIES WERE SPECIFICALLY ABOUT FOBT OR FIT TESTS SHOWING SIMILAR RISK RATIO, SOME STUDIES SPECIFIC TO COLONOSCOPY, ELEVATED RISK RATIO, MOST STUDIES HAD ANY TESTS, PATIENTS HAD DECISIONS ABOUT WHAT THEY PREFERRED AND SO THAT'S WHERE MOST OF THE TRIALS WERE. AND THOSE WERE ALL ELEVATED. THE DATA GETS THINNER IN THE OBSERVATIONAL STUDIES WHEN LOOKING AT SPECIFIC TYPE OF TESTS, BUT I THINK WHAT'S MOST REVEALS WE SHOW ONE PLOT TODAY, WE HAVE MANY IN THE REVIEW. THEY ALL ARE REALLY SHOWING BENEFITS, SO TO ORIENT YOU TO THE META-ANALYSIS AND I INVITE YOU TO LOOK AT THE DRAFT EVIDENCE REPORT POSTED REALLY LOOK AT THE MORE DETAILS HERE BECAUSE THERE ARE A LOT OF DETAILS WE CAN'T GET INTO IN OUR SHORT TIME WITH YOU. BUT YOU SEE THE TABLES ARE ALL SET UP WITH SCREENING TEST, REFERENCE TO INDIVIDUAL STUDY ON THE FAR SIDE. DISPARITY GROUP USING OUR ABBREVIATION CODE, SO YOU WILL NEED TO DECIPHER THAT WITH OUR TABLE THERE. WE ALSO LOOKED AT WHETHER THE POPULATION HAD SCREENING ADHERENCE AT BASELINE, IF THEY HAD BEEN PREVIOUSLY ADHERENT OR NON- ADHERENT, MOST ENROLLED INDIVIDUALS WITHOUT PRIOR ADHERENCE TO SEPARATE THAT TO SEE IF THAT WOULD BE A DIFFERENCE. FOLLOW-UP TIMES VARIED, MOST A YEAR OR LESS. THE QUALITY RATINGS WE PUT IN THE TABLE, FOR THE INDIVIDUAL STUDIES, AND THEY RANGE FROM THE LOWEST RANKING OF POOR TO A FEW GOOD QUALITY STUDIES. UNLIKE A LOT OF REVIEWS THAT WE DO WE INCLUDED THE POOR QUALITY STUDIES IN THESE META-ANALYSES, MOSTLY BECAUSE THE QUALITY RATING CRITERIA AREN'T GEARED FOR TRIALS OF MEDICATIONS, AND SOME OF THE ASPECTS OF RATING QUALITIES SUCH AS BLINDING DON'T REALLY FIT THIS TYPE OF STUDY. SO WE WERE MORE GENEROUS IN HAVING THEM IN THE OVERALL ESTIMATES WE DO SEPARATE THEM OUT LATER IN SENSITIVITY ANALYSES. WE HAVE RISK RATIO FOLLOWED BY NUMBER OF EVENTS, MEETING SCREENING EVENTS FOR TREATMENT AND CONTROL GROUPS. AND SO ESSENTIALLY ALL COMBINE AND ALL WORK. WE KNOW A COUPLE STUDIES DID NOT HAVE STATISTICALLY SIGNIFICANT RESULTS, THERE ARE REASONS FOR THAT, BUT THIS IS KIND OF THE LAY OF THE LAND FOR PATIENT NAVIGATION. OUR SUBANALYSES SHOWED WE BROKE THEM DOWN BY SCREENING, BY FOLLOW-UP TIME, BY STUDY QUALITY; SCREENING, ADHERENCE AT BASELINE, WHERE THEY FALL OUT WE HAVE LESS STUDIES. THERE WERE OTHER INTERVENTIONS FOR COLORECTAL CANCER SCREENING, INCLUDING TELEPHONE CALLS AND PROMPTS RANDOMIZED TRIAL, THEY SHOWED INCREASED EFFECT AMONG UNDERSERVED, MODERATE LEVEL. TARGETED TO SPECIFIC CULTURAL LANGUAGE GROUPS. SCREENING CHECK LIST TRIALS SHOWED INCREASED LOW INCOME POPULATION, PROVIDER TRAINING NOW GETTING INTO HEALTH SYSTEM INTERVENTIONS SHOWED INCREASED COLONOSCOPY RATES, AND COMMUNITY ENGAGEMENT IS ALSO — YOU'LL SEE WHEN WE LOOK AT BREAST AND CERVICAL SCREENINGS SHOWED INCREASED SCREENING AMONG UNDERSERVED IN THAT HUGE POPULATION OF MANY LOW INCOME CLINICIAN. WHAT WAS INCLUDED IN THE PRACTICE CHANGE INTERVENTION INVOLVED PATIENT AND HEALTH SYSTEM CHANGES WITH NUMBER OF INTERVENTIONS OCCURRING AT THE SAME TIME. SO MOVING ON TO BREAST CANCER SCREENING, AGAIN PATIENT NAVIGATION SHOWED THAT INCREASED SCREENING IN ALL STUDIES, ONE TRIAL SHOWED INCREASED SCREENING FOR AFRICAN-AMERICAN AND ALL OTHER RACES IN THAT TRIAL BUT NOT FOR HISPANICS. SO WE HAD EIGHT TRIALS, ONE BEFORE-AFTER STUDY, AGAIN THE SUMMARY, WE DID THE SAME SENSITIVITY ANALYSES AND AGAIN SIGNIFICANT INCREASES ACROSS THE BOARD, GETTING THIN, CONFIDENCE INTERVALS START TO CHANGE BUT ESSENTIALLY SIMILAR POSITIVE RESULTS. BREAST CANCER SCREENING ALSO INTERVENTIONS REGARDING PATIENT EDUCATION SHOWED INCREASED SCREENING RATES, TELEPHONE CALLS AND PROMPTS, INCREASED IN TWO TRIALS, NO INCREASE IN OTHERS SO A LITTLE BIT MORE MIXED. WHEN THEY USED TELEPHONE CALLS ACROSS THE COMMUNITY RESOURCES AGAIN INCREASED SCREENING FOR SPECIFIC GROUPS WITH NO INCREASED SCREENING IN A STUDY WITH CHINESE AMERICANS. LAY HEALTH WORKERS EFFECTIVE IN BREAST CANCER SCREENING AND HOME VISITS WHICH WE HAVEN'T SEEN IN OTHER STUDIES BUT WAS EFFECTIVE IN INCREASING RATES IN RURAL AFRICAN-AMERICAN WOMEN. LOOKING AT SOME SYSTEM CHANGES, SCREENING CHECK LISTS AND THAT BIG STUDY ON PRACTICE CHANGES AND COMMUNITY ENGAGEMENT ALSO INCREASED RATES. CERVICAL CANCER SCREENING WE HAD FEWER STUDIES OF PATIENT NAVIGATION BUT THEY ESSENTIALLY SHOWED INCREASED SCREENING AND IN THE CASES CERVICAL CANCER WE WANT INDIVIDUALS WITH ABNORMAL PAP SMEARS TO COME BACK FOR A COLPOSCOPY, HELPING GET WOMEN BACK FOR THE SECOND TEST. ONE TRIAL SHOWED NO INCREASE AMONG HISPANICS IN THAT PARTICULAR TRIAL. TELEPHONE CALLS AND PROMPTS UNLIKE BREAST CANCER SCREENING THIS ONE SHOWED NO DIFFERENCE IN THREE INTERVENTION GROUPS IN REGARDS TO THE COLPOSCOPY RATE. INCREASED SCREENING FOR HISPANICS IN ONE BUT NOT ANOTHER. NO INCREASED IN LOW INCOME WOMEN, EFFECTIVE FOR BREAST CANCER SCREENING. AGAIN, PRACTICE CHANGES, COMMUNITY ENGAGEMENT STUDY SHOWED INCREASED RATES. WE HAD THREE TRIALS OF OBESITY MANAGEMENT WHICH INVOLVED PATIENT EDUCATION IN ONE TRIAL, SHOWED LOWER BMI, HEALTHIER DIET, MORE EXERCISE AMONG LATINO LOW INCOME INDIVIDUALS HOWEVER THIS TRIAL DID NOT CONTROL WELL FOR BASELINE BMI SO WE GAVE IT A LOW RATING. A STUDY OF LAY HEALTH WORKER CASE MANAGEMENT SHOWED NO DIFFERENCE IN BMI AMONG TWO INTERVENTION GROUPS OF LATINO INDIVIDUALS. BEHAVIOR CHANGE PRESCRIPTION HAD NO DIFFERENCE EITHER. SO A SMALL SET OF STUDIES BUT MAYBE A STARTING POINT FOR PLANNING OTHER STUDIES. ONE STUDY OF HIGH BLOOD PRESSURE SCREENING, IDENTIFICATION OF WOMEN WITH HIGH BLOOD PRESSURE, AND THEN ACTING ON THAT SHOWED NO DIFFERENCES IN HIGH BLOOD PRESSURE DESPITE PATIENT EDUCATION COUNSELING AND GROUP ACTIVITIES. A SUMMARY OF THESE STUDIES, 57 STUDIES, PATIENT NAVIGATION CLEARLY WAS EFFECTIVE IN ALL THREE TYPES OF CANCER SCREENING AND NO MATTER HOW WE SLICED AND DICED WE FOUND PERSISTENT EFFECT. I WOULD SUGGEST DRILLING DOWN INTO THE DETAILS OF WHAT THOSE NAVIGATION INTERVENTIONS LOOK LIKE WHEN YOU HAVE A CHANCE TO LOOK AT OUR REVIEW. PATIENT EDUCATION ALSO HELPFUL FOR BREAST CANCER SCREENING, OBESITY MANAGEMENT, DIDN'T HAVE EFFECT IN ONE STUDY ON HIGH BLOOD PRESSURE SCREENING. TELEPHONE CALLS AND PROMPTS WERE HELPFUL FOR INCREASING COLORECTAL AND BREAST CANCER SCREENING RATES BUT NOT CERVICAL CANCER SCREENING. LAY HEALTH WORKERS TARGETED TO SOME VERY SPECIFIC GROUPS, VERY EFFECTIVE INCREASING CANCER SCREENING, DIDN'T HELP FOR ONE TRIAL ON OBESITY MANAGEMENT. HOME VISITS EFFECTIVE IN AFRICAN-AMERICAN WOMEN IN RURAL SETTINGS. SCREENING CHECK LISTS, SOME SYSTEM CHANGES WERE HELPFUL IN SOME CANCER SCREENINGS BUT NOT FOR CERVICAL CANCER. PROVIDER TRAINING INCREASED RATES OF COLONOSCOPY IN ONE STUDY AND THE MULTIPLE EFFORT SET INTERVENING IN PRACTICE CHANGES AND ENGAGING WITH COMMUNITY ON PATIENT IN-HEALTH SYSTEM LEVELS INCREASED SCREENING FOR COLORECTAL, BREAST AND CERVICAL CANCER. SO THERE WERE OF COURSE THERE'S ALWAYS LIMITATIONS, EVEN WITH A LOT OF STUDIES THIS TIME, BUT THERE WERE FEW STUDIES OF INTERVENTIONS BESIDES CANCER SCREENING AND THE ONES WE HAD DIDN'T LEAD US TO CONCLUSIONS. THEY WERE SMALL AND DIDN'T CONTROL FOR IMPORTANT THINGS. SO THAT'S THE LIMITATIONS OF WHAT I'LL TELL YOU TODAY. WE HAVE A LOT ON CANCER SCREENING BUT LITTLE ON OTHERS. TIMES OF INTERVENTIONS VARIED WIDELY. PATIENT NAVIGATION INCLUDED MANY COMPONENTS AND IT WAS HARD TO TEASE OUT IF ONE TYPE OF APPROACH WOULD BE BETTER THAN ANOTHER. DEFINITIONS OF POPULATIONS WERE ALSO UNCLEAR THROUGH THE BIGGEST CATEGORY OF PATIENTS WERE UNDERSERVED OR LOW INCOME, IMPORTANT BUT VARYING WIDELY POPULATION. WE HAVE SUGGESTIONSES FOR FUTURE RESEARCH, TO IDENTIFY OPTIMAL METHODS TO IMPLEMENT PATIENT NAVIGATION REMINDERS AND OTHER EFFECTIVE INTERVENTIONS INTO HEALTHCARE SETTINGS IN POPULATIONS, SEEMS WHEN THE HEALTH SYSTEM IS INVOLVED IT MAYBE HAS MORE EFFECTIVE REACH THAN THOSE IN CLINIC ENVIRONMENTS THAT ARE MORE BASED ON A SMALLER SET OF RESOURCES. IDENTIFYING MOST EFFECTIVE COMPONENTS WOULD BE HELPFUL, DEFINING SERVICES MEASURES AND OUTCOMES SO THEY CAN BE APPLIED TO OTHER HEALTH SYSTEMS WOULD BE USEFUL INSTEAD OF HAVING IT BE UNIQUE TO ONE SYSTEM. EVALUATING BUNDLING OF PREVENTIVE SERVICES, THE FEW STUDIES THAT DID MORE THAN ONE TYPE OF CANCER SCREENING FOR INSTANCE FOUND IT WAS EFFECTIVE FOR A NUMBER OF THINGS, MAYBE DOING THAT WITH SOME OF THE OTHER PREVENTIVE SERVICES WOULD CREATE A MORE EFFICIENT MODEL. MEASURE BENEFITS THAT MAY BE PERIPHERAL TO ENGAGEMENT SUCH AS PATIENT ADHERENCE FOR OTHER TYPES OF HEALTHCARE, IMPROVED ACCESS, HEALTH LITERACY, A NUMBER OF THINGS. STUDIES OF INTERVENTIONS THAT FOCUS ON UNSTUDIED POPULATIONS ARE STILL NEEDED. AND WE THOUGHT IT WOULD BE USEFUL TO RECRUIT GENERAL POPULATIONS WHICH SOME LARGE STUDIES DID. BUT IT INCLUDE AND REPORT OUTCOMES BASED ON DISADVANTAGED GROUPS. WE RARELY SAW DATA SPECIFIC TO THOSE GROUPS IN THE RESULTS SECTIONS. SO THAT WOULD BE VERY HELPFUL. SO THE KEY MESSAGES ARE THAT WE SAW INCREASED RATES OF PREVENTIVE SERVICES WITH PATIENT NAVIGATION, TELEPHONE CALLS AND PROMPTS, LAY HEALTH WORKERS THAT WERE TARGETED TO SPECIFIC GROUPS. THIS MAY REFLECT THE HUMAN TOUCH, WE WERE TALKING ABOUT YESTERDAY AS WELL AS TODAY. EVIDENCE IS STRONGEST FOR PATIENT NAVIGATION TO INCREASE COLORECTAL, BREAST AND CERVICAL CANCER SCREENING. STUDIES VARIED, INTERVENTIONS INCLUDED MULTIPLE COMPONENTS, NOT SURE WHAT WAS MAGIC, BUT THEY WERE A COLLECTION OF THINGS THAT HAPPENED. SO PLEASE LOOK AT OUR FULL EVIDENCE REPORT. THIS IS MY LAST CHANCE TO GIVE A PITCH FOR PROVIDING COMMENTS. IT'S AVAILABLE FOR PUBLIC COMMENT OVER THE NEXT FOUR WEEKS, FINAL VERSION AVAILABLE AFTER THAT, INCLUDING NEW STUDIES, MAYBE WE'LL HAVE TO TWEAK OUR META-ANALYSIS AND SEE ADDITIONAL MATERIAL. WE'RE HERE TO TALK ABOUT CENTRAL FOUNDATION WHICH IS A TRIBEALLY OWNED AND OPERATED HEALTHCARE SYSTEM. I'M DONNA GALBREATH, SENIOR MEDICAL DIRECTOR OF QUALITY ASSURANCE, A FAMILY PRACTICE PROVIDER, WORKED AT SOUTHCENTRAL FOUNDATION FOR ABOUT 13 1/2 YEAR'S, FROM ALASKA. >> GOOD MORNING. I'M DENISE DILLARD, I WORK FOR SOUTHCENTRAL FOUNDATION, I'VE BEEN THERE SINCE 2001, I AM AN ESKIMO, MY MOTHER FROM AND ISLAND OFF THE COAST OF NOME, I'M DIRECTOR OF RESEARCH FOR SOUTHCENTRAL FOUNDATION. DONNA AND I WILL ALTERNATE, GIVEN OUR DIFFERENT ROLES, BOTH INTEREST TO DISCLOSE. THESE ARE THE OBJECTIVES OF OUR PRESENTATION, AND SO WE'RE GOING TO BE DESCRIBING A COMPLETE REDESIGN OF THE HEALTHCARE SYSTEM WAS IMPLEMENTED IN& ALASKA, AS WELL AS ASSOCIATED RESEARCH FINDINGS, AND THEN ALSO TALK MORE BROADLY ABOUT CONSIDERATIONS FOR CONDUCTING RESEARCH AND HEALTH CARE IMPLICATIONS IN TRIBAL COMMUNITIES. I WANTED TO START WITH JUST SOME BASIC BACKGROUND INFORMATION. YOU'LL NOTICE THAT I'VE PROVIDED CITATIONS FOR MOST OF THE INFORMATION THAT I'M PRESENTING. YOU'LL SEE THAT IN MANY OF THESE PUBLICATIONS THERE ISN'T REALLY CURRENT DATA AND THAT REALLY REFLECTS KIND OF THE PAUCITY OF PUBLISHED LITERATURE IN THE AREA OF AMERICAN INDIAN AND ALASKA NATIVE HEALTH. ON THE LEFT SIDE WE SEE THE LEADING CAUSES OF MORTALITY BETWEEN 1999 AND 2009. AND AS YOU CAN SEE, CURRENTLY THEY ARE THE CHRONIC CONDITIONS THAT ARE THE FOCUS OF THIS WORKSHOP, WHICH INCLUDE HEART DISEASE, AND CANCER, AND THEN DIABETES. THIS IS THE SIGNIFICANT CHANGE FROM EARLIER IN HISTORY WHERE REALLY THE POPULATION WAS VERY MUCH IMPACTED BY INFECTIOUS DISEASES, AS WELL AS HIGH RATES OF INFANT MORTALITY, BUT YOU SEE THE SHIFT AS PEOPLE ARE GIVEN PUBLIC HEALTH MEASURES BUT ALSO KIND OF THE CHANGING DEMOGRAPHY OF THE POPULATION, AND AS PEOPLE MOVE INTO URBAN ENVIRONMENTS AND ALSO CHANGES IN THE DIET. DESPITE SUCCESS OF MANY OF THE PUBLIC HEALTH INTERVENTIONS, IF YOU LOOK AT THE AVERAGE LIFE EXPECTANCY THERE IS STILL A SHORTENED LIFE EXPECTANCY FOR AMERICAN INDIAN AND ALASKA NATIVE PEOPLE IN GENERAL COMPARED TO BOTH NON-HISPANIC BLACK AND NON-HISPANIC WHITE IMPORTANT IS CHRONIC UNDERFUNDING OF HEALTHCARE SYSTEM WHICH PROVIDES SERVICES TO AMERICAN INDIAN AND ALASKA NATIVE COMMUNITIES. THIS IS THE SLIDE WHICH SHOWS EXPENDITURES PER CAPITA, PROVIDING SERVICES TO AMERICAN INDIAN AND ALASKA NATIVE PEOPLE IN EXCHANGE FOR LAND AND OTHER RESOURCES BUT YOU CAN SEE, THIS HASN'T REALLY CHANGED A LOT, SO THERE'S LESS EXPENDED PER CAPITA FOR THE AVERAGE PERSON THAN FOR A PERSON IN A FEDERAL PRISON. THIS CONTINES TO BE THE CASE. THE REASON THIS IS IMPORTANT WHEN IT COMES TO PREVENTIVE SERVICES IS IMPLICATION THAT MANY INDIAN HEALTH SERVICE FACILITIES OR OTHER TRIBAL FACILITIES THE MAJORITY OF CARE IS REALLY PROVIDED IN EMERGENCY ROOMS AND SO IT'S ADDRESSED AT KIND OF IMMEDIATE CRISIS, NOT AS MUCH TIME DEDICATED TO PREVENTIVE SERVICES. >> THERE WERE LOTS OF TREATIES IN ALASKA, BUT THE CHANGE ACTUALLY OCCURRED WITH ALASKA NATIVE SETTLEMENT ACT, AND THAT'S WHERE THE FEDERAL GOVERNMENT RECOGNIZED ALASKA NATIVE PEOPLE, AND SETTLED CLAIMS AROUND LAND. SO EACH AREA WAS GIVEN LAND AND MONEY. AS A RESULT OF THAT CORPORATIONS WERE FORMED, AND EVEN OF THESE CORPORATIONS SERVES HEALTHCARE NEEDS OF THE ALASKA NATIVE PEOPLE IN THAT AREA. SO WE'RE SOUTHCENTRAL FOUNDATION, AND WE'RE DOWN AT THE BOTTOM OF THE SLIDE, THE DARK COLORED AREA. THAT'S WHERE WE PROVIDE PRIMARY CARE. EVEN THOUGH IT'S NOT THE MAJORITY OF THE STATE, IF YOU TAKE ALASKA, IT'S HUGE. IF YOU WERE TO PUT IT ON TOP OF THE U.S., IT WOULD GO COAST TO COAST. AND SO THE AREA THAT WE SERVE IS BASICALLY — IF YOU GO TO THE TIP, THE ALEUTIANS, FROM CALIFORNIA, PEOPLE FROM CALIFORNIA WOULD BE GOING TO MISSOURI TO GET THEIR HEALTH CARE, SO THAT'S THE SPAN OF AREA THAT WE'RE INVOLVED WITH. THE INDIAN SELF DETERMINATION ACT AND INDIAN HEALTH CARE IMPROVEMENT ACT IN THE '70s SAID THAT HEALTH CARE WOULD BE IMPROVED IF THE PEOPLE WHO ARE BEING SERVED WERE ACTUALLY INVOLVED IN THEIR OWN HEALTH CARE, BETTER YET IF THEY OWNED IT. SO SOUTHCENTRAL FOUNDATION WAS INCORPORATED IN 1982, AND PRIMARILY DEALT WITH DENTAL AND OPTOMETRY SERVICES. IN 1998, SOUTHCENTRAL FOUNDATION TOOK OVER THEIR OWN HEALTHCARE SYSTEM AND HAVE BEEN DOING THAT EVER SINCE. ONE OTHER THING I WANT TO POINT OUT ABOUT THE STATE OF LEAKS IS IN ADDITION TO BEING BIG, THERE'S A LOT OF TRIBES HERE. 22 9 FEDERALLY RECOGNIZED TRIBES WITH LOTS OF CULTURES, THOSE ARE THE PEOPLE WE SERVE. WHEN WE TOOK OVER HEALTH CARE THERE WERE A LOT OF FOCUS GROUPS WHERE WE TALKED WITH CUSTOMER OWNERS, THOSE ARE THE PEOPLE WE SERVE. MOST PEOPLE REFERRED TO THEM AS PATIENTS BUT WE DON'T. WE ASKED WHAT THEY WANTED. AT THE TIME HEALTH CARE BEING RUN BY INDIAN HEALTH SERVICE HAD A LOT OF ROOM FOR IMPROVEMENT. WAIT LINES WERE LONG, 32% OF THE POPULATION WERE EMPANELED TO A PROVIDER OR HAD THEIR OWN PROVIDER IS WHAT I SHOULD SAY. THE WAIT TO BE SEEN, AT LEAST 30 DAYS LONG. A MONTH WAIT. MOST CARE WAS DONE IN THE EMERGENCY ROOM, YOU CAN HEAR STORIES FROM PEOPLE WHO LIVED THROUGH THAT ERA WHO ACTUALLY WOULD DESCRIBE THE WHOLE FAMILY GETTING TOGETHER, THEY WOULD PACK LUNCHES AND GO SIT IN THE EMERGENCY ROOM UNTIL THEY COULD BE SEEN. WE ASKED CUSTOMER OWNERS WHAT THEY WANTED. THEY WANTED TO KNOW THE PROVIDER, THEY WANTED TO BE SEEN WHEN THEY WANTED TO BE SEEN. THEY WANTED ACCESS. THEY WANTED A SYSTEM THAT WAS SUSTAINABLE, THAT WAS FINANCIALLY SUSTAINABLE AND ALSO A SYSTEM THAT TOOK CARE OF NOT ONLY THEM AS AN INDIVIDUAL BUT THEIR FAMILY, THE COMMUNITY, AND THE POPULATION. SO, THAT'S WHAT WE BASED OUR ENTIRE MODEL ON WHICH IS VERY INTERESTING, A LOT OF THINGS THAT HAVE BEEN DISCUSSED YESTERDAY AND EVEN SOME TODAY ABOUT WHAT NEEDS TO BE DONE IN TERMS OF HEALTH CARE. SO WE CREATED A SYSTEM OF CARE WHERE WE HAVE EMPANELMENT. OUR CUSTOMER OWNERS EMPANEL TO A TEAM WHICH CONSISTS OF THE PRIMARY CARE PROVIDER, CASE MANAGER SUPPORT AND CERTIFIED MEDICAL ASSISTANT. THEY ARE ABOUT 1100 CUSTOMER OWNERS PER TEAM, SO THAT THROUGH TIME THE TEAM GETS TO KNOW THAT CUSTOMER-OWNER AND THEY GET TO KNOW THE TEAM, LEVERAGING THE RELATIONSHIP PIECE FOR THAT CARE. WHAT WE SAW IS WE HAD A DECREASE IN EMERGENCY ROOM USE, AND DECREASE IN HOSPITALIZATION AND IN PATIENT STAYS, OVERALL IMPROVED HEALTH CARE. WE TARGETED CERTAIN HEALTH CARE ISSUES WHEN WE TOOK OVER, SUCH AS DIABETES, AND WHICH LED TO INCREASED SCREENING, AND ALSO INCREASED OVERALL CARE OF DIABETES. SO THIS IS SOME OF THE DATA THAT WE HAVE HERE ON PREVENTIVE SERVICES ON OUTCOMES. BENCH MARK AGAINST HEDIS, USUALLY HIGH. THERE'S ONE IN THE TENTH PERCENTILE BUT MOST IN 75th — WELL, ACTUALLY THE 10th PER PERCENTILE IS A GOOD ONE, FOR POOR CONTROL, WE WANT TO BE AS LOW AS POSSIBLE FOR THAT SO WE'RE LESS THAN 10%. SO FOR THE OTHER SCREENINGS SUCH AS BREAST, CERVICAL, COLORECTAL AND CARDIOVASCULAR, WE SCORE VERY HIGH COMPARED TO HEDIS. DATA WAS REALLY IMPORTANT WHEN WE TOOK OVER HEALTH CARE, WE REALIZED IN ORDER TO UNDERSTAND WHAT WE WERE DOING, WHETHER IT WAS MAKING A DIFFERENCE, WE NEEDED DATA. WE'VE HEARD THAT FROM A LOT OF DIFFERENT PEOPLE YESTERDAY, SO WHAT WE DID IS WE CREATED OUR OWN DATA SYSTEM. WE ACTUALLY HAVE REALTIME DATA, SO ONCE IT'S IN THE SYSTEM AND FEEDS INTO OUR DATA, AND THEN PEOPLE CAN USE THAT TO SEE WHETHER WHAT THEY ARE DOING MAKES A DIFFERENCE, BUT ALSO JUST AS IMPORTANTLY, OUR TEAMS USE THAT DATA SO AS A PROVIDER YOU CAN GO IN AND LOOK AT EVERYBODY WHO IS EMPANELED TO YOU AND SEE WHO IS DUE FOR WHAT. WE HAVE ACTION LISTS SO YOU CAN IMMEDIATELY KNOW WHAT SOMEBODY IS DUE FOR, AND ACT ON THAT. WHEN THEY COME IN. SO YOU'RE NOT HAVING TO GO THROUGH THE MEDICAL RECORD OR ANYTHING, YOU CAN ACTUALLY GET TO THOSE THINGS. THE OTHER PART OF THAT DATA SYSTEM IS THAT IT'S UNBLINDED, SO I CAN LOOK AT EVERY PROVIDER IN OUR SYSTEM ACTUALLY ANY PROVIDERS CAN AND THEY CAN SEE HOW THEY ARE DOING AND THEY CAN SEE WHO HAS BEST PRACTICE AND YOU MIGHT BE ABLE TO GO TO THAT PERSON AND SAY WHAT ARE YOU DOING THAT'S DIFFERENT THAN ME, I WANT MY NUMBERS HIGHER AND ACTUALLY TAKE THOSE BEST PRACTICES. SO THIS IS AS BIT MORE OF OUR TEAM. SINCE WE WANT THE RELATIONSHIP BASE, WE WANT OUR CUSTOMER OWNERS TO STAY WITH OUR TEAM, WE ACTUALLY HAVE IMPROVED SUPPORT AROUND OUR TEAM. SO PART OF OUR TEAM IS AN INTEGRATED APPROACH. WE HAVE BEHAVIORAL HEALTH CONSULTANTS, CERTIFIED NURSE MIDWIVES, REGISTERED DIETITIANS, PHARMACISTS RIGHT THERE SITTING WITH THE TEAM. WE ALSO HAVE CO-LOCATED PROVIDERS TO HELP SUPPORT THE TEAM SO THE CARE CAN CONTINUE TO BE DONE WITHIN THE TEAM. WE HAVE A PAIN PHYSICIAN, HIV CONSULTANT, PSYCHIATRIST, HOME HEALTH, LACTATION, PEDIATRICIAN, EHR COACH, COLORECTAL CANCER SCREENING THAT SUPPORT THE TEAMS. BEYOND THAT WHERE YOU HAVE BRIEF INTERMITTENT CARE SO YOU WOULD HAVE LIKE SURGERY AND ENT BUT WE ALSO INCLUDE TRADITIONAL HEALING AND COMPLEMENTARY MEDICINE SUCH AS MASSAGE THERAPY AND CHIROPRACTIC CARE. SO THIS GETS TO SOME RURAL VILLAGES WE GO TO, A LOT ARE NOT ON THE ROAD SYSTEM. WE USE LOCAL WORKFORCE, COMMUNITY HEALTH, AND SUPPORT THROUGH TELEMEDICINE, PROVIDERS ARE ASSIGNED PER VILLAGE AND SO, AGAIN, IT'S A RELATIONSHIP-BASED APPROACH THAT WE USE FOR THAT INCLUDING WITH TELEMEDICINE AND INCLUDING WHEN THE PROVIDER GOES OUT TO THAT COMMUNITY. >> SO ONE OF THE THEMES OF THIS WORKSHOP REALLY IS KIND OF THE UNDERREPRESENTATION OF PEOPLE OF DIVERSITY WITHIN RESEARCH. I THINK IT'S REALLY IMPORTANT TO KIND OF MENTION HISTORICAL BACK DROP THAT MIGHT PARTLY HELP EXPLAIN WHY THIS IS THE CASE. AND I KNOW WITHIN AMERICAN INDIAN AND ALASKA NATIVE PEOPLE THERE'S NEGATIVE HISTORY BOTH WITHIN HEALTH CARE AS WELL AS IN RESEARCH WHICH LEADS TO DISTRUST AND SKEPTICISM. IN TERMS OF THE MEDICAL ABUSES, THERE WAS WIDESPREAD FOR INSTANCE STERILIZATION OF AMERICAN INDIAN WOMEN IN THE 1970s BY THE INDIAN HEALTH SERVICE WITHOUT CONSENT OR KNOWLEDGE. I HAVE A COUPLE EXAMPLES OF RESEARCH ABUSES THAT ARE LISTED HERE AND DESCRIBED IN THIS PUBLICATION. THE FIRST ONE WAS INJECTION OF RADIOACTIVE IODINE INTO ALASKA NATIVE PEOPLE, WITH EVEN AT THAT TIME WHAT WAS CONSIDERED NOT APPROPRIATE CONSENT. AND THEN THE LAST TWO EXAMPLES, WHAT IS COMMON, THAT IN BOTH OF THESE INSTANCES THE TRIBE APPROACHED RESEARCHERS FOR HELP WITH AN ISSUE THAT THEY WERE STRUGGLING WITH, BUT ENDED UP IN THAT PROCESS TO FEEL STIGMATIZED AND THAT THEIR TRUST WAS VIOLATED. SO THE BARROW ALCOHOL STUDY LET TO FRONT PAGE NEWSPAPER ARTICLE THAT SAID NUPIAK IS I ESKIMO, MY TRIBE, WILL BE EXTINCT BY 2020 FOR ALCOHOL USE. AND ARTICLES WERE PUBLISHED ON INBREEDING AND SCHIZOPHRENIA. SO DONNA TALKED ABOUT SELF DETERMINATION AND HEALTH CARE AND THERE'S BEEN A NATIONAL MOVEMENT AMONG TRIBES THROUGH DIFFERENT ACTS, AND KIND OF A SHARED CONSENSUS. ORE TRIBES TAKING OVER CONTROL OF RESEARCH CONDUCTED WITH THEIR TRIBAL MEMBERS, AND THERE'S BEEN A WIDESPREAD CALL FOR COMMUNITY MEMBERS TO BE INVOLVED, IF NOT INVOLVED TO DRIVE RESEARCH, AND SOUTHCENTRAL FOUNDATION ESTABLISHED A RESEARCH POLICY IN 2005 AND WHERE THEY HAVE APPROVAL PROCESS FOR ALL RESEARCH, THEY HAVE A RESEARCH AGREEMENT SPECIFYING THAT OWNERSHIP AND USE OF THE DATA IS UP TO SOUTHCENTRAL FOUNDATION AND SPECIMENS REMAIN IN A LOCAL SPECIMEN BANK. THERE'S AN EXPRESSED GOAL OF BUILDING CAPACITY WITHIN THE AMERICAN INDIAN AND ALASKA NATIVE COMMUNITY TO DO THEIR OWN RESEARCH, SO 75% OF THE DEPARTMENT THAT I RUN IS AMERICAN INDIAN OR ALASKA NATIVE. THIS IS AN EXAMPLE IN ADDITION TO THE INTERRUPTED TIME SERIES STUDIES WE DID, ABOUT THE TRANSFORMATION. THIS IS A COUPLE OF SLIDES OF DIFFERENT TYPES OF PREVENTIVE SERVICES RESEARCH, TEXT MESSAGE REMINDER STUDY WAS DESCRIBED EARLIER. ONE OF THE THINGS ABOUT THAT STUDY IS THE COMPARATOR WAS A PRETTY STRONG SET OF REMINDERS FOR COLORECTAL CANCER SCREENING, SO THE TEXT MESSAGE REMINDERS WERE NOT STATISTICALLY SIGNIFICANT IN ADDITION TO THAT BUT THAT WAS AN EXAMPLE OF KIND OF AN APPLIED STUDY CO-DESIGNED WITH OUR PROVIDERS, AND THEY WERE VERY HAPPY WITH THE FACT THAT ALTHOUGH IT WASN'T STATISTICALLY SIGNIFICANT WE HAD MORE PEOPLE, GREATER PROPORTION OF PEOPLE ENGAGED IN COLORECTAL CANCER SCREENING. WE LOOKED AT PATIENT AND PROVIDER FACTORS THAT ARE ASSOCIATED WITH SCREENING. SO MORE SPECIFICALLY IN DEPRESSION AND WE TEND TO FIND THAT AMERICAN — ALASKA NATIVE AND AMERICAN INDIAN YOUNG MEN TEND TO BE MISSED, TEND TO USE THE HEALTH SYSTEM LESS OFTEN. THERE'S PROVIDER VARIATION SO AS PROVIDERS ARE NEWER TO OUR SYSTEM IT TAKES THEM A WHILE TO GET KIND OF THEIR NUMBERS AND SCREENING RATES UP. I ALSO PRESENT A COUPLE OF EXAMPLES OF PHARMACOGENETIC RESEARCH WE HAVE EMBARKED ON, AND THESE ARE LOOKING AT VARIANTS WHICH MIGHT IMPACT RESPONSE TO DIFFERENT TYPES OF MEDICATION, INCLUDING WARFARIN. >> SO SOME OF THE THINGS THAT WENT INTO DESIGNING A SYSTEM THAT'S BEEN SUCCESSFUL IS ACTUALLY PLACING THE CUSTOMER-OWNER IN THE MIDDLE AND MEETING THEIR NEEDS, NOT MEETING THE NEEDS OF THE PROVIDERS AND NOT LOOKING AT THE REIMBURSEMENT NEEDS, BUT WHAT ARE THE CARE NEEDS OF AN INDIVIDUAL. AND THEN LOOKING AT THE ENTIRE SYSTEM OF CARE, EVERY SINGLE ASPECT, PART OF IT THAT GOES INTO HEALTH CARE, AND CHANGING IT AS NEEDED TO MEET THE NEEDS OR MEET YOUR MISSION AND VISION FOR HEALTH CARE. YOU KNOW, SUCH AS OPEN EMPANELMENT, OPEN ACCESS AND EMPANELMENT SO PEOPLE GET TO KNOW EACH OTHER. RELATIONSHIP IS REALLY ALSO PRETTY KEY TO THIS. YOU KNOW, PEOPLE ARE COMFORTABLE WITH ONE ANOTHER, THEY ACTUALLY HAVE OPEN AND HONEST DIALOGUE, WHICH HELPS WITH CARE. DATA IS ALSO ABSOLUTELY CRUCIAL, SO THAT'S WHY WE CREATED OUR OWN DATA SYSTEM FOR THAT >>
I'M GOING TO END WITH A COUPLE OF KEY CONSIDERATIONS FROM THE RESEARCH PERSPECTIVE, I'VE DESCRIBED KIND OF THE GENERAL PAUCITY OF RESEARCH. THIS IS REALLY KIND OF A POINT OF TENSION I THINK BETWEEN RESEARCH AND COMMUNITIES. WHAT COMMUNITIES REALLY WANT IS IMMEDIATE BENEFIT. THEY WANT TO SEE THEIR FAMILY MEMBERS, TO SEE IMPROVEMENTS IN THEIR HEALTH. THERE'S A VARIETY OF METHODOLOGICAL LIMITATIONS, SOME SPEAKS TO ISSUES THAT ARE REALLY JUST COMPLICATED. THERE'S DIVERSITY ACROSS TRIBES, WHAT WORKS IN ONE WON'T NECESSARILY WORK IN ANOTHER TRIBE. BECAUSE THE SETTINGS DEVICE, CULTURE IS DIFFERENT. ACCEPTABILITY AND ETHICS OF CERTAIN RESEARCH APPROACHES IS IMPORTANT. RANDOMIZED CONTROL TRIALS ESPECIALLY THOSE THAT INVOLVED BLINDING. IF YOU'RE WORKING WITH COMMUNITIES TO REBUILD TRUST, THAT BLINDING BY DEFINITION MAKES THAT REALLY CHALLENGING IN TERMS OF TRANSPARENCY. I ALSO DID WANT TO TALK ABOUT A COUPLE OF OTHER THINGS THAT I THINK MAY BE RELEVANT TO PARTICIPATION OF TYPICALLY UNDERREPRESENTED PARTICIPANTS IN RESEARCH. ONE IS THAT I THINK WE NEED TO RECONSIDER SOME OF OUR TIMEFRAMES. SO COMMUNITY-BASED PARTICIPATORY RESEARCH WAS TALKED ABOUT BUT FUNDING MECHANISMS DON'T ALLOW FOR IN A LONGER KIND OF STARTUP TIME. RESEARCH TENDS TO TAKE LONGER. IN OUR WORK WE HAVE TO GET APPROVALS FROM MULTIPLE TRIBES, THAT TAKES A WHILE. BUT THERE'S ALSO THIS WEIRD PARADOX, I FEEL LIKE I NEVER HAVE ENOUGH TIME TO DO WHAT I WANT BUT WHEN SOMEBODY LIKE DONNA APPROACHES ME WITH A RESEARCH IDEA I TELL HER GIVE ME A COUPLE YEARS AND WE'LL SEE IF WE CAN START A STUDY. WHAT SITES WANT IS TO START SOMETHING NOW. I THINK THERE'S ALSO ISSUES RELATED TO RANDOMIZED CONTROL TRIAL, THAT I HAVE ALREADY MENTIONED. AND WITH OUR HELD SYSTEM THERE'S ALSO AN ISSUE OF COMPARATOR LIKE WHAT WOULD BE OUR COMPARATOR HEALTH SYSTEM POPULATION IF WE WERE TO TRY TO DISENTANGLE SOME IMPACTS, WE HAVE FOUND SOME SUCCESS WITH RANDOMIZED CONTROL TRIALS AT THE CLINIC LEVEL BECAUSE WE HAVE DIFFERENT CLINICS, BUT THAT REALLY REDUCES YOUR SAMPLE SIZE TO THE NUMBER OF CLINICS. AND I WANT TO END WITH I ALSO THINK THAT WE NEED TO REALLIY TAKE A LOOK AT IMPLICIT BIAS BUILT INTO THE RESEARCH ENTERPRISE ITSELF. WE'VE HEARD TALK ABOUT STANDARDIZED MEASURES. I UNDERSTAND THAT AS A RESEARCHER BUT MANY MEASURES WHEN PUT BEFORE COMMUNITY MEMBERS TEND TO FOCUS ON PATHOLOGY AND FEEL STIGMATIZING, OR USE EXAMPLES THAT ARE NOT REALLY RELEVANT WITHIN THE POPULATION. I ALSO THINK THAT IF YOU LOOK AT KIND OF THE TYPES OF INVESTIGATORS WHO WORK WITHIN AMERICAN INDIAN AND ALASKA NATIVE COMMUNITIES, I KNOW THERE IS A PREFERENCE WITHIN COMMUNITIES TO HAVE AMERICAN INDIAN AND ALASKA NATIVE PEOPLE DRIVING THEIR OWN RESEARCH. SO REALLY IN SOME WAYS IT'S RESEARCH IN SERVICE OF THE COMMUNITY AND SO YOU'RE REALLY JUDGED NOT NECESSARILY ON THE NUMBER OF PUBLICATIONS THAT YOU HAVE OR WHAT TYPE OF JOURNAL YOU'RE PUBLISHED IN BUT HAVE YOU ESTABLISHED TRUSTING RELATIONSHIPS WITH THAT COMMUNITIES, DOES YOUR WORK MAKE AN IMPACT ON THE BOTTOM LINE OF PEOPLE GETTING HEALTHIER. I THOUGHT THAT WAS REALLY IMPORTANT TO MENTION, JUST SO THAT WE KIND OF NOTE WITHIN THE FINAL REPORT THAT WE ALSO NEED TO LOOK AT THOSE BIASES AND MAKE SURE WE'RE NOT GOING TO FUND MORE OF THE SAME WITH THE SAME APPROACHES AND GET THE SAME RESULT IN THE FUTURE. THANK YOU FOR BEING HERE. I'M DELIGHTED TO HAVE THE OPPORTUNITY TO TALK TO YOU ABOUT PATIENT ENGAGEMENT STRATEGIES AND IMPROVING HEALTH EQUITY WITHIN HEALTH CARE DELIVERY SYSTEMS. I DON'T HAVE ANYTHING TO DISCLOSE. I'D LIKE TO START BY TALKING ABOUT KAISER PERMANENTE NORTHERN CALIFORNIA WHICH IS THE LARGE HEALTH CARE DELIVERY SYSTEM IN WHICH I DO RESEARCH. IT'S AN INTEGRATED DELIVERY SYSTEM, MEANING PEOPLE RECEIVE THEIR PREVENTIVE SERVICES AND INPATIENT AND OUTPATIENT, LABORATORY, PHARMACY SERVICES, ALL WITHIN THE KAISER PERMANENTE UMBRELLA, IT'S A CAPITATED PAYMENT MODEL, NOT A FEE FOR SERVICE MODEL. SO THE HEALTH CARE ORGANIZATIONS RECEIVES A FLAT FEE. WE DON'T HAVE PATIENTS, WE CALL THEM MEMBERS. WITHIN NORTHERN CALIFORNIA ALONE THERE ARE MORE THAN 4 MILLION MEMBERS, NATIONALLY THERE ARE APPROXIMATELY 12 MILLION I BELIEVE RIGHT NOW. MAJORITY ARE WITHIN NORTHERN CALIFORNIA AND SOUTHERN CALIFORNIA. SO WITHIN NORTHERN CALIFORNIA IN SYSTEM WHERE I WORK THERE ARE APPROXIMATELY 300,000 PEOPLE WITH DIABETES AND WELL OVER 600,000 PEOPLE WITH PREDIABETES. THE WAY THAT HEALTH CARE IS PROVIDED IS THROUGH A CONTRACT BASED SYSTEM WITH TPMG PHYSICIANS, ANTI-TRUST, FOR KAISER PERMANENTE TO BE THE EMPLOYER OF OUR PHYSICIANS. SO THAT'S SOMETHING I LIKE TO SAY UP FRONT. PEOPLE THINK OUR PHYSICIANS ARE EMPLOYEES, AND THEY ARE NOT ACTUALLY. AND WE'VE TALKED ABOUT THE EHR, I'LL TALK ABOUT IT AS WE MOVE FORWARD. THERE'S AN INTEGRATED EHR WITHIN THE KAISER PERMANENTE NORTHERN CALIFORNIA SYSTEMS, MORE AND MORE SYSTEMS HAVE ADOPTED EHRs OVER TIME SO THAT'S LESS OF A UNIQUE CHARACTERISTIC OF OUR SYSTEM BUT HAS COME UP MANY TIMES, THAT IS REALLY A NECESSARY BUT NOT SUFFICIENT BASIS TO BE DOING WIDESPREAD POPULATION PREVENTIVE SERVICES. I WILL ALSO SAY WITHIN NORTHERN CALIFORNIA CERTAINLY WE HAVE A VERY DIVERSE POPULATION THAT MAKES UP OUR MEMBERSHIP. BOTH IN TERMS OF RACE/ETHNICITY AND INCOME. WE HAVE A LARGE MEDICAID IN OUR STATE WE CALL IT MEDICAL MEMBERSHIP. I'D LIKE TO SAY A LITTLE ABOUT THE HISTORY OF KAISER PERMANENTE BECAUSE MAYBE IF YOU THINK YOU KNOW ABOUT KAISER PERMANENTE, AS A HEALTHCARE SYSTEM, WHAT YOU MIGHT NOT KNOW AND IS IMPORTANT TO STRESS IN THIS CONTEXT IS THAT KAISER PERMANENTE ACTUALLY HAS A HISTORY OF PREVENTIVE CARE AND COMMUNITY CARE THAT GOES BACK TO ITS VERY BEGINNINGS. HENRY J KAISER AND SIDNEY GARFIELD, A PHYSICIAN WORKING WITH HIM, BACK IN THE 1930s WHEN HENRY KAISER WAS GOING PEOPLE AT LARGE FACTORIES HAD THIS IDEA HOW DO WE KEEP THE PEOPLE WHO ARE WORKING HERE HEALTHY, HOW DO WE KEEP THEIR FAMILIES HEALTHY. IN RICHMOND THERE IS THE ROSY THE RIVETER HOME FRONT MUSEUM, IF YOU GET A CHANCE TO VISIT, IT'S FASCINATING AND TALKS ABOUT HOW THE POPULATION OF RICHMOND, CALIFORNIA, GREW TEN TIMES ITS SIZE DURING WORLD WAR II TO BUILD SHIPS. AND PEOPLE FLOODED INTO RICHMOND, THEY BROUGHT THEIR FAMILIES, THE COMMUNITY GOT REALLY BIG, AND THIS WHOLE IDEA OF WHAT KIND OF MEDICAL CARE COULD KEEP THIS COMMUNITY HEALTHY AND KEEP PEOPLE'S FAMILIES HEALTHY WAS WHAT MOTIVATED THE ENTIRE DELIVERY SYSTEM. SO THERE ARE A LOT OF DIAGRAMS THAT TALK ABOUT LEARNING HEALTH CARE SYSTEMS. I CHOSE ONE I PUBLISHED WITH A COLLEAGUE. WHAT I'D LIKE TO STRESS HERE IS THAT IT'S VERY IMPORTANT WHEN WE THINK ABOUT INTEGRATED CARE DELIVERY SYSTEMS, OUR HEALTHCARE SYSTEM AT LARGE, WE THINK HOW IT CAN BE A LEARNING HEALTHCARE SYSTEM. TRADITIONALLY WE OFTEN AS RESEARCHERS LIKE TO THINK OF OURSELVES AS GENERATORS OF KNOWLEDGE, AND QUALITY LEADERS AS END USERS OF WHAT WE DO, AND I DON'T THINK WE TEND TO BE NEARLY HUMBLE AND SELF AWARE ENOUGH TO REALIZE THE PEOPLE WHO ARE WORKING WITHIN HEALTH CARE DELIVERY SYSTEMS AND FRANKLY PEOPLE WHO ARE WORKING IN COMMUNITIES TO PROVIDE HEALTH CARE AND WORK WITH COMMUNITY MEMBERS ACTUALLY SOMETIMES KNOW A LOT MORE THAN WE DO. WE HAVE TO LEARN FROM THEM AND HAVE TO ENGAGE IF WE WANT SYSTEMS LEARNING, WE HAVE TO ENGAGE VERY MEANINGFULLY AS PART OF THAT HEALTHCARE SYSTEM. SO, I'D LIKE TO TALK IN TERMS OF DIABETES WHICH IS REALLY MY AREA OF EXPERTISE AND MY AREA OF RESEARCH, ABOUT COMMUNITY, FAMILY AND SOCIAL CONTEXT FOR DIABETES RISK. THESE POINTS HAVE COME UP MULTIPLE TIMES DURING THE LAST COUPLE DAYS. I'M GLAD TO HEAR THAT BECAUSE I THINK THAT ONE OF THE THEMES THAT HAS COME UP IS HEALTH RISK AND NEED FOR PREVENTIVE CARE IS CORRELATED AMONG SOCIAL CONNECTIONS. PEOPLE WHO ARE — WHOA. ING YOU THERE WE GO. PEOPLE WHO ARE RELATED SOCIALLY SHARE ENVIRONMENTS AND RESOURCES, SHARE ACTIVITIES, OFTEN SHARE HEALTH INFORMATION WITH EACH OTHER, HAVE SIMILAR HEALTH BELIEFS. THERE IS WHAT'S CALLED ZIP CODE EFFECT, PLACE MATTERS. THIS HAS COME UP IN THE LAST COUPLE OF DAYS AS WELL. WE REALLY KNOW THAT THERE'S A LOT THAT YOUR NEIGHBORHOOD ENVIRONMENT HAS TO DO WITH YOUR HEALTH AND YOUR LIFE EXPECTANCY, BUT WHEN WE DO PREVENTION RESEARCH AND DO SIMULATION MODELS AND DO RISK PREDICTION MODELS WE OFTEN DON'T TAKE THOSE THINGS INTO ACCOUNT. WE ACTUALLY REALLY TEND TO FOCUS A LOT MORE ON WHAT IS TRADITIONALLY IN THE EHR AND WHAT WE TRADITIONALLY CONSIDER TO BE INDIVIDUAL LEVEL FACTORS. WE DON'T THINK ABOUT FAMILY AND COMMUNITY FACTORS AS MUCH AS WE SHOULD AND DON'T TAKE THOSE THINGS INTO ACCOUNT WHEN WE'RE THINKING ABOUT HOW TO UNDERSTAND TARGETING AND PROVIDING PREVENTIVE CARE. SO I'D LIKE TO SAY A LITTLE BIT ABOUT WORK I DID CAN COLLEAGUES AT EMORY A COUPLE YEARS AGO. WE LOOKED AT DIABETES INCIDENCE OVERALL AND WITHIN KAISER PERMANENTE NORTHERN CALIFORNIA AND WE ALSO LOOKED AT DIABETES INCIDENCE AMONG SPOUSES AND PARTNERS OF PEOPLE WHO ALREADY HAD DIABETES, INCIDENT DIABETES. SO YOU'LL SEE BY LOOKING AT THE BLUE BAR AND ORANGE BAR THAT AGAIN WE HAVE A REPRESENTATIVE POPULATION, INCIDENCE RATE OF DIABETES OVERALL AMONG MEN AND WOMEN IS QUITE SIMILAR IN OUR HEALTHCARE SETTING COMPARED TO THE NATION AT LARGE. BUT IF YOU LOOK AT THE DIABETES INCIDENCE OF THE SPOUSES AND PARTNERS OF PEOPLE WHOSE SPOUSE DEVELOPED DIABETES IN THE LAST YEAR, IT'S QUITE A BIT HIGHER. BASICALLY, TO USE MYSELF AS EXAMPLE, IF MY HUSBAND GOT DIABETES THIS YEAR MY CHANCE OF GETTING IT NEXT YEAR OR THE YEAR AFTER IS QUITE A BIT HIGHER. THAT REALLY DOES EMPHASIZE HOW RISK IS SHARED, HOW WE NEED TO THINK ABOUT FAMILY AND COMMUNITIES WHEN WE THINK ABOUT TARGETING RISK PREVENTION. I GUESS MAYBE COMPLEMENTARY PART OF THAT STUDY IS WE TOOK THOSE SAME COUPLES, THE INCIDENT — PATIENTS WITH INCIDENT DIABETES, AND RESPECTIVE SPOUSES, AND LOOKED AT THE HEALTH BEHAVIOR CHANGE OF THE SPOUSES AND SAID IF YOUR SPOUSE DEVELOPD DIABETES WHAT HAPPENED TO YOUR HEALTH BEHAVIORS? WERE YOU MORE LIKELY TO COME IN FOR GLUCOSE OR LIPID TESTING IF YOU SMOKED, WERE YOU MORE LIKELY TO GET A SMOKING CESSATION MEDICATION, TO COME IN FOR A WELLNESS CHANCE. THE ANSWER WAS QUESTION. WE THINK OF PARTNERS AS CAREGIVERS AND THEY CERTAINLY ARE. WE THINK OF THEM THAT WAY BUT WE DON'T THINK OF THEM AS PEOPLE WHO HAVE NOT ONLY ELEVATED RISK BUT PEOPLE WHO MIGHT REALLY BE THERE AT A MOMENT OF OPPORTUNITY TO HELP TRY TO PREVENT. I USED TO CALL IT A TEACHABLE MOMENT. THAT'S TOO CONDESCENDING SO I'M TRYING TO CALL IT A MOMENT OF OPPORTUNITY TO ENGAGE. I THINK THAT'S REALLY IMPORTANT. ANOTHER STUDY I DID WITH A COLLEAGUE OF MINE AGAIN GOES BACK TO THIS QUESTION OF WE OFTEN JUST THINK ABOUT INDIVIDUAL RISK FACTORS AND THINK ABOUT WHAT WE CAN PULL ON INDIVIDUALS FROM EMR WHEN WE PUT RISK PREDICTION MODELS TOGETHER. WE DID A VERY BASIC NO MACHINE LEARNING, NO DEEP LEARNING, REALLY JUST PROOF OF CONCEPT STUDY TO LOOK AT PREDICTION OF CORRECTING DIABETES AMONG PREDIABETES IN 157,000 KAISER PERMANENTE NORTHER CALIFORIA PATIENTS, PUT AGE AND BMI AND BASELINE, A1c, TYPICAL THINKS WHEN YOU THINK MUCH INDIVIDUAL LEVEL DIABETES RISK AND ONLY SHOW THIS, ADJUSTED TO SHOW WE CERTAINLY DID SEE RELATIONSHIP BETWEEN RACE ETHNICITY AND DEVELOPING DIABETES AMONG PRE-DIABETES POPULATION BUT ON TOP OF THAT WE HAD THE OPPORTUNITY AGAIN THIS WAS A TEST TO SEE IF WE ACTUALLY PUT IN SOME CENSUS INFORMATION ABOUT NEIGHBORHOODS, WE PUT IN INCOME AND EDUCATION. WE ALSO PUT IN CENSUS TRACT LEVEL INFORMATION ABOUT THE PERCENTAGE OF HOUSEHOLDS RECEIVING FOOD STAFFS, ON TOP OF ALL THE OTHER THINGS. WE FOUND THAT NOT ONLY WAS IT STATISTICALLY SIGNIFICANT THAT IN THOSE CENSUS BLOCKS WHERE 10% OR MORE PEOPLE WERE RECEIVING SNAP BENEFITS, THAT IT WAS A MARKER OF ELEVATED RISK BUT IMPROVED OUR PREDICTION ABILITY AS WELL, NOT BY A LOT, BUT IT WAS REALLY JUST TO SAY IF WE START TO THINK OUTSIDE THE RISK PREDICTION BOXES AND PUT IN SOME OTHER FACTORS COULD WE DO A BETTER JOB OF IDENTIFYING WHO WE SHOULD BE REACHING OUT TO AND I BELIEVE THE ANSWER IS YES. SO, ANOTHER WAY OF THINKING DIABETES PREVENTION OR PREVENTION AT ALL IS TO THINK ABOUT PEERS, TO THINK ABOUT CREATING COMMUNITIES AMONG PEERS AND REINFORCING COMMUNITY BONDS AMONG PEERS, AND THIS IS A RELATIVELY NEW STUDY THAT I AM DOING ALONG WITH MICHELLE HIGHSLER AT UNIVERSITY OF MICHIGAN, I'M SURE A LOT OF FOLKS HEARD OF HER. SHE'S AN INTERNATIONAL EXPERT ON PEER SUPPORT, REALLY MOSTLY IN CHRONIC DISEASE THOUGH SO WE PUT OUR HEADS TOGETHER AND SAID COULD WE HARNESS THE POWER OF PEER SUPPORT, WHAT WE KNOW ABOUT BRINGING PEOPLE TOGETHER TO HELP MANAGE CHRONIC DISEASES AND ACHIEVE THEIR DESIRED HEALTH OUTCOMES IF THEY HAVE CHRONIC DISEASE AND USE THAT TO PREVENT DISEASE AMONG PEOPLE THAT HAVE PREDIABETES. NIDDK THAT THOUGHT IT WAS A NICE IDEA. WE'RE RECRUITING. THERE'S A PEER SUPPORT INTERVENTION. WHAT THAT INVOLVES IS COACH AND PEER CONTACT VIA PHONE OR TEXT OR IN PERSON. THEY START IN PERSON. WE'RE FINDING VERY EARLY ON PEOPLE LOVE TO TEXT. WHICH IS GREAT. WE'VE TALKED ABOUT SOME OF THESE KINDS OF INTERVENTIONS IN THE LAST PANEL AND JUST AGAIN AN ANECDOTAL, WHEN GIVEN THE OPTION, THEY WANT TO TEXT A LOT WHICH I LOVE AND THINK IS FANTASTIC. THERE'S A SIX-MONTH DEFINED COMMUNICATION PERIOD. WE WANT TO TALK, COMMUNICATE ONCE A WEEK. THEY ARE OFTEN COMMUNICATING MORE. BUT THERE'S SIX MONTHS AFTER THAT THAT'S A MAINTENANCE PERIOD WHERE THEY ONLY HAVE TO TOUCH BASE ONCE A MONTH. SEEMS LIKE PEOPLE ARE BONDING AND COMMUNITIES ARE BEING CREATED. WOULDN'T SURPRISE ME IF THEY END UP COMMUNICATING MORE THAN THAT AND THE USUAL CARE ARM, THIS IS A PRAGMATIC RANDOMIZED TRIAL, STANDARD PREDIABETES PROGRAMS AND CARE AND BOTH ARMS ARE RECEIVING STANDARD HEALTHCARE SYSTEM AND COMMUNITY-BASED WELLNESS PROGRAM RESOURCE LISTS SO THEY CAN GO AND DO THAT SO THAT'S STANDARDIZED BUT WE THINK IT'S THE PEER SUPPORT AND CREATING COMMUNITY THAT IT'S HYPOTHESIZED THAT WILL MAKE THE DIFFERENCE. SO, IT'S ASKED TO TALK ABOUT HEALTH CARE DELIVERY SYSTEMS AND THINKING ABOUT COMMUNITY ENGAGEMENT, I THINK INVESTMENT IN THE COMMUNITY AND AGAIN THIS HAS COME UP AS A THEME AS WELL IS VERY IMPORTANT. IT'S NOT JUST ME THAT THINKS THAT. I WANT TO CITE THIS REPORT FROM KPMB, INVESTING IN SOCIAL SERVICES AS A CORE STRATEGY IN DEVELOPING A BUSINESS CASE. I WOULD LIKE TO ECHO POINTS THAT CAME UP YESTERDAY ABOUT WHAT A BUSINESS CASE REALLY MEANS. I THINK WE OFTEN TEND TO THINK BIT AS DOLLARS AND CENTS BUT IN FACT IT'S A LOT MORE THAN THAT. I THINK THAT REPUTATION WITHIN THE COMMUNITY, REPUTATION AMONG OUR MEMBERS AND OUR PATIENTS, THE POINT WAS BROUGHT UP ABOUT PEOPLE COMING INTO AN ORGANIZATION THAT THEY WANT TO WORK FOR AND THINKING WHAT'S THEIR SOCIAL MISSION. THERE ARE A LOT OF COMPLICATED COMPLEX RIGHTFULLY SO COMPLEX WAYS OF THINKING ABOUT BUSINESS CASES THAT GO WELL, I WANT TO BRING THAT UP HERE, INVESTMENTS HAVE PAYOFFS OTHER THAN REDUCED E.R. VISITS. AT LEAST AT KAISER PERMANENTE THERE HAVE BEEN COMMUNITY INVESTMENTS. I PULLED THIS OFF THE WEB. IT WAS REALLY THE QUOTE HERE FROM BERNARD TYSON, NATIONAL CEO. HE'S SAYING RIGHT THERE, HOUSING SECURITY IS A CRUCIAL HEALTH ISSUE FOR VULNERABLE POPULATIONS. SO IN HIS MIND, HE REALLY IS MAKING THAT LINK BETWEEN ADDRESSING SOCIAL NEEDS, INSTABILITY, SOCIAL INSTABILITY AND NEEDS WITHIN THE COMMUNITY, AND HEALTH CARE. AND I THINK THAT'S ABSOLUTELY RIGHT. AND ONE OF THE WAYS TO THINK ABOUT THAT IS THROUGH DIFFERENT KINDS OF INVESTMENTS. ANOTHER THEME THAT HAS COME UP MULTIPLE TIMES IS THINKING ABOUT EVIDENCE BASE, AND IF THERE ARE COMMUNITY INVESTMENTS, INVESTMENTS IN SOCIAL NEEDS, SCREENING FOR SOCIAL NEEDS. WHAT ARE WE LEARNING ABOUT THOSE KINDS OF INTERVENTIONS? AND THE BASIC ANSWER TO QUOTE LAURA GOTTLIEB, NOT A LOT ACTUALLY. SYSTEMIC REVIEW OF ADDRESSING SOCIAL NEEDS AND SCREENING FOR SOCIAL NEEDS, HOW IT MIGHT IMPACT HEALTH CARE AND HEALTH OUTCOMES IS BURGEONING. WE'VE SEEN SO FAR WHAT IS PROMISING BUT THERE'S MORE THAT NEEDS TO BE DONE, RESEARCH OPPORTUNITIES, AND CERTAINLY WE NED TO BE THINKING ABOUT CREATIVE WAYS TO DO THAT. NATURAL EXPERIMENTS HAVE COME UP. OTHER METHODS HAVE COME UP. WHAT'S BEEN CONSISTENT IS TYPICAL FIVE-YEAR RANDOMIZED TRIAL TO DO ALL OF THIS KIND OF WORK IS PROBABLY NOT THE WAY WE'LL BUILD THE EVIDENCE BASE AS FAST AS WE NEED TO. SO I WANTED TO SAY THAT THIS IDEA OF THINKING ABOUT SOCIAL NEEDS AND PSYCHOSOCIAL CARE IS SOMETHING THE AMERICAN DIABETES ASSOCIATION STARTED TO EMBRACE, IN THE 2016 STATEMENT THAT CAME OUT. AND I THINK THAT IS VERY IMPORTANT TO POINT OUT THAT THIS IDEA, THESE IDEAS ABOUT COMMUNITY ENGAGEMENT AND ABOUT THINKING ABOUT PSYCHOSOCIAL NEEDS ARE DEFINITELY TAKING OFF IN THE MAINSTREAM. AND SO IS POPULATION CARE FOR PREVENTION. AND THE STANDARDS OF MEDICAL CARE AND DIABETES IN 2018 QUOTED HOW POPULATION CARE IS REALLY IMPORTANT FOR DIABETES CARE AND PREVENTION. SO I DO THINK THERE IS A LITTLE BIT MORE OF AN EMPHASIS ON THIS. SOME COLLEAGUES AND I WROTE A PAPER ABOUT A YEAR AGO THAT ACTUALLY TRIED TO TAKE AGAIN WHAT DO WE KNOW FROM CHRONIC DISEASES AND APPLY TO PREVENTION, WHAT DO WE KNOW ABOUT POPULATION BASED APPROACHES WE'VE BEEN IMPLEMENTING THROUGH THE CHRONIC CARE MODEL OVER THE YEARS AND THINK ABOUT DIABETES SCREENING AND PREVENTION. AND SO REALLY JUST TO REALLY SAY THAT THAT KIND OF IDEA THAT RISK ASSESSMENT, THINKING ABOUT PREVENTIVE CARE, DOES NEED TO HAPPEN AT THE POPULATION LEVEL AS WELL AS PATIENT, CLINICIAN AND HEALTHCARE SYSTEM LEVEL, ALL THOSE LEVELS NEED TO BE ADDRESSED, WHEN WE THINK ABOUT PREVENTIVE CARE, REALLY IMPORTANT. AND THAT IN TERMS OF ACTUALLY WHEN PEOPLE HAVE FOUND TO BE PREDIABETES, WE DO KNOW QUITE A BIT ABOUT WHAT TO DO FROM THE DPP. WE KNOW A LOT ABOUT THE INTENSIVE LIFESTYLE, AND I COULD TALK ALL DAY ABOUT THIS, THE FORGOTTEN ARM OF THE DPP, METFORMIN, WE KNOW A LOT ABOUT WHAT METFORMIN CAN DO TO REDUCE DIABETES RISK AND IN MY OPINION VERY LITTLE METFORMIN IS BEING PRESCRIBED FOR THAT. SO AGAIN IN THAT SORT OF LIKE WHERE IS THE FIELD GOING, THERE ARE NEW MEDICARE ADVANTAGE RULES THAT WILL BE COMING OUT, WHAT THESE WILL LOOK LIKE AND HOW THEY WILL BE SHAPED, WE DON'T KNOW YET. BUT I WOULD JUST POINT YOU TO THE HIGHLIGHTED THING HERE ABOUT THERE IS A MOVEMENT TOWARDS HAVING MEDICARE ADVANTAGE BENEFITS THAT CAN BE USED TO ADDRESS SOCIAL DETERMINANTS OF HEALTH FOR BENEFICIARIES WITH CHRONIC DISEASE, WHETHER THAT COULD MEAN ADDRESSING FOOD INSECURITY, HOUSING INSECURITY, IS NOT CLEAR YET BUT THE FACT THAT THAT IS PART OF THE UPCOMING POLICY IS IMPORTANT TO NOTE AND ADD CREDENCE TO THESE IDEAS. JUST A COUPLE OTHER POINTS, IT'S INTERESTING HOW THIS HAS COME UP, WHAT CAN WE LEARN FROM OTHER FIELDS AND WHAT DO WE NEED TO THINK ABOUT. IN MY MIND YOU CAN'T IMPROVE WHAT YOU AREN'T MEASURING. AGAIN, THAT HAS COME UP BEFORE. THIS IS NOT AN EVIDENCE-BASED REVIEW. THIS IS ME GOING TO THE NCQA WEBSITE AND COUNTING. WHICH IS WHY I DON'T HAVE EXACT NUMBERS HERE. BUT IT IS REALLY STRIKING, THERE'S A LOT IN HEDIS AND NCQA AROUND CANCER PREVENTION AND SCREENING, RIGHTFULLY SO, AWESOME, IT'S NOT A KNOCK AT ALL. THERE'S A ALSO BIT ON DIABETES SCREENING AND PREVENTIONF YOU THINK ABOUT THINGS THAT ARE DIABETES ADJACENT, OBESITY, AND THAT'S REALLY INTERESTING THAT BALANCE OF WHAT THE EVIDENCE REVIEWS HAVE SHOWN AND WHAT THE TALKS HAVE BEEN ABOUT REALLY ARE MUCH MORE ABOUT CANCER PREVENTION AND SCREENING, DIABETES SCREENING, BUT MOST IMPORTANTLY IS WHEN WE'RE THINKING ABOUT DO WE HAVE HEALTH CARE METRICS, DO WE HAVE NATIONAL STANDARDS AROUND ADDRESSING SOCIAL DETERMINANTS OF HEALTH, AROUND ADDRESSING DISPARITIES, AROUND ACHIEVING HEALTH EQUITY, NOT THAT I CAN SEE. AND I ACTUALLY THINK IF WE WANT TO SEE SOME MOVEMENT IN THAT AREA WE ACTUALLY DO HAVE TO HAVE STANDARDS AND ACCOUNTABILITY AROUND IT. SO IS THE GLASS HALF FULL OR HALF EMPTY? I'LL LEAVE THAT TO YOU. MAYBE YOU CAUGHT ME ON AN OPTIMISTIC DAY, BUT I THINK IT IS HALF FULL. I THINK THAT THE MOVEMENT TOWARDS UNDERSTANDING HOW IT REALLY IS POLICY AND PAYMENT THAT HAS A LOT TO DO WITH OUR ABILITY TO BUILD COMMUNITIES AND ADDRESS SOCIAL NEEDS, I REALLY THINK THIS IDEA AROUND LEARNING HEALTH CARE SYSTEMS AND HOW THEY REALLY DO INVOLVE HEALTH CARE DELIVERY SYSTEMS AND BROADER COMMUNITY I THINK A LOT OF THOSE MOVEMENTS ARE TAKING SHAPE AND I AM VERY OPTIMISTIC. SO MY RECOMMENDATIONS WOULD BE WE REALLY DO NEED TO THINK ABOUT DISEASE PREVENTION PROGRAMS THAT TARGET HOUSEHOLD AND COMMUNITIES, FOSTER AT FAMILY AND PEER AND COMMUNITY LEVEL, THINK VERY BROADLY ABOUT THAT. WE HAVE TO THINK ABOUT HOW ADDRESSING AND SCREENING FOR SOCIAL NEEDS AND ENHANCING COMMUNITY RESOURCES CAN HELP PREVENT DISEASE AND IMPROVE HEALTH OVERALL. AND SO THESE ARE THINGS I'VE REALLY ALREADY SAID. I WOULD WRAP UP BY SAYING THAT THE APPROACHES HERE I REALLY THINK WE CAN APPLY TO A LOT OF TYPES OF HEALTH CARE SYSTEMS. I THINK SOME OF MY RESEARCH HAS BEEN IN KAISER PERMANENTE BUT THERE ARE MODELS HERE THE WHOLE COUNTRY IS MOVING TOWARDS THAT HAVE A LOT OF PROMISE. THANK YOU. [APPLAUSE] >> I'M DAVID ADKINS, DIRECTOR OF HELD SERVICES RESEARCH AT THE VA, IN THE POSITION OF BEING THE CLOSER. MY JOB IS THROW STRIKES AND WORK FAST. AND I KNOW LIKE THE SCATTERED PEOPLE IN THE NINTH INNING ARE DEVOTED FANS AND ARE THE PEOPLE WE REALLY DEPEND ON TO GET THE WORK DONE. SO I HAVE A CLICKER HERE. LET'S SEE. I'M PUSHING THE WRONG BUTTON. MY FIRST JOB IS TO ACKNOWLEDGE THE MANY PEOPLE IN V.A. WHO CONTRIBUTED TO THIS WORK, THE GREAT THING ABOUT WORKING AT THE V.A. IS YOU HAVE A WIDE POOL OF RESEARCHERS WHO ARE DEDICATED TO ISSUES OF PREVENTION AND EQUALITY, WE HAVE A NATIONAL CENTER FOR PREVENTION, SOME PEOPLE HAVE BEEN AT THE MEETING. WE HAVE THE EVIDENCE SYNTHESIS PROGRAM, AND WE HAVE AN OFFICE OF HEALTH EQUITY UNDER DR. ERNIE MOY, WHICH HAS ITS FOCUS ON LOOKING AT OUR DATA TO FIGURE OUT WHERE WE HAVE EQUITY PROBLEMS, AND WE HAVE NATIONAL PROGRAMS LIKE TOBACCO CESSATION AT THE V.A. HAVE THAT BEEN RESPONSIBLE FOR MUCH OF OUR PROGRESS. DECLARING WHAT IS BRILLIANCE, SO — I
REALLY MUST HAVE COLD HANDS OR SOMETHING. OKAY. SORRY. WE'LL GET THROUGH THIS. SO, FOR THOSE OF YOU WHO HAVE TO LEAVE EARLY, THIS IS THE — WHAT I'LL TRY TO LAY OUT OVER THE AND IT REALLY ECHOES THE THEMES WE'VE HEARD FROM OUR PREVIOUS SPEAKERS, IT'S NOT A COINCIDENCE THE V.A. LEADERS AS THEY WERE THINKING ABOUT TRANSITIONS AND TRANSFORMATIONS TO A PATIENT CENTERED MEDICAL HOME WENT UP TO TALK TO LEADERS AND ALASKA HEALTHCARE SYSTEM AND KAISER. YOU'LL HEAR FAMILIAR MESSAGES. INTEGRATED HEALTHCARE SYSTEM ESPECIALLY ONE THAT HAS BUILT PATIENT CENTERED MEDICAL HOME THAT YOU'VE HEARD ABOUT CAN DELIVER HIGH QUALITY PREVENTIVE CARE AND FOCUSING ON DELIVERING HIGH QUALITY PREVENTIVE CARE ACROSS ALL PATIENTS YOU ARE ABLE TO ELIMINATE MANY OF THE DISPARITIES THAT ONE WOULD OTHERWISE SEE. HOWEVER, YOU WON'T ELIMINATE ALL DISPARITIES AND I'LL SHOW YOU SOME OF THE DATA ABOUT WHAT WE STILL HAVE. AND THOSE ARE ESPECIALLY THOSE DISPARITIES THAT RELY ON LONG-TERM CHRONIC ISSUES THAT ARE INFLUENCED BY SOCIETAL FACTORS, THE THINGS THAT GO ON OF THE A AFTER THE PATIENT LEAVES THE HEALTH CARE ENCOUNTER, ELIMINATING REQUIRES ADDRESSING ISSUES THAT WERE JUST LAID OUT FOR YOU ABOUT BUILDING CONNECTIONS INTO THE COMMUNITY TO ADDRESS SOCIAL DETERMINANTS OF HEALTH, FORMING PARTNERSHIPS WITH THE COMMUNITY, WITH PEERS, TO HELP PATIENTS IN THAT 95% OF THE TIME THEY ARE OUTSIDE THE WALLS OF YOUR HEALTHCARE SYSTEM. SO BACKGROUND, WE'RE AN INTEGRATED HEALTHCARE SYSTEM, PROVIDE COMPREHENSIVE PRIMARY, MENTAL HEALTH AND INPATIENT CARE, A GREAT LABORATORY BECAUSE WE CAN ELIMINATE OFTEN DOMINANT EFFECT OF HEALTH INSURANCE COVERAGE. WE SERVE — OF 20 MILLION VETERANS, WE SERVE 6 MILLION IN ANY ONE YEAR, 172 CENTERS, A THOUSAND CLINICS. OLDER AND POORER, AND IN GENERAL COMPARED TO AVERAGE U.S. POPULATION. WE HAVE A FAIRLY LARGE REPRESENTATION OF RACIAL AND ETHNIC MINORITIES, DUE TO THE LARGE NUMBER THAT VOLUNTEER TO SERVE IN THE MILITARY. AND THIS IS LIKELY TO GROW BECAUSE THE PROPORTION OF RACIAL DUTY IS HIGHER. POPULATION, AGAIN DUE TO PEOPLE WHO VOLUNTEER IN THE ALL-VOLUNTEER ARMY, IS LARGELY RURAL. 50% LIVE IN AN AREA THAT WOULD BE CLASSIFIED AS RURAL. PROPORTION OF WOMEN IS INCREASING DUE TO NUMBER OF WOMEN WHO WERE PART OF THE IRAQ AND AFGHANISTAN CONFLICTS. IT WAS ABOUT 7% IN 2016, UP TO 10% NOW. WILL GRADUALLY GROW. WE HAVE ADVANTAGE OF HAVING EMBEDDED RESEARCH PROGRAM FUNDED BY CONGRESS, AND HAVE THAT THROUGH THE RESEARCH AND DELIVERY SYSTEM HAVE ALWAYS HAD A STRONG FOCUS ON EQUITY. WHAT HAS V.A. DONE AS A SYSTEM TO PROVIDE PREVENTIVE CARE? THE FIRST THING IS IMPORTANCE OF LEADERSHIP COMMITMENT, AND THIS INCLUDES EVERYTHING FROM TOP OF THE SYSTEM AT THE SECRETARY LEVEL DOWN TO OUR REGIONAL WHAT WE CALL DIVISION DIRECTORS AND LOCAL FACILITY DIRECTORS. THAT'S REINFORCED BY A PERFORMANCE MEASUREMENT SYSTEM THAT TRACKS A LARGE NUMBER OF QUALITY, THESE ARE PARTS OF OF PERFORMANCE PLANS OF SENIOR LEADERSHIP, TAMPA FACILITATED BY HEALTH RECORDS FOR TWO DECADES. WE'RE REACHING POINT OF REMINDER FATIGUE AS WE LOAD MORE PROMPTS INTO THE ELECTRONIC HEALTH RECORD SO WE'RE ACTIVELY WORKING TO TRY TO FIGURE OUT HOW TO EFFICIENTLY USE HELD INFORMATION TECHNOLOGY AND TEAM-BASED CARE TO PREVENT THAT BURNOUT. AS I MENTIONED, WE UNDERWENT A PATIENT-CENTERED MEDICAL HOME TRANSFORMATION FIVE YEARS AGO, SPENT OVER A BILLION DOLLARS IN MOVING TO TEAM-BASED CARE. THAT REQUIRED HIRING MORE NURSE CARE MANAGERS, BEHAVIORAL SPECIALISTS TO SERVE THE TEAM, PHARMACY CARE MANAGERS, WE'VE HAD INTEGRATED MENTAL HEALTH IN PRIMARY CARE FOR UP TO A DECADE. AND THAT'S BEEN VERY IMPORTANT IN KEEPING PATIENTS WERE MENTAL HEALTH DISABILITIES WITHIN PRIMARY CARE MAKING SURE THEY GET PREVENTION. WE INCREASINGLY HAVE INTEGRATED PREVENTION INTO SPECIALTY CLINICS RECOGNIZING THOSE ARE SERIOUS MENTAL ILLNESS, IT MIGHT NOT BE THE PRIMARY CLINIC OR HIV, TRYING TO TAKE SERVICES TO WHAT THOSE PATIENTS SEE AS THEIR ENVELOPE MEDICAL HOME. FOR TOBACCO, MAMMOGRAPHY, OBESITY, NATIONAL PROGRAMS MAKE SURE WE'RE DELIVERING ACROSS THE SYSTEM. THE CHALLENGE IS WITH 172 HOSPITALS, THERE'S POTENTIAL, THOSE RANGE IN LARGE LEVEL TERTIARY CARE, STRONG ACADEMIC PARTNERSHIPS, TO SMALL COMMUNITY RURAL HOSPITALS. POTENTIAL FOR VARIATION IS GREAT. AND SO YOU NEED A NATIONAL SYSTEM TO TRY TO MAKE SURE THAT WE'RE HELPING TO ADDRESS THAT. WE'RE BEGINNING TO PILOT LUNG CANCER SCREENING, AND WE'VE — I'LL TALK ABOUT TARGETED INTERVENTIONS USING TELEHEALTH AND PEER SUPPORT FOR PLACES WE KNOW ARE POPULATIONS AT HIGH RISK AND WHERE WE HAVEN'T SUCCESSFULLY ELIMINATED ALL DISPARITIES. SO THIS IS JUST A QUICK WALK THROUGH WHAT WE'VE DONE WITH TOBACCO TREATMENT. IT'S REALLY AN ANALOGY OF HOW TO TACKLE A PREVENTION PROBLEM THROUGH A SYSTEM APPROACH, TOBACCO PREVALENCE WAS VERY HIGH AMONG VETERANS, MANY PEOPLE SMOKED DURING ACTIVE DUTY. SO CESSATION BEGINNING MORE THAN A DECADE AGO WAS INTEGRATED INTO PRIMARY CARE. IT WAS TRACKED AS A PERFORMANCE MEASURE. THERE WERE PROMPTS TO MAKE SURE PATIENTS GOT SCREENED FOR TOBACCO USE, BRIEF COUNSELING, ACCESS TO MEDS, THERE WERE SPECIALTY TOBACCO CESSATION PROGRAMS THAT PATIENTS COULD BE REFERRED TO WHO NEEDED CLOSER FOLLOW-UP. WE HAVE BEHAVIORAL HEALTH COUNSELORS NOW EMBEDDED TO PROVIDE MORE INTENSIVE COUNSELING. WE USE TELEHELD TO DELIVER IN-HOME MESSAGING, COORDINATED BY TELEHEALTH COORDINATOR. AND WE TOOK TOBACCO TREATMENT SPECIFICALLY INTO MENTAL HEALTH AND SPECIALTY CARE, TO ADDRESS THE FACT THAT THOSE PATIENTS MAY NOT BE, AS I MENTIONED, SEEING PRIMARY CARE. WE RECOGNIZE THE NEED TO TRAIN A CADRE OF LEADS TO CONTINUE TO KEEP THIS ON THE RADAR. AS A RESULT SINCE IN THE LAST TWO DECADES WE'VE CUT SMOKING PREVALENCE BY 50% IN THE V.A. SO LET ME TRY TO PICK UP MY PACE, BUT THIS IS JUST TO SHOW THAT ON A NATIONAL BASIS V.A. COMPARED TO COMMERCIAL MEDICAID OR MEDICARE HAS CONTINUED TO DO VERY WELL WITH HIGH LEVELS OF PERFORMANCE ON PREVENTION, 90% FOR SMOKING CESSATION, ABOVE 80% FOR COLORECTAL CANCER SCREENING, AND THEN FOR COMPREHENSIVE DIABETES, CARDIOVASCULAR RISK FACTOR CONTROL. WE'RE DOING WELL COMPARED TO PEERS, A FUNCTION OF THE THINGS I LAID OUT, HAVING A NATIONAL SYSTEM, ELECTRONIC HEALTH RECORD, WILL ALLOW YOU TO DO. ARE WE TREATING VETERANS EQUALLY AND WHAT ARE THE POPULATIONS TO PAY ATTENTION TO TO CHECK THAT. WE HAVE RACIAL AND ETHNIC MINORITIES. MANY ARE POOR, MENTAL HEALTH PREVALENCE IS HIGH. PATIENTS FROM RECENT CONFLICTS WITH ACUTE MENTAL HEALTH CONDITIONS SUCH AS PTSD. SO, THIS IS JUST QUICK WALK-THROUGH WHERE WE ARE IN TERMS OF DISPARITIES BY — I'LL GO THROUGH THE CATEGORIES. IN TERMS OF RACE AND ETHNICITY, YELLOW IS GOOD. THESE ARE FOR 15 HEDIS MEASURES THAT WE TALKED ABOUT. BLUE INDICATES PLACES WHERE THERE IS A DISPARITY. AS YOU CAN SEE, WHILE WE DO WELL, THERE ARE SOME EXISTING DISPARITIES FOR BLACK VETERANS AND FOR AMERICAN INDIAN AND ALASKA NATIVE THAT WE HAVE NOT YET SUCCEEDED IN ELIMINATING. AS WE LOOK AT RURALITY, WE DO BETTER, BEING IN A RURAL LOCATION IS NOT A DISADVANTAGE. THERE ARE SOME THINGS WHERE WE DO WORSE FOR WOMEN, AND THAT'S LARGELY LIPID CONTROL. AND THERE ARE SOME PLACES WHERE SERIOUS MENTAL ILLNESS. WHAT ARE THE PLACES WE HAVE PROBLEMS? ONE OF THEM IS DIABETES CONTROL. WE'VE HEARD A LOT ABOUT THAT. AND IT'S NOT A PROBLEM IN SCREENING, IT'S A PROBLEM IN PROVIDING THE CONTINUED SUPPORT TO DO EFFECTIVE SELF MANAGEMENT. SO HERE HIGHER LEVEL IS WORSE, AND SO YOU CAN SEE THAT AMONG AMERICAN INDIANS AND ALASKA NATIVE, POOR CONTROL COMPARED TO 18% IN WHITE IS UP TO 27%, AND IT'S 24%, 23% FOR BLACK AND HISPANIC PATIENTS. WE SEE DISPARITIES IN DIABETES CONTROL BASED ON GENDER. ALTHOUGH INTERESTINGLY WE DON'T SEE IT BASED ON RURAL LOCATION AND ALSO SEE IT FOR SERIOUS MENTAL ILLNESS. SIMILARLY IN HYPERTENSION CONTROL WE DO WELL AS A SYSTEM, OVERALL CONTROL WE STILL HAVE GAPS TO DEAL WITH FOR AMERICAN INDIAN, ALASKA NATIVES, AND BLACK VETERANS. SLIGHTLY SMALLER GAPS, STATISTICALLY SIGNIFICANT, FOR HISPANICS. SO WHAT ARE THE UNDERLYING CONTRIBUTORS? THINGS YOU'VE DISCUSSED AT LENGTH OVER THE LAST TWO DAYS, ISSUES OF TRUST AND SATISFACTION, THOUGH GENERAL SATISFACTION IS HIGH WITH V.A. DESPITE WHAT YOU READ IN THE NEWSPAPERS. WE DO SEE A PERSISTENT GAP IN PATIENT EXPERIENCE MEASURES FOR RACIAL AND ETHNIC MINORITIES. THERE'S A GAP IN LONG-TERM ADHERENCE TO MEDICATIONS THAT SOMETIMES LEADS TO LATER PRESENTATION WITH CARE. THERE CAN BE GAPS ATTRIBUTED TO HEALTH LITERACY OR EXPECTATIONS, OR USE OF NON-MEDICAL ALTERNATIVES. AND SOME OF OUR RESEARCH HAS SUGGESTED THAT SOMETIMES PATIENT ENGAGEMENT IN TERMS OF ASKING QUESTIONS AND THEIR INTERACTIONS WITH PROVIDERS SHOWS SOME DIFFERENCE. AND AS WE ALL HAVE BEEN DISCUSSING, THE ISSUES IS WHEN THEY LEAVE THE CLINIC THERE ARE PROBLEMS OF SOCIAL SUPPORT IN COMMUNITIES THEY GO BACK TO. INTERESTINGLY WE DO NOT SEE MAJOR GAPS BY THE FACILITY. SO THERE ARE NOT BIG DIFFERENCES BY A SORT OF LOCAL CULTURE. WE DON'T SEE BIG DIFFERENCES IN HOW THE PROVIDERS THEMSELVES ARE COMMUNICATING. SO I THINK I DO BELIEVE THAT OUR CLINICIANS DO TREAT OUR PATIENTS, THEY OBVIOUSLY HAVE IMPLICIT BIASES BUT REALLY DO — ARE COMMITTED TO TREATING ALL OF OUR PATIENTS EQUALLY. SO I'M GOING TO CLOSE IN THE LAST FIVE MINUTES BY TALKING ABOUT SOME INTERVENTIONS WE'VE TACKLED AND THIS IS GOING TO FOLLOW ON PRESENTATION FROM KAISER, USING PEER SUPPORT FOR DIABETES AND HYPERTENSION CONTROL. SO WE KNOW WE HAVE A GAP IN LONG-TERM CONTROL. AND SO AGAIN WE'RE TALKING ABOUT MICHELLE HEISLER AGAIN, SHE BEGAN WORK USING PEER SUPPORT. VETERANS ARE VERY ATTACHED TO THEIR VETERAN IDENTITY. AND SO A VETERAN PEER MEANS A LOT TO OUR VETERANS, IN THE SAME WAY THAT PATIENTS MAY REALLY IDENTIFY FROM SOMEONE WHO THEY FEEL IS FROM THEIR LOCAL COMMUNITY. AND THE PEER PROVIDES FOUR IMPORTANT FUNCTIONS. FIRST IS SOCIAL AND EMOTIONAL SUPPORT FROM FEELING LIKE THEY UNDERSTAND THE ISSUES. THAT TRANSLATES INTO THE VALUE OF ONGOING REGULAR SUPPORT. AND ABILITY TO LINK TO RESOURCES AND PRACTICAL ADVICE RELATED TO DAILY MANAGEMENT, TAKING MEDICATIONS, DEALING WITH CHALLENGES, DEALING WITH BARRIERS THAT MAKE IT HARD TO COMPLY, TO ADHERE TO, RECOMMENDED LIFESTYLE CHANGES, RECOMMENDED MEDICATION REGIMENS. SO, THIS IS A STUDY THAT ONE OF MICHELLE'S EARLIER STUDIES ON DIABETES CONTROL USING PEERS, THIS WAS IN A MIDWEST COMMUNITY, TWO MIDWEST HOSPITALS SHOWING THAT FOR — WHILE THE CONTROL INTERVENTION OVER THE SIX-MONTH PERIOD HAD SLIGHT WORSENING OF HEMOGLOBIN A1c, THE INTERVENTION HAD A SIGNIFICANT INCREASE, TRANSLATING TO ONE-POINT DIFFERENCE IN HEMOGLOBIN A1c. JUDITH LONG DID WORK ON THE EAST COAST, PEER MENTORS HAD SIMILAR ONE-POINT IMPROVEMENT. ALMOST TWICE AS MUCH AS GOT WITH FINANCIAL INCENTIVES TO PROMOTE BETTER DIABETES CONTROL. ONE GREAT THING ABOUT OUR RESEARCH WE USE A LOT OF QUALITATIVE METHODS ALONG WITH QUANTITATIVE METHODS TO UNDERSTAND WHAT'S GOING ON. AND THESE ARE JUST SOME QUOTES FROM OUR VETERANS ABOUT WHAT THEY GOT FROM THE PEER INTERACTIONS. YOU HAVE MORE TIME TO EXPRESS YOUR FEELINGS WITH THE COACH THAN DO YOU WITH A DOCTOR. THIS IDEA YOU'RE NOT RUSHED AND FEELING GUILTY ABOUT TAKING UP YOUR PHYSICIAN'S TIME. TALKING TO THE COACH FEELS GOOD, LIKE A FRIEND. I DON'T MIND TALKING TO HIM. I LIKE HE WAS A GODLY MAN, COMMON INTERESTS, BOTH IN THE MILITARY. HELPFUL IT WAS SOMEONE ELSE WITH DIABETES I COULD RELATE TO, THAT'S THE BIGGEST ISSUE. IT'S COMON BUT I DON'T RUN INTO MANY PEOPLE WHO ARE DIABETIC. SO THAT'S THE GOOD NEWS. AND THIS IS SORT OF THE — LIKE THE GLASS HALF FULL AND HALF EMPTY, MY ENGINEER SON SAYS, NO, YOU HAVE A GLASS THAT'S TWICE AS BIG AS YOU NEED. SO WE CONTINUE TO STRUGGLE WITH THE ISSUE OF OVERWEIGHT AND OBESITY. AND I SEE A NUMBER OF PEOPLE IN THE AUDIENCE WERE PART OF A STATE-OF-THE-ART CONFERENCE WE HELD I THINK 2 1/2 YEARS AGO, ON THIS. AND THIS SHOWS OVER TIME THE PREVALENCE OF OBESITY AND OVERWEIGHT HAS CONTINUED TO RISE, IN THE V.A. WE HAVE A NATIONAL PROGRAM CALLED MOVE, WHICH REFERS PATIENTS TO BEHAVIORAL LIFESTYLE SUPPORT, A STRUCTURED PROGRAM OF ADVICE ABOUT PHYSICAL ACTIVITY AND HEALTHY DIET. THE PROBLEM WE HAVE WITH MOVE IS WE'VE HAD TROUBLE, MANY PATIENTS GET REFERRED AND GO TO ONE VISIT. THE PROPORTION THAT STICK WITH THE FULL REGIMEN OF COUNSELING IS VERY SMALL. SO WE'VE BEEN MOVING INTO TRYING TO LOOK AT THE USE OF DIGITAL ALTERNATIVES, TELEHEALTH ALTERNATIVES, OTHER COMMUNITY EFFORTS THAT MAY BE MORE EFFECTIVE THAN HOSPITAL BASED BEHAVIORAL INTERVENTION. THIS IS A REMINDER THAT OBESITY IS A PARTICULAR PROBLEM IN CERTAIN GROUPS, SLIGHTLY HIGHER AMONG AFRICAN-AMERICAN WOMEN, THOSE WITH SERIOUS MENTAL ILLNESS, AMONG AMERICAN INDIAN AND ALASKA NATIVE, NATIVE AMERICANS AND PACIFIC ISLANDERS. THIS
SHOWS THAT SUBPOPULATION RACIAL AND ETHNIC SUBPOPULATIONS AND WOMEN WERE MORE LIKELY TO ENGAGE. WE'RE ABLE TO ENGAGE. WE'RE STILL STRUGGLING WITH HOW TO SUSTAIN THEM INTO MEANINGFUL LIFESTYLE INTERVENTIONS. I'M GOING TO WRAP UP NOW. I THINK THESE RECOMMENDATIONS ARE NOTHING NEW TO YOU. A SYSTEM APPROACH WHICH OBVIOUSLY ISN'T AVAILABLE TO EVERYBODY, THAT INCORPORATED PERFORMANCE MEASUREMENT AND DELIVERY SYSTEM DESIGN TEAM BASED CARE CAN BE VERY EFFECTIVE PROVIDING HIGH QUALITY PREVENTIVE CARE REGARDLESS OF PATIENT SUBPOPULATION, WE STILL NEED TO FIGURE OUT HOW TO BUILD WAYS TO BRIDGE THE COMMUNITY, RESOURCES IN THE COMMUNITY TO PROMOTE LONGSTANDING BEHAVIORAL INTERVENTIONS. I WILL CLOSE WITH TWO OBSERVATIONS. ONE IS THAT I THINK WE STILL STRUGGLE TO UNDERSTAND THE VALUE PROPOSITION, AND THAT'S JUST AS TRUE IN A SYSTEM LIKE THE V.A. OR KAISER AS IT IS IN A FEE FOR SERVICE SYSTEM WHERE YOU'RE TRYING TO WORK WITH PAYERS. AT THE END OF THE DAY SOMEONE HAS TO INVEST IN THE SYSTEM CHANGE YOU THINK IS GOING TO WORK AND YOU NEED TO SHOW THE VALUE THAT IT IS. IT'S NOT NEARLY DOLLARS AND CENTS, IT'S ABOUT HOW CAN IT ALIGN WITH YOUR VALUES, IMPROVE PATIENT EXPERIENCE AND IMPROVE PROVIDER EXPERIENCE. THE LAST COMMENT I'LL SAY, ONE THING WE'VE LEARNED IS THAT DEVELOPING A LOT OF SINGLE DISEASE FOCUSED INTERVENTIONS IS A BARRIER TO THAT VALUE PROPOSITION. PEOPLE DO NOT WANT TO HIRE SINGLE DISEASE COACHES, SINGLE DISEASE PROGRAMS. SO WE NEED TO THINK ABOUT HOW DO WE TRAIN COACHES THAT CAN DEAL ACROSS A RANGE OF PREVENTIBLE CONDITIONS BECAUSE IT'S A HARD SELL TO SAY WE'RE GOING TO HAVE SOMEONE WHO DEALS WITH JUST ONE OF THE FOUR OR FIVE CONDITIONS THAT WE DEAL WITH. THAT DOESN'T MEAN WE DON'T NEED SYSTEMS THAT FOCUS ON THEM. BUT THE INDIVIDUALS NEED TO BE MORE PLURIPOTENT. THANK YOU. [APPLAUSE] >> THANK YOU. THIS DID TIE TOGETHER A NUMBER OF THEMES THROUGH THE LAST TWO DAYS. LET'S START WITH QUESTIONS AND COMMENTS FROM THE PANEL. >> THANKS SO MUCH. IT SEEMS LIKE ALL OF YOU ARE WORKING IN CAPITATED PLANS. I WASN'T SURE ABOUT, FROM ALASKA, YOU'RE CAPITATED TOO, CORRECT? YEAH. SO IT'S INTERESTING THAT ALL OUR SPEAKERS COME FROM CAPITATED PLANS POTENTIALLY GLOBAL BUDGETS, HOWEVER YOU WANT TO LOOK AT IT. AND I WONDER IF YOU COULD REFLECT ON THE ADVANTAGES THAT YOU HAVE IN THAT TYPE OF A SYSTEM AND HOW THE INCENTIVES CHANGE IN AN ENVIRONMENT SUCH AS YOURS, COMPARED TO WHAT MANY OF US FACE IN THE REST OF THE COUNTRY WITH FEE FOR SERVICE SYSTEMS. PARTICULARLY FOR THOSE IN ALASKA WHO DID SOME REDESIGN RECENTLY HOW DID — SOMEBODY MADE THE DECISION TO ORGANIZE, IF YOU COULD REFLECT ON WHY THOSE DECISIONS WERE MADE, WHO MOTIVATED, INTERESTED IN YOUR THOUGHTS ABOUT HOW WE POTENTIALLY GET THE REST OF THE COUNTRY ALIGNED WITH ALL OF YOU. >> WE DEFINITELY STARTED OFF WITH A SET BUDGET BECAUSE BASICALLY THE INDIAN HEALTH SERVICE GAVE US THEIR BUDGET BUT WE STARTED LOOKING AT FINANCES. VERY DIFFERENT PERSPECTIVE. WE KNEW WE HAD TO BE SUSTAINABLE AND LOOKED AT WAYS TO IMPROVE THAT SO IN TERMS OF THIRD PARTY BILLING WE GOT VERY GOOD AT THAT AND BILLING AND CODING TO ACTUALLY IMPROVE OUR FINANCIAL OUTLOOK SO TO SPEAK. AND THEN WITH THE AFFORDABLE CARE ACT AND MEDICAID-MEDICARE INCREASES THAT ALSO HELPED. DON'T KNOW WHAT THE FUTURE IS GOING TO BRING BUT THAT HELPED RECENTLY. BUT IN TERMS OF FUNDING BY INDIAN HEALTH SERVICE, IT IS STILL VERY POOR AND HASN'T BEEN MET, BUT IN TERMS OF INDIVIDUAL NEEDS, BUT WE ALSO HAVEN'T BEEN DRIVEN BY THE FINANCIAL IMPACT AT ALL. WE DO WHAT'S BEST. SO LIKE WITH BEHAVIORAL HEALTH CONSULTANTS WE'VE HAD THOSE FOR MANY, MANY YEARS BECAUSE THAT WAS BEST CARE FOR OUR CUSTOMER OWNERS AND SO WE DO WHAT'S BEST AND WE BELIEVE THAT THE PAYOFF IS THERE BECAUSE WE'LL HAVE DECREASED USE OF THE E.R., DECREASED HOSPITALIZATION, SO WE'RE LOOKING AT THE WHOLE SYSTEM OF HEALTH CARE AND HOW TO IMPROVE COSTS FOR THE WHOLE SYSTEM, NOT JUST WITHIN PRIMARY CARE. BECAUSE IT IS A SYSTEM. >> I THINK A CAPITATED SYSTEM, WHAT THE V.A. HAS IS A GLOBAL BUDGET THAT CONGRESS GIVES US. AND THEN IT'S DISTRIBUTED TO FACILITIES BASED ON THEIR PATIENT NEED. SO THAT ALLOWS THEM TO NOT SORT OF REALLY WORRY ABOUT WHO IS DELIVERING THE SERVICE AND WHO CAN BILL FOR IT. AND EXACTLY WHAT IS COVERED. SO IT GIVES I THINK MORE FLEXIBILITY ABOUT DESIGNING A TEAM-BASED CARE AND FIGURING OUT WHO IS GOING TO DO COUNSELING WITHOUT THE KIND OF FEE FOR SERVICE MENTALITY OF WHAT'S COVERED AND WHO HAS TO DELIVER IT FOR IT TO BE COVERED. WE'RE NOT COMPLETELY FREE FROM SOME OF THE ISSUES IN THE SENSE THAT PROVIDER WORK LOAD IS MEASURED AND TRACKED, AND SO WE DID HAVE TO FIGURE OUT HOW TO COUNT TELEHEALTH VISITS AND PROVIDER WORK LOAD, IN THE SAME WAY THAT IT'S A DIFFERENT TYPE OF BARRIER BUT THE SAME WAY WHETHER YOU CAN BILL FOR TELEHEALTH VISIT COUNTS. SO WE ARE STILL TRACKING TO SEE AS WE EXPAND NEW SERVICES, WHETHER IT'S TELEHEALTH, TEXT MESSAGING, THINGS LIKE THAT. DOES THAT ACTUALLY REPLACE OTHER KINDS OF VISITS? DOES IT ADD VALUE? BECAUSE WE, AT THE END OF THE DAY, STILL HAVE TO DELIVER A CERTAIN AMOUNT OF CARE WITH THE CERTAIN NUMBER OF STAFF AND SO WE — EVEN THOUGH WE AREN'T PAYING INDIVIDUAL BILLS FOR THAT WE HAVE TO BE ACCOUNTABLE. >> AND I WOULD JUST ECHO THOSE POINTS THAT, YES, IN THE CAPITATED SYSTEM THERE MIGHT BE SOME DISINCENTIVES THAT FEE FOR SERVICE INTRODUCES THAT WE MIGHT NOT HAVE TO WORRY ABOUT BUT IT DOESN'T MEAN THAT WE DON'T FACE A LOT OF THESE CHALLENGES, LIKE YOU SAID, YOU MIGHT HAVE MORE ABILITY TO DO TEAM-BASED CARE BUT THAT DOESN'T MEAN THAT PHYSICIANS MIGHT NOT STILL BE OVERWHELMED BY THE NUMBER OF SECURE MESSAGES COMING IN, RIGHT? OR WE TALKED YESTERDAY ABOUT SHARED DECISION MAKING AND THAT'S REALLY IMPORTANT, JUST BECAUSE THERE MIGHT BE DIFFERENT INCENTIVES OR DISINCENTIVES TO ENCOURAGE SOMEONE TO HAVE A MAMMOGRAM IF SHE DOESN'T NIECELY NEED IT ACCORDING TO THE TASK FORCE, THAT DOESN'T MEAN A SHARED DECISION-MAKING PROCESS WAS ENGAGED AND INDIVIDUAL PROVIDERS DON'T HAVE STRONG PERSONAL OPINIONS THEY MIGHT BRING TO THE TABLE AS WELL. >> CAN I JUST ADD, MOST STUDIES I PRESENTED WERE NOT IN CAPITATED SYSTEMS, SO THE CASE CAN BE MADE, I WAS A MEDICAL DIRECTOR IN A LARGE INTEGRATED SYSTEM, NOT A CAPITATED SYSTEM. IF HAVE YOU ECONOMY EFFICIENCIRY AND QUALITY THOSE ARE DRIVERS THAT SYSTEMS CAN HELP INDIVIDUAL CLINICS ACCOMPLISH. SO THERE'S NOT NECESSARILY NO MAN'S LAND BY NOT BEING CAPITATED, WORKING PARTICULARLY IN INTEGRATED SYSTEMS, A PITCH FOR THAT. ALSO HEALTH SYSTEMS IN MY STATE MADE A BIG POINT TO LEGISLATORS TO MAKE TELEMEDICINE VISITS A BILLABLE VISIT. AND IT IS IN OUR STATE. SO THERE ARE WAYS TO FIX WHAT'S MAYBE A BARRIER. >> SO THIS IS FOR DAVID ATKINS. I FIND IT REALLY INTERESTING WHAT YOU'RE SAYING ABOUT RURAL, THAT WERE NOT THE SAME DISPARITIES THAT WE SAW IN SO MANY OF OUR OTHER TALKS, ET CETERA. SO, YOU WERE VERY CLEAR ON SAYING, YOU KNOW, WITH V.A. YOU CAN FOCUS ON REDUCING DISPARITIES THAT YOU HAVE CONTROL OVER WITHIN YOUR AGENCY BUT NOT THOSE IN THE COMMUNITY, RIGHT? SO, HOW WOULD YOU — TO WHAT WOULD YOU ATTRIBUTE THE FACT THAT WE'RE NOT SEEING THE SAME RURAL/URBAN DIFFERENCES WE MIGHT EXPECT, EVEN AT THE SAME TIME AS YOU'RE SAYING THERE'S GREAT VARIATION ACROSS THESE 172 HOSPITALS AND CLINICS, ET CETERA? >> SO, I GUESS IT DEPENDS ON WHAT THE SOURCES OF THE RURAL DISPARITIES ARE OUTSIDE THE V.A. IN THE V.A. YOU HAVE RURAL VETERANS, THEY HAVE ACCESS. THEY MAY HAVE TO DRIVE FARTHER, BUT DUE TO OUR EXPANSION OF COMMUNITY-BASED CLINICS THEY PROBABLY CAN GET TO A V.A. PROVIDER EVEN THOUGH IT MAY BE A SINGLE PROVIDER COMMUNITY-BASED OUTPATIENT CLINIC, IN A REASONABLE AMOUNT OF TIME. I THINK THEY HAVE AN ATTACHMENT TO THE V.A. THAT MAYBE OTHER PEOPLE DON'T HAVE TO ANOTHER SYSTEM SO THEY ARE WILLING TO ACTUALLY, WE COMPENSATE PEOPLE FOR DRIVING. SO WE REDUCE THAT FINANCIAL BARRIER. IF SOMEONE HAS TO DRIVE 100 MILES, THEY ACTUALLY — THE V.A. WILL HELP PAY FOR THAT. AND A LOT OF PREVENTION CAN BE DELIVERED AT COMMUNITY-BASED CLINIC, YOU DON'T HAVE TO COME TO A TERTIARY FACILITY. WE'VE DONE A LOT WITH TELEHEALTH. WE PROVIDE A LOT OF TELEHEALTH FROM A HOSPITAL TO CLINIC, IF YOU NEED TO SEE A PSYCHIATRIST OR YOU NEEDED HIV ADVICE ABOUT MEDICATION OR COMPLICATED DIABETES. BUT NOW WE'RE INCREASINGLY DOING TELEHEALTH TO HOME. SO, I THINK IT'S SOME COMBINATION OF THOSE THINGS THAT — BUT IT OBVIOUSLY DEPENDS ON WHAT ARE THE — HOW MUCH OF THE BARRIER IS — I THINK WE'VE BEEN ABLE TO ELIMINATE THE PHYSICAL DISTANCE BARRIER, AS A MAJOR FACTOR. THERE MAY BE OTHER COMMUNITY ISSUES IN RURAL COMMUNITIES THAT CONTRIBUTE TO THOSE DISPARITIES. >> THANK YOU. ON THE RIGHT. >> GOOD AFTERNOON. DO I HAVE PERMISSION TO MAKE SOME GENERAL COMMENTS FROM THE LAST TWO DAYS? >> ABSOLUTELY, TWO MINUTES' WORTH. >> SESSION ONE, ONE OF THE THINGS I WANTED TO BRING UP IS THE NATIONAL PREVENTION STRATEGY. OUR PANELISTS WERE ASKED TO MAKE THE CASE FOR PREVENTION, I THINK THE NATIONAL PREVENTION STRATEGY MAKES THE CASE. A SPEAKER MADE A COMMENT ABOUT THE STRENGTH-BASED APPROACH. I THINK ASSETS BASED COMMUNITY DEVELOPMENT HAS BEEN UNDERUTILIZED IN PROMOTING HEALTH EQUITY. THIS APPROACH HAS BEEN USED
IN FAITH COMMUNITIES, [ NO AUDIO ] BECAUSE THERE ARE GOING TO BE — WE WANT PEOPLE WHO ARE NATIVE TO THE COMMUNITIES, WE'RE GOING TO HAVE CROSS-CULTURAL BRIDGES BETWEEN OUR COMMUNITIES SO WE NEED TO START INCORPORATING CULTURAL HUMILITY TRAINING. THE OTHER THING I WOULD LIKE TO MENTION IS IMPORTANCE OF INTERPROFESSIONAL EDUCATION FOR PRE-SERVICE PROFESSIONALS AND ALSO CONTINUING EDUCATION FOR THOSE WHO ARE IN PRACTICE. SO THAT WE CAN STRENGTHEN CONNECTION BETWEEN PRIME CARRY CARE PROVIDERS AND FOLKS TRAINED LIKE ME AS COMMUNITY EDUCATION SPECIALISTS. THAT'S IT FOR COMMENTS. I THANK THE SPEAKERS FOR THE LAST TWO DAYS, I'M A PUBLIC HEALTH KID, THAT'S WHY I'M BRINGING UP THE COMMUNITY THINGS. >> THANK YOU VERY MUCH. COMMENTS FROM THE GROUP? THANK YOU. WE HAVE A COMMENT FROM THE WEB. >> SO DENTAL SERVICES ARE UNDERUTILIZED, THERE ARE BARRIERS INCLUDING LACK OF INSURANCE AND OUT-OF-POCKET COSTS. THIS PERSON WOULD LIKE TO HEAR ABOUT STRATEGIES ABOUT INTERVENTION, BUNDLING, TO ENHANCE UPTAKE OF DENTAL SERVICES, ANY SUGGESTIONS WOULD BE APPRECIATED. >> ONE OF THE THINGS I WANTED TO MENTION, IT WAS ON THE SLIDE, I DON'T KNOW IF WE HAVE TIME IS ALASKA IS SUCCESSFUL IN CREATING A DENTAL HEALTH AID PROGRAM, NOT WELL RECEIVED BY THE PROFESSIONAL DENTAL SOCIETIES BUT ONCE PEOPLE STARTED THINKING THROUGH MOST DENTISTS DON'T WANT TO FLY TO RURAL ALASKA TO PROVIDE CARE. AND SO THERE'S A REAL PRAGMATIC GAP. DENTAL HEALTH AID PROGRAM HAS BEEN VERY SUCCESSFUL AND THERE ARE VERY CLEAR DENTAL-RELATED DISPARITIES IN THE ALASKA NATIVE POPULATION, SO WE'LL SEE WHAT THAT IMPACT IS OVER TIME. >> COULD YOU SAY WHAT ARE THE SERVICES THAT THE AIDS ARE ABLE TO PROVIDE? >> THEY — DONNA CAN HELP. I KNOW THEY CAN DO — I THINK GENERAL FILLINGS, THEY CAN DO CLEANINGS AND FLUORIDE. >> THAT'S GREAT TO HEAR. I WANTED TO SAY AT KAISER PERMANENTE NORTHWEST THEY HAVE DENTAL AS PART OF THE SERVICES THEY PROVIDE. THAT'S NOT THE REGION I'M AT SO I CAN'T GIVE DATA BUT AT LEAST ONE REGION IS DOING THAT, SPEAKING FOR MYSELF PERSONALLY I THINK IT'S GREAT. WE'RE TALKING ABOUT DISINCENTIVES FOR FEE FOR SERVICE, CAPITATED PAYMENT, IMPORTANCE OF PREVENTION, I THINK DENTAL HEALTH IS A FRONTIER THAT WE SHOULD DIG INTO. THAT WASN'T THE FOCUS BUT THAT POINT IS VERY WELL TAKEN AND WE CAN AND SHOULD DO MORE >> I'LL SAY THE V.A. PROVIDES DENTAL SERVICES TO SOME OF ITS VETERANS, BUT IT'S MORE LIMITED THAN MEDICAL COVERAGE. WE STRUGGLE WITH THAT. I'LL COMMENT THAT WE ARE LEARNING MORE ABOUT THE LINK BETWEEN DENTAL HEALTH AND OTHER PHYSICAL HEALTH, WE HAVE A STUDY LOOKING AT DENTAL CLEANING AS A WAY OF REDUCING PNEUMONIA, COMMUNITY-ACQUIRED PNEUMONIA. AND SO WE'RE — THERE HAVE BEEN SORT OF PENDULUM SWINGING ABOUT THE RELATIONSHIP BETWEEN DENTAL DISEASE AND CARDIOVASCULAR DISEASE. >> GOOD MORNING. MICHAEL PARCHMAN, KAISER PERMANENTE OF WASHINGTON. A STIMULATING SESSION, CREATING THOUGHTS. I'LL TRY NOT TO RAMBLE BUT IT SEEMS LIKE IF WE'RE TALKING ABOUT HEALTH SYSTEM INTERVENTIONS THAT ADDRESS DISPARITIES, IN PREVENTIVE SERVICES DELIVERY, WE REALLY ARE TALKING ABOUT INTERVENTIONS AT THE LEVEL OF THE ORGANIZATION, IN TERMS OF HOW CARE IS ORGANIZED AND DELIVERED BY THE ORGANIZATION. THERE IS A FIELD OF ORGANIZATIONAL SCIENCE THAT HELPS US UNDERSTAND HOW ORGANIZATIONS CHANGE AND LEARN AND ADRAFT AND DO THINGS DIFFERENTLY, I WONDERED, DO YOU HAVE ANY COMMENTS OR THOUGHTS ABOUT RELEVANCE OF LEARNING FROM ORGANIZATIONAL SCIENCE EWEI CAN IMPORT TO ADDRESS DISPARITIES, I WON'T PUT DAVID ON THE SPOT BECAUSE THERE ARE HEALTH SERVICES RESEARCH PROGRAMS THAT EXPLICITLY HAVE ORGANIZATIONAL SCIENCES, SCIENTISTS IN THEM AS FAR AS THE V.A. IS CONCERNED. THE V.A. HAS DONE WORK IN THIS AREA BUT I WONDER IF YOU HAVE OTHER THOUGHTS WHAT WE CAN LEARN FROM ORGANIZATIONAL SCIENCE THAT WOULD INFORM THIS ISSUE OF HOW WE DO HEALTH SYSTEM INTERVENTIONS TO ADDRESS DISPARITIES. >> SO I'LL TAKE A FIRST CRACK. WE DO HAVE SOME ORGANIZATIONAL RESEARCH I WOULD SAY IT'S OUR THINNEST PART OF OUR BENCH. I THINK YOU HAVE YOUR FINGER ON AN IMPORTANT ISSUE. I DO THINK IT'S IMPORTANT, AND I WOULD SAY THAT THE PATIENT CENTERED MEDICAL HOME IS THE BEST EXAMPLE OF FIXING A TRAP AND THE RUBE GOLDBERG APPARATUS OF SOMEONE OWNS MAMMOGRAPHY AND SCREENING AND SOMEONE ELSE OWNS DEPRESSION SCREENING, AND SO I THINK THE MOVE TOWARDS PATIENT-CENTERED MEDICAL HOME AND IT MAY BE SIMILAR IN BOTH OF YOUR ORGANIZATIONS WAS IN PART TO TRY TO BRING A LITTLE MORE COHERENCE BUT I THINK WE STILL HAVE THE UNDERLYING PROBLEM OF HOW DO WE MAKE THE MOST OF OUR RESOURCES TO GO THE FARTHEST AROUND A CORE SET OF HIGH PRIORITY PREVENTIVE CARE, AND HOW DO WE — WHO OWNS THE COORDINATION OF THAT, AND SO I THINK WE STILL HAVE A LOT TO LEARN ABOUT — ESPECIALLY AS WE GET INTO SMARTPHONES AND TELEHEALTH, THERE'S POTENTIAL FOR EVEN MORE FRAGMENTATION AS TO WHO OWNS THAT BECAUSE I WORRY A LITTLE BIT ABOUT WE'RE ALREADY AT THE SORT OF STRETCHING OUR PRIMARY CARE TEAMS TO THE BREAKING POINT AND IF YOU LAYER ON NOW YOU HAVE TO DO TELEHEALTH VISITS TO YOUR PATIENTS AND YOU HAVE TO MANAGE THE SMARTPHONE COMMUNICATION, AND THE SECURE MESSAGING, THAT UNLESS YOU GROW THE CAPACITY OF THOSE TEAMS TO HANDLE THAT YOU MAY END UP REALLY BURNING OUT PEOPLE. WE'RE ALREADY STARTING TO SEE SOME CONCERNS IN TRANSFORMATION TO PATIENT CENTERED MEDICAL HOME IN SOLVING ONE PROBLEM WE'RE CONTRIBUTING TO ANOTHER. >> WE USE BEST PRACTICES ACROSS THE BOARD WITHIN OUR SYSTEM. SO COMPLEXITY SCIENCE WAS A BIG THING WE LOOKED AT. WE ALWAYS LOOK AT WHAT WE HAVE OPERATING PRINCIPLES BASED ON CULTURAL VALUES AND WHAT CUSTOMER OWNERS WANT AND WE USE BEST PRACTICES AND LAYER OVER THAT. ALWAYS OUR GUIDING PRINCIPLES ARE THE OPERATING PRINCIPLES MISSION ENVISIONED BUT WE USE OTHER THINGS. IF SOMEBODY HAS A GREAT IDEA WE'LL LOOK AT THAT IDEA AND WE'LL ADAPT IT TO FALL WITHIN OUR OPERATING PRINCIPLES. SO WE'RE CONSTANTLY USING THAT STYLE. ONE OF THE THINGS WE SAY WHEN PEOPLE COME TO OUR ORGANIZATION IS THAT IF YOU DON'T LIKE CHANGE, THIS ISN'T A GOOD FIT FOR YOU BECAUSE WE'RE CONSTANTLY CHANGING. WE ALWAYS WANT TO BE IMPROVING. WE'RE ENGAGED WITH CUSTOMER OWNERS CONTINUOUSLY AND ASKING THEM WHAT THEY WANT, AND HOW TO IMPROVE IT, AND BASED ON THAT INPUT AND BASED ON OUTCOME MEASURES AND BEST PRACTICES, WE'VE ACTUALLY INTEGRATED IMPROVEMENT THROUGHOUT THE ENTIRE ORGANIZATION AND SO WE HAVE IMPROVEMENT SPECIALISTS WHO ARE CONSTANTLY WORKING ON THINGS AND JUGGLING THINGS AND TRYING TO FIGURE OUT HOW TO DO IT BEST. >> THAT'S AMAZING. THIS IS THE IMPLEMENTATION PIECE OF THE CHALLENGE THAT YOU'RE TACKLING. AND WE KNOW HALF OF IMPLEMENTATION EFFORTS IN ORGANIZATIONS FAIL, IN GENERAL. SO I'M EXCITED THAT YOU GUYS ARE EMBRACING SORT OF THE COMPLEXITY THEORY FROM ORGANIZATIONAL SCIENCE INTO HOW YOU DO IMPLEMENTATION, BUT I THINK THAT'S A CHALLENGE FOR RESEARCH IN TERMS OF HOW WE DO RESEARCH ON THESE ISSUES, IN TERMS OF PUTTING PREVENTION INTO PRACTICE AND ADDRESSING THAT. SO I WOULD ENCOURAGE US TO THINK ABOUT HOW WE MIGHT BE ABLE TO THINK ABOUT THE FIELD OF IMPLEMENTATION SCIENCE AND THESE ORGANIZATIONAL SCIENCE ISSUES IN TERMS OF HOW WE DO RESEARCH ON THIS TO IMPROVE OUR UNDERSTANDING OF HOW TO DO IT BETTER. SO THANK YOU VERY MUCH. >> IF THERE'S A MOMENT, I'LL QUICKLY ADD TO THE POINTS YOU MADE AND ALL THE GREAT POINTS JUST MADE HERE THAT IT IS TRUE THAT WE'RE OFTEN AS HEALTH SERVICES RESEARCHERS NOT — WE DON'T RECEIVE TRAINING IN HEALTHCARE MANAGEMENT, THOSE ARE TWO DIFFERENT DEPARTMENTS AT MOST SCHOOLS. THEY DON'T USUALLY GET TOGETHER. I WOULD SAY WHEN I THINK ABOUT LEARNING HEALTH CARE SYSTEMS AND THE POINT THAT I MADE EARLIER ABOUT HOW WE AS RESEARCHERS HAVE TO BE HUMBLE HOW MUCH WE HAVE TO LEARN WE'RE WORKING WITH HEALTHCARE SYSTEM LEADERS THAT KNOW A LOT ABOUT HOW TO RUN A COMPLEX ORGANIZATION AND MAYBE WE SHOULD LEARN FROM THEM, CERTAINLY BRINGING THE BEST PRINCIPLES TO THE FIELD AS WELL BUT WE ALSO NEED TO LEARN FROM PEOPLE WHO ACTUALLY DO THIS FOR A LIVING. >> THANK YOU. A QUESTION FOLLOWING ON RESEARCH QUESTION AROUND ENGAGED RESEARCH. THIS TYPE OF RESEARCH THAT WE HEARD IN THE QUESTION NUMBER 5 IS GENERALLY CONDUCTED AT THE SYSTEMS LEVEL, AND WHILE THERE'S IRB OVERSIGHT, THE PATIENTS ARE NOT INDIVIDUALLY CONSENTED BECAUSE RANDOMIZATION OCCURS AT THE AREA, AND OUR SOLUTION TO THAT HAS BEEN TO HAVE STAKEHOLDER HOPEFULLY A PATIENT OR CONSUMER OF THE SERVICES ENGAGED IN RESEARCH FROM THE BEGINNING AND CLASSIC STAKEHOLDER ENGAGED RESEARCH. YET SOMETIMES, I'M INTERESTED IN DR. DILLARD'S VIEW ON THIS, THAT STAKEHOLDER– THEY ARE RELUCTANT TO SAY I REPRESENT MY COMMUNITY BECAUSE NOBODY ELECTED THEM, WE FOUND THEM AND HOPEFULLY TRAINED THEM YET IT SOUNDS LIKE IN YOUR ORGANIZATIONS THAT'S DIFFERENT WHERE YOU DO HAVE TRUE REPRESENTATION BECAUSE OF THE NATURE OF THE COMMUNITIES. AND MY GUESS IS EVERYBODY WHO DOES THIS TYPE OF WORK ADDRESSES THESE SOMEWHAT DIFFERENTLY, WHILE THERE IS SOME GENERAL GUIDANCE AND A LOT WRITTEN OUT THERE, WE HAVEN'T STANDARDIZED THIS, I'D BE INTERESTED IN YOUR THOUGHTS. >> I DO THINK YOU BRING UP A REALLY GOOD POINT. WE DO IS A LOT OF QUALITATIVE RESEARCH. IT'S VERY COMMON FOR PEOPLE TO SAY SOMETHING ALONG THE LINES WITH I'M GOING TO SHARE MY OPINION, I WANT TO MAKE SURE THIS DOESN'T GET RECORDED WHAT ALL ALASKA NATIVE PEOPLE THINK. PEOPLE ARE COGNIZANT OF THAT. ONE THING WE TRY TO DO IS BUILD IN THE ENGAGEMENT IT'S A MULTIPLE LEVELS, IN SOME WAYS IT'S INFUSED INTO OUR SYSTEM BECAUSE OVER 50% OF PEOPLE WHO WORK FOR SOUTHCENTRAL FOUNDATION IS HIGHER, 60% ALASKA NATIVE, AMERICAN INDIAN. I TALKED ABOUT THAT LONGER START-UP PHASE, WHEN WE HAVE A RESEARCH IDEA OR WE TAKE OUR RESEARCH IDEAS FROM PROVIDERS, CUSTOMER OWNERS, WE SPEND A LOT OF TIME HAVING DISCUSSIONS ABOUT WOULD THIS BE A USEFUL AREA FOR EXPLORATION. IF SO, HOW. AND TO REALLY GET INTO SOME OF THOSE SPECIFICS, WE'VE ASKED OUR CUSTOMER OWNERS FOR INSTANCE ABOUT RANDOMIZATION, LIKE WHEN WOULD THAT BE ACCEPTABLE OR NOT ACCEPTABLE, SO WE SPEND A LOT OF TIME BUT IT'S VERY TIME CONSUMING AND ONE OF THE THINGS THAT WE HAVE LEARNED ABOUT VIEWS IS OF ALASKA NATIVE PEOPLE, SO IT DEPENDS ON SO MANY DIFFERENT FACTORS AND SO FOR INSTANCE GENETIC RESEARCH MIGHT BE ACCEPTABLE IN SOME INSTANCES BUT NOT OTHERS, AND IT'S GOING TO BE FOR SOME ALASKA NATIVE PEOPLE, NOT OTHER ALASKA NATIVE PEOPLE, SO YOU'RE NOT GOING TO FIND KIND OF THIS ONE VIEW BUT YOU'RE REALLY TRYING TO WORK AND FIND KIND OF AN APPROACH AT LEAST THAT ADDRESSES MOST OF PEOPLE'S MAJOR CONCERNS AND REALLY THINK IT MEANS A LOT TO PEOPLE LIKE WE HEAR FEEDBACK ALL THE TIME, CUSTOMER OWNERS LOVE BEING ASKED THEIR OPINION. THEY JUST LOVE THE ENGAGEMENT PROCESS. THEY AND GET THERE'S COMPROMISES THAT THE IDEAL STUDY PROBABLY CAN'T REALISTICALLY BE DONE, SO ONCE AGAIN I THINK THEY ARE WILLING TO ENGAGE IN THESE CONVERSATIONS WITH US ABOUT — SO THESE ARE CONSIDERATIONS FROM OUR END, YOU KNOW, YOU MAY RECOMMEND STUDYING CERVICAL, COLORECTAL CANCER, DIABETES, ET CETERA. WE CAN'T GET THAT FUNDED SO HOW CAN WE MAKE THIS FIGURE AND FIGURE OUT THOSE SOLUTIONS. >> THANK YOU. >> YES. >> THANK YOU. MY NAME IS LEE YOUNG. THANK YOU FOR THE EFFORT IN THE AREA TO PROMOTE PEOPLE'S HEALTH AND HOW TO PREVENT IT. AS A FEDERAL RESEARCHER MYSELF, I FIND ANOTHER PROBLEM IN DATA ITSELF, A PROBLEM IN GOVERNMENT EMPLOYEE ON DIFFERENT LEVELS FROM LOCAL TO FEDERAL, AND WANT TO SEE ABOUT GLOBAL TASK, THIS EXTENSION, AND THINKING MYSELF WILL OBSERVE A LOT OF PROBLEM HOW WHEN FELT PROFICIENT, ACTUALLY NOT, MEDICINE, MEDICAL FIELD, BUT ALSO SOCIAL WORKERS AND EVERYTHING, PSYCHOLOGISTS, EVEN THE STAFF, GIVE YOU SOME EXAMPLES THERE WILL BE MISDIAGNOSIS, UNJUST DIAGNOSIS, POOR PEOPLE (INDISCERNIBLE) HEALTH FACILITIES, WHETHER THAT'S HOSPITAL OR MENTAL INSTITUTION OR REHAB BEHAVIORS, INSTITUTE, THE PROBLEM IS THEY USE THE DIABETES, NOT TO EAT SOMETHING SWEET, WHAT THEY ARE DOING IS UNJUST MEASUREMENT OF THE — EVERYTHING THEY WANT TO RECORD BUT THEY DON'T WANT TO GIVE PATIENTS MEDICAL RECORD SOMETHING, TREATMENT RECORD. AND WHAT THEY ARE DOING IS (INDISCERNIBLE) MEASUREMENT AND ALSO RECORD OF FALSE RECORD AND PATIENT VERY HUGE (INDISCERNIBLE) EXTRA SWEET AND STUFF, AND MEASURE TIMING WHETHER AFTER OR BEFORE AND DENY PATIENT TO PARTICIPATE ACTIVITIES TO SEE THE PATIENT CANNOT DO ANYTHING AT ALL. >> THANK YOU. >> ALL THIS TYPE OF THINGS THERE'S NO WAY THAT YOU WANT TO REPORT AND GET THE REAL RESOLUTION. AND SO — >> THANK YOU. >> PUT PATIENT LIFE IN VERY BIG DANGER AND THEY EVEN CAN DEPRIVE SPOUSE OR CHILDRENS RIGHT TO TAKE CARE OF PATIENTS. >> OKAY. THANK YOU, MA'AM. >> WE CAN WORK TOGETHER, WE GOT TO GET RID OF MISUSE, ABUSE OF SYSTEM, OTHERWISE IF YOU WANT TO DO RESEARCH NO MATTER HOW GOOD EFFORT THERE'S ALWAYS SUBSTITUTE OF FALSE RECORD. >> OKAY, THANK YOU. >> THANK YOU. >> MAYBE OUR PANELISTS COULD TALK ABOUT THE SHARING OF MEDICAL RECORDS. DIFFERENT SYSTEMS HAVE DIFFERENT CUSTOMS AND RULES, EVEN WITHIN THE CONSTRAINTS OF HIPAA ON THAT ABOUT NEEDS TO KNOW WHAT. I KNOW IT'S DIFFERENT IN RURAL AREAS. INTERESTED IN YOUR THOUGHTS. THANK YOU FOR THAT COMMENT. >> ONE OF THE THINGS THAT WE'VE WORKED AT IS HAVING AS MANY TRIBAL ORGANIZATIONS WITHIN THE STATE OF ALASKA HAVE THE SAME HEALTH RECORD. WE HAVE CERNER, A LOT OF TRIBAL ORGANIZATIONS HAVE CERNER, SO WE CAN ACTUALLY SEE THE MEDICAL RECORD FROM DIFFERENT AREAS ACROSS THE STATE. SO SOMEBODY WHO COMES FROM NOME, OUTSIDE OUR SERVICE AREA, WE CAN SEE THE MEDICAL RECORD FOR THAT PERSON. AND SO WE SHARE PRETTY READILY THAT INFORMATION BASICALLY BECAUSE IT'S CULTURALLY APPROPRIATE BECAUSE PEOPLE ARE NOMADIC IN ALASKA AND TRAVEL SO IT'S NO BIG DEAL TO GET CARE IN DIFFERENT AREAS SO WE'VE ADAPTED. WE HAVE ALL SORTS OF LIMITS ON THAT IN TERMS OF LIKE DATA SHARING AND DON'T ALLOW JUST EVERYBODY, ALL THE PROVIDERS TO ACCESS THE HEALTHCARE SYSTEM IN RIGHT ORDERS SO THERE'S ALL SORTS OF SAFEGUARDS THAT WE BUILD IN BUT THE ACTUAL INFORMATION ITSELF IS THERE, AND THEN THE OTHER LIMITATION IS IF THERE'S 42 CFR SERVICES WE CAN'T SEE THOSE. THAT CAN BE A BIG ISSUE AND YOU PROBABLY ALL KNOW THAT AS WE ARE DEALING WITH LIKE DETOX SYSTEMS AND OPIOIDS AND NOT SHARING INFORMATION BUT IT DEFINITELY IMPACTS LET, YOU KNOW, THERE'S ISSUES WITH THAT. BUT IN GENERAL WE TRY TO HAVE AS MUCH SHARING AS POSSIBLE. >> IF I THINK ONE OF OUR POINTS WAS ABOUT INACCURATE INFORMATION, SO ONE ONE THING WE'VE DONE IS PATIENTS NOW THROUGH OPEN NOTES CAN SEE THEIR ENTIRE RECORD, INCLUDING THE NOTES, AND SO IF THEY SEE SOMETHING IN THE RECORD THAT THEY DON'T THINK IS RIGHT, THEN THEY HAVE THE ABILITY TO SORT OF RAISE THAT. THE OTHER IS THAT WE HAVE SOMETHING CALLED BLUE BUTTON, WHICH ALLOWS PATIENTS TO DOWNLOAD SORT OF A COPY OF THEIR PROBLEM LIST AND MEDICATIONS AND PROCEDURES SO THAT THEY CAN TAKE THAT IF THEY ARE SEEING SOMEBODY ELSE. WE HAVE A TERRIBLE PROBLEM WITH SHARING RECORDS OUTSIDE OUR SYSTEM. AND IT'S — WE STILL HAVEN'T SOLVED WHAT SHOULD HAVE BEEN A SOLVABLE PROBLEM OF DoD AND V.A. RECORDS MERGING SEAMLESSLY. SO I DON'T THINK WE'VE SOLVED, I'M NOT ANY SYSTEM HAS REALLY SOLVED THE PROBLEM OF SHARING ACROSS SYSTEMS, ACROSS DIFFERENT EHRs, BUT I DO THINK ABILITY TO BRING A COPY OF YOUR RECORD WHEN YOU'RE MIGRATING TO SYSTEMS, WE HAVE THE ADVANTAGE THAT WE HAVE A NATIONAL RECORD AND CAN EASILY SEE CARE DELIVERED ANYWHERE IN OUR SYSTEM. BUT STILL STRUGGLE IF THEY HAVE GONE TO, YOU KNOW, — HAD A MEDICARE HOSPITALIZATION OUTSIDEED V.A. AND COME FOR PRIMARY CARE FOLLOW-UP, THAT RECORD IS PROBABLY IN SOME PDF BURIED IN THE ELECTRONIC HEALTH RECORD THAT CLINICIAN HAS TO SEARCH THROUGH AND HOPEFULLY FIND THE RIGHT DOCUMENT. >> THANK YOU. >> YES, WE FACE ALL THOSE CHALLENGES YOU JUST POINTED OUT. THE SAME ADVANTAGES AND SAME CHALLENGES. >> ANY LAST QUESTIONS OR COMMENTS FROM THE PANEL? THANK YOU. I WANT TO THANK ALL OF YOU. THIS REALLY WAS A GOOD SUMMARY OF THE LAST TWO DAYS, BRINGING IT TOGETHER AT THE SYSTEMS LEVEL. NEXT UP IS THE INTRODUCTION OF OUR WRAP-UP SPEAKER. THANK YOU. [APPLAUSE] >> I WANT TO THANK YOU FOR BEING AN ATTENTIVE AND ENGAGED AUDIENCE, ALSO TO LET YOU KNOW WE HAVE ABOUT 100 PEOPLE WHO ARE ON THE VIDEOCAST RIGHT NOW SO WE HAVE A VIRTUAL AUDIENCE AS WELL AS THE AUDIENCE THAT'S IN THE ROOM. I'M THE TEAM LEAD FOR THE PATHWAYS TO PREVENTION PROGRAM IN THE NIH OFFICE OF DISEASE PREVENTION, AND YOU REPRESENTING THE NIH PLANNING GROUP FOR THIS WORKSHOP. SO THE PLANNING GROUP HAD DECIDED TO OPEN THE WORKSHOP WITH A PANEL DISCUSSION ON CATALYZING HELD EQUITY INNOVATION AND TO CLOSE WITH A KEYNOTE SPEAKER WHO COULD LEAVE US WITH SOME FOOD FOR THOUGHT, SOME IDEAS AND REFLECTIONS NOT ALREADY PRESENTED AT THE WORKSHOP. OUR TOP CHOICE FOR THE KEYNOTE CLOSING PRESENTER WAS DR. JOHN AYANIAN, AND WE WERE DELIGHTED THAT HE ACCEPTED OUR INVITATON TO DO THE CLOSING PRESENTATION. JOHN IS A PRIMARY CARE PHYSICIAN AND HEALTH SERVICES RESEARCHER WHO CURRENTLY DIRECTS INSTITUTE FOR HEALTHCARE POLL POLICY AND INNOVATION, UNIVERSITY OF MICHIGAN, ONE OF THE LARGEST HEALTH POLICY RESEARCHERS IN THE WORLD. DR. AYANIAN HAD A DISTINGUISHED CAREER AS INVESTIGATOR, ASSESSING EFFECTS OF RACE, ETHNICITY, GENDER IN INSURANCE COVERAGE, ACCESS TO CARE AND HEALTH OUTCOMES. HE HAS A LONGSTANDING COMMITMENT TO REDUCING HEALTH DISPARITIES, HE HAS PUBLISHED SEVERAL INNOVATIVE AND INFLUENTIAL STUDIES ON THIS TOPIC, IN HIGH IMPACT JOURNALS. HE CURRENTLY LEADS A TEAM OF 15 FACULTY MEMBERS AT THE UNIVERSITY OF MICHIGAN IN A LONG-TERM EVALUATION OF THE HEALTHY MICHIGAN PLAN WHICH HAS EXPANDED MEDICAID COVERAGE TO OVER 650,000 ADULTS IN THE STATE OF MICHIGAN. SO I'M VERY DELIGHTED TO BE ABLE TO WELCOME DR. AYANIAN WHO WILL SHARE HIS THOUGHTS ON FUTURE DIRECTIONS FOR ACHIEVING HEALTH EQUITY AND PREVENTIVE SERVICES. >> THANK YOU FOR THE PRODUCTION. IT'S A PLEASURE AND HONOR TO SPEAK TO THE PANEL AND PARTICIPANTS IN THE AUDIENCE, IT'S BEEN A FASCINATING TWO DAYS OF INSIGHT ABOUT THE RESEARCH TO PROMOTE GREATER HEALTH EQUITY IN MY REMARKS, I'D LIKE TO BUILD ON EVERYTHING WE HEARD AND TAKE US TO A LEVEL OF OVERARCHING TO THINK ABOUT SOME OF THE POLICY CONTEXT FOR MUCH OF THE WORK THAT'S BEEN PRESENTED OVER THE PAST DAY AND A HALF. DAVID ATKINS MENTIONED HE WAS THE CLOSER, THAT MAKES ME THE RELIEF PITCHER COMING OUT OF THE BULLPEN WITH THE GAME TIED AND HOPEFULLY GET US TO THE FINISH. SO LIKE OTHER SPEAKERS, I HAVE NO CONFLICTS TO DISCLOSE. I WANT TO HIGHLIGHT THREE THEMES. THE FIRST IS TO TALK ABOUT THIS BROADER CONTEXT OF THE IMPLICATIONS OF THE AFFORDABLE CARE ACT FOR HEALTH EQUITY, PARTICULARLY FOR ACHIEVING GREATER HEALTH EQUITY IN PREVENTIVE SERVICES. SECONDLY, I WANT TO COMMENT ON SOME CITY-WIDE INTERVENTIONS IN CHICAGO AND NEW YORK THAT HAVE I THINK MADE SIGNIFICANT STRIDES IN PROMOTING HEALTH EQUITY IN CANCER SCREENING. AND THEN FINALLY MY THIRD THEME IS TO TALK ABOUT MEDICARE ADVANTAGE AS A MODEL FOR EQUITY SERVICES, AND THIS THIRD THEME BUILDS CLOSELY ON THE LAST PANEL THAT TALKED ABOUT ORGANIZATIONAL AND SYSTEMS APPROACHES TO ACHIEVING GREATER HEALTH EQUITY IN PREVENTIBLE SERVICES. THE AFFORDABLE CARE ACT WAS FOCUSED ON EXPANDING INSURANCE COVERAGE FOR POPULATIONS WITHOUT HIGH RATES OF INSURANCE BEFORE 2010. ONE IMPORTANT COMPONENT WAS EXPANSION OF MEDICAID FOR LOW INCOME ADULTS. SECOND WAS SUBSIDIZED INSURANCE COVERAGE FOR MIDDLE NOOK ADULTS THROUGH THE MARKET PLAN EXCHANGE, BUILT ON A FOUNDATION OF INDIVIDUAL MANDATES, THE EXPECTATION IF PEOPLE WOULD BE OFFERED HELD INSURANCE REGARDLESS OF THEIR HEALTH, PARTICULARLY PRIVATE INSURANCE MARKET, WE NEEDED INDIVIDUAL MANDATE TO REQUIRE PEOPLE TO PARTICIPATE IN THAT MARKET. THERE WERE IMPORTANT HEALTH INSURANCE MARKET REFORMS. WE KNOW SINCE DECEMBER OF 2017 THE PENALTY THAT GOES WITH THE INDIVIDUAL MANDATE, THE TAX PENALTY HAS BEEN ELIMINATED. BUT PROBABLY IN THE PAST YEAR AND A HALF WE HAVEN'T SEEN AS MUCH DECLINE IN INSURANCE COVERAGE SUGGESTING THE MANDATE WAS USEFUL BUT NOT NECESSARILY ESSENTIAL FOR KEEPING PEOPLE INSURED IN THE UNITED STATES. I THINK FOR THE PURPOSES OF OUR WORKSHOP HERE, TALKING ABOUT PREVENTIVE SERVICES, THE FACT THAT COST SHARING WAS ELIMINATED FOR EFFECTIVE PREVENTIVE SERVICES THROUGH THE AFFORDABLE CARE ACT IS AN IMPORTANT COMPONENT THAT ALL THE RESEARCH THAT WE'VE BEEN DISCUSSING ARE IMPORTANT TO UNDERSTAND. SO IF WE THINK WHAT'S HAPPENED TO INSURANCE COVERAGE IN THE UNITED STATES, HOW THAT AFFECTED PREEXISTING DISPARITIES, EFFORTS TO ACHIEVE HEALTH EQUITY, IF WE LOOK AT TRENDS IN INSURANCE COVERAGE BY INCOME OR POVERTY STATUS THIS GRAPH SHOWS THE PAST DECADE SINCE THE ACA WAS ENACTEDDED IN 2010 BASED ON DATA FROM NATIONAL HEALTH INTERVIEW SURVEY. BACK IN 2010, THOSE WHO WERE POOR LIVING BELOW POVERTY LEVEL IN TERMS OF HOUSEHOLD INCOME WERE NEAR POOR, BETWEEN ONE AND TWO TIMES THE POVERTY LEVEL ARE HIGHER RATES OF, OVER 40%, RELATIVE OF 12 TO 14% ABOVE 200% OF THE POVERTY LEVEL, GREATEST DECLINE OVER EIGHT TO NINE YEARS IN RATES OF UNINSURANCE AMONG THOSE BELOW 200% OF THE POVERTY LEVEL, LOW TO MID-20% RANGE, SMALLER DECLINES FOR THOSE WITH HIGHER INCOMES. WE THINK ABOUT RACIAL AND ETHNIC DISPARITIES, GOING BACK TO 2010,HISPANICS IN THE UNITED STATES HAD HIGHEST RATES OF UNINSURANCE OVER 40%, FOLLOWED BY NON-HIS PANIC BLACK AMERICAN, BETWEEN 25 AND 30%, AND LOWER RATES, ABOUT 20% FOR ASIAN-AMERICANS ADULTS AS WELL AS LOWER RATES OF 15% FOR NON-HISPANIC WHITES. THOSE RATES HAVE COME DOWN SUBSTANTIALLY IN ALL GROUPS BUT ABSOLUTE MAGNITUDE OF THE REDUCTION HAS BEEN GREATEST FOR HISPANIC AND NON-HIS PANIC BLACK ADULTS. HOW IS THAT TRANSLATED INTO ACCESS TO CARE? INSURANCE BY ITSELF DOESN'T NECESSARILY PROMOTE HEALTH EQUITY UNLESS IT PROMOTES BETTER ACCESS TO PREVENTIVE IT WASES. FROM 2013 TO 2015 THE BLACK-WHITE DISPARITY AND HISPANIC WHITE DECLINED, MUCH SMALLER THAN DECLINES IN ABSOLUTE RATES OF INSURANCE COVERAGE SUGGESTING WE'RE JUST BEGINNING ON THE PATHWAY OF TRANSLATING INTO EXPANDED ACCESS TO PRIMARY CARE AND EFFECT OF PRIMARY SERVICES WE EXPECT WOULD FOLLOW. THIS VERY MUCH FOLLOWS SOME REMARKS WE HEARD YESTERDAY FROM CAROL MANGIONE, TRANSITION FROM EFFECTIVE PRIMARY CARE TO PREVENTIVE SERVICES FOR CANCER SCREENING AND RELATED TO CARDIOVASCULAR DISEASE. SO ONE OF THE IMPORTANT CHALLENGES WE FACE FROM EQUITY STAND POINT IS NOT ALL STATES EXPANDED MEDICAID. WHEN THE ACA WAS EXACTED IT WAS EXPECTED ALL STATES WOULD EXPAND MEDICAID BECAUSE THERE WAS A PENALTY STATES COULD LOSE TRADITIONAL MEDICAID FUNDING BUT IN 2012 WHEN THE CONSTITUTIONALITY OF THE AFFORDABLE CARE ACT WAS QUESTIONED AND CHALLENGED IN THE SUPREME COURT, THE SUPREME COURT RULED THE LAW WAS CONSTITUTIONAL BUT EXPANSION OF MEDICAID AND REQUIREMENT FOR STATES TO EXPAND MEDICAID OR LOSE THEIR EXISTING MEDICAID FUNDS WAS COERCIVE AND THAT LEFT IT UP TO THE DECISIONS OF INDIVIDUAL STATES AND THUS WE'VE SEEN OVER THE PAST 8 TO 9 YEARS A WIDE RANGE OF RESPONSES AMONG STATES ACROSS THE COUNTRY AND WE'RE LEFT WITH ABOUT 14 STATES THAT HAVE DECIDED NOT TO EXPAND MEDICAID AS OF 2019. THOSE ARE SOME OF THE REGIONS WHERE WE FACE THE GREATEST RISK OF PERSISTENT DISPARITIES AND GREATEST CHALLENGES IN TERMS OF ACHIEVING HEALTH EQUITY. THAT'S BASED ON WHAT WE HEARD OVER THE PAST DAY AND A HALF, GEOGRAPHIC VARIATIONS, DIFFERENCES BETWEEN URBAN AND RURAL AREAS AND RURAL AREAS IN DIFFERENT PARTS OF THE COUNTRY. SO THAT'S SOME OF WHAT WE'VE LEARNED ABOUT THE EARLY IMPACTS OF THE AFFORDABLE CARE ACT AND MEDICAID EXPANSION AROUND THE COUNTRY. WHAT DO WE KNOW FROM SOME LOCAL OR REGIONAL EFFORTS TO ADDRESS HEALTH DISPARITIES? THIS IS A PUBLIC SERVICE AD PART OF THE LAUNCH OF THE NEW YORK CITY COLON CANCER COALITION BACK IN 2003 AND 2004. IT WAS AN EFFORT TO EXPAND AND PROMOTE COLORECTAL CANCER SCREENING IN THE CITY OF NEW YORK AND SIMULTANEOUSLY TO REDUCE SIGNIFICANT RACIAL AND ETHNIC DISPARITIES IDENTIFIED IN THAT CITY. THIS IS A SLIDE FROM A RECENT JOURNAL ARTICLE THAT LOOKED AT THE EFFECT OF THIS PROGRAM OVER A 10-YEAR PERIOD FROM 2003 TO 2013. IT'S IMPORTANT TO HIGHLIGHT WHEN A COMPREHENSIVE APPROACH WAS ADOPTED ACROSSED CITY INCLUDING PUBLIC EDUCATION LIKE THE PUBLIC SERVICE ANNOUNCEMENT THAT I SHOWED THAT WAS CULTURALLY TAILORED TO DIFFERENT RACIAL AND ETHNIC GROUPS OVER AGE 50 INCLUDED PROVIDER EDUCATION, INCLUDED PATIENT NAVIGATORS WHICH WE HEARD AT LENGTH, ONE OF THE EARLIER SESSIONS TODAY, AS WELL AS EXPEDITED SYSTEMS OF CARE SUCH AS DIRECT REFERRALS AND THEN ANNUAL SURVEYS OF NEW YORK CITY RESIDENTS TRACTION PROGRESS. WHAT THIS SLIDE SHOWS IS THAT BACK IN 2003 BEFORE THIS PROGRAM WAS LAUNCHED, RATES OF COLORECTAL CANCER SCREENING WERE LOW OVERALL WITH SUBSTANTIAL DISPARITIES. SO AMONG WHITES THEY WERE JUST UNDER 50%, THEY WERE IN THE MID-30% RANGE FOR BLACK AND HISPANIC ADULTS IN NEW YORK CITY, AND ABOUT 25% FOR ASIAN ADULTS IN NEW YORK CITY. AND OVER THIS NEXT TEN YEARS WHAT HAPPENED WAS RATES OF SCREENING INCREASED FOR THE WHOLE POPULATION, NOW APPROACHING 70%. AND THE RACIAL AND ETHNIC DISPARITIES WERE ESSENTIALLY ELIMINATED OVER THIS TIME PERIOD WITH THIS COMPREHENSIVE APPROACH AND PARTNERSHIPS BETWEEN HEALTH SYSTEMS AND COMMUNITY ORGANIZATIONS, TO GET THE WORD OUT ABOUT COLON CANCER SCREENING AND ENSURE AS MANY ADULTS AS POSSIBLE WERE TAKING ADVANTAGE OF IT. ANOTHER EXAMPLE COMES FROM WORK IN THE CITY OF CHICAGO FOCUSED ON BREAST CANCER SCREENING AND TREATMENT. SO BACK IN THE LATE '90s AND 1996 THE MORTALITY RATE FOR BREAST CANCER AMONG AFRICAN-AMERICAN AND WHITE WOMEN IN CHICAGO WAS ESSENTIALLY IDENTICAL. OVER THE NEXT SEVEN YEARS OUT TO 2003 THAT RATE OF MORTALITY WENT DOWN FOR WHITE WOMEN IN THE CITY OF CHICAGO BY A THIRD, WENT UP BY 10%, SO IN A CASE WHERE THERE PREVIOUSLY WAS NO DISPARITY WITHIN JUST A SEVEN-YEAR PERIOD A SUBSTANTIAL DISPARITY IN HEALTH OUTCOMES AND BREAST CANCER MORTALITY BECAME EVIDENT IN THE CITY. HERE'S THE VALUE OF POPULATION LEVEL DATA. COALITIONS OF RESEARCHERS, PUBLIC HEALTH PROFESSALS AND SYSTEM LEADERS WORKING TOGETHER TO ADDRESS DISPARITIES WHEN THEY ARE FOUND IN A LOCAL OR REGIONAL AREA. THIS TRIGGERED FORMATION OF THE METROPOLITAN BREAST CANCER TASK FORCE WITHIN THE CITY OF CHICAGO, INCLUDING EACH OF THOSE MAJOR STAKEHOLDERS AS WELL AS PATIENT AND CONSUMER REPRESENTATIVES. AND THEY FOCUSED ON ACCESS TO MAMMOGRAMS, WHICH HAS BEEN A FOCUS OF SOME OF OUR DISCUSSION OVER THE PAST DAY AND A HALF, TOOK THAT EVEN FURTHER TO LOOK AT QUALITY OF PREVENTIVE SERVICES, IN THIS CASE QUALITY OF MAMMOGRAM FACILITIES, HOW THAT TRANSLATED TO TREATMENT, ADDRESSING DELAYS, ACCESS TO TREATMENT AFTER WOMEN WERE DIAGNOSED. AND WITH THAT THREE-PRONGED APPROACH WHAT WE NOW KNOW FROM MORE RECENT DATA IS THAT OVER SUBSEQUENT SEVEN-YEAR PERIOD FROM 2006 TO 2013 THE BLACK-WHITE MORTALITY RATIO FOR BREAST CAN BEGAN TO RETURN BACK TO WHERE IT WAS BACK IN 1996, NOT ALL THE WAY THERE YET BUT THE RATES OF BREAST CANCER MORTALITY FOR BLACKS RELATIVE TO WHITES WENT FROM 73% TO 41% HIGHER WHEN THE DISPARITY BY RACE WAS INCREASING SLIGHTLY ACROSS THE WHOLE UNITED STATES. SUGGESTING SOME OF THESE EFFORTS TO IMPROVE ACCESS TO SCREENING, QUALITY OF SCREENING, AND ACCESS TO HIGH QUALITY EFFECTIVE TREATMENTS FOR WOMEN WITH BREAST CANCER WERE HELPING INTEND THE CURVE IN TERMS OF RACIAL DISPARITIES IN BREAST CANCER MORTALITY IN CHICAGO. SO THE THIRD THEME I'D LIKE TO HIGHLIGHT IS WHAT WE'VE LEARNED FROM MEDICARE ADVANTAGE PLANS WHICH ARE THE PRIVATE HEALTH PLANS AS OF 2018 SERVE ABOUT 34% OF MEDICARE ENROLLEES OVER AGE 65, EXPECTED TO RISE TO 42% BY 2028, ESTIMATED BY CONGRESSIONAL BUDGET OFFICE. SO WE'VE DONE SOME WORK, COLLEAGUES AND I, LOOKING AT WHAT HAPPENS TO BREAST CANCER SCREENING IN MEDICARE ADVANTAGE PLANS, AND HOW THAT COMPARES TO TRADITIONAL MEDICARE ENROLLEES, IN FEE-FOR-SERVICE MEDICARE PROGRAM IN THE SAME GEOGRAPHIC AREAS. AND WHAT WE FOUND WAS THAT THE LEVELS OF BREAST CANCER SCREENING FOR WOMEN AGE 65 TO 69 WAS CONSISTENTLY HIGHER OVERALL IN MEDICARE ADVANTAGE PLANS, AND THAT NOT ONLY WERE RACIAL DISPARITIES ELIMINATED THEY WERE SLIGHTLY FLIPPED, MINORITY WOMEN HAD HIGHER RATES THAN WHITE WOMEN IN THE SAME PLANS AND REVERSAL WAS SEEN IN CONTRAST TO TRADITIONAL MEDICARE ENROLLEES IN THE SAME AREAS WHERE RACIAL AND ETHNIC DISPARITIES ABOUT 3 TO 8% PERSISTED FOR BLACK, HISPANIC AND ASIAN OR PACIFIC WHITE WOMEN IN THE SAME GEOGRAPHIC AREAS. THEN MORE RECENTLY WE'VE LOOKED AT WHAT HAPPENS TO MANAGEMENT OF DIABETES, HYPERTENSION, AND CHOLESTEROL AS A MAJOR CARDIOVASCULAR RISK FACTOR AMONG MEDICARE ADVANTAGE HEALTH PLANS ACROSS THE COUNTRY. WE KNEW GOING BACK TO THE EARLY 2000s THAT DISPARITIES AND PROCESSES OF CARE FOR THESE CONDITIONS, SO SCREENING FOR DIABETES AND MONITORING BLOOD PRESSURE, LARGELY HAD BEEN ELIMINATED IN MOST MEDICARE ADVANTAGE HEALTH PLANS BUT IMPORTANT DISPARITIES IN INTERMEDIATE OUTCOMES, CONTROL OF BLOOD PRESSURE, CONTROL OF GLUCOSE, CONTROL OF CHOLESTEROL WHICH ARE INTERMEDIATE STEPS ON THE PATHWAY TO ADVERSE COMPLICATION SUCH AS STROKE, HEART ATTACK, LOSS OF VISION, LOSS OF KIDNEY FUNCTION, AMPUTATION, MORBIDITY AND MORE MORTALITY, WHAT WE FOUND FROM 2006 TO 2011 ON THE LEFT-HAND SIDE OF THE SLIDE WAS THAT CARE IMPROVED SLIGHTLY IN TERMS OF CONTROL OF THESE RISK FACTORS, BY RACE AND — FOR BLACKS AND WHITES, ACROSS THE COUNTRY, PERSISTENT RACIAL DISPARITIES WERE EFFECTEDDENED. THEY WERE EVIDENT IN THREE OF THE FOUR MAJOR CENSUS REGIONS, SO NORTHWEST, MIDWEST AND SOUTH. IF YOU MOVE TO THE RIGHT-HAND SIDE OF THE SLIDE WE SAW SOMETHING WE HAVEN'T SEEN FREQUENTLY ENOUGH IN THE HEALTH DISPARITIES AND HEALTH EQUITY LITERATURE, AT A BROAD POPULATION LEVEL WE'RE STARTING TO SEE ELIMINATION OF DISPARITIES AND IMPROVEMENT IN OVERALL CONTROL OF RISK FACTORS SO BY 2011 THIS SLIDE SHOWS CONTROL OF LDL CHOLESTEROL FOR AFRICAN-AMERICANS AND WHITES IN MEDICARE ADVANTAGED HELD PLANS IN THE WEST, THOSE DISPARITIES HAD BEEN ELIMINATED AND QUALITY OF CARE WAS AT THE HIGHEST LEVEL OF ANY HEALTH PLAN ACROSS THE COUNTRY. WE SAW ALMOST IDENTICAL EFFECT FOR CONTROLLED BLOOD PRESSURE WITH HYPERTENSION AND CONTROL OF GLUCOSE, HEMOGLOBIN A1c FOR THOSE WITH DIABETES. BUT AS WE CONCLUDE OUR CONFERENCE, IT'S IMPORTANT TO RECOGNIZE THAT WE'RE NOT JUST FOCUSED ON IMPROVING ACCESS TO PREVENTIVE SERVICES OR IMPROVING INTERMEDIATE OUTCOMES. MOST IMPORTANTLY WE WANT TO REDUCE DISPARITIES IN MORTALITY AND MORBIDITY AND IMPROVE EQUITY AND HEALTH RELATED QUALITY OF LIFE, RESEARCH PUBLISHED IN THE NEW ENGLAND JOURNAL OF MEDICINE LAST YEAR WHICH SHOWS TRENDS IN MORTALITY FOR NON-HISPANIC BLACK MEN AND WOMEN AND NON-HISPANIC WHITE MEN AND WOMEN WITHIN THE UNITED STATES, GOING BACK TO 19 99 THROUGH 2016. WHAT IT SHOWS ON THE LEFT-HAND SIDE IS THAT FOR ALL THESE FOUR RABBLE AND ETHNIC GROUPS THERE'S IMPROV. IN MORTALITY, LARGER FOR BLACKS IN THE UNITED STATES WITH AN UPTICK. WE NEED TO REMAIN VIGILANT
FOR PEOPLE AT RISK, WHETHER THAT'S COMPLICATIONS AND MORBIDITY AND MORTALITY THAT ARISES FOR PEOPLE WITH CARDIOVASCULAR DISEASE OR DIABETES, THOSE ARE SOME OF THE MOST IMPORTANT HEALTH CONCERNS THAT WE NEED TO LINK SOME IMPROVED PROCESSES OF CARE WE'VE BEEN DISCUSSING OVER THE PAST TWO DAYS WITH IMPROVED OUTCOMES TO BE SURE WE'RE GETTING GOOD VALUE FOR THE SERVICES THAT WE'RE PROVIDING. I WANT TO CLOSE BY HIGHLIGHTING SOME WORK THAT DR. RICHARD ALAN WILLIAMS AND I, FOUNDER OF ASSOCIATION OF BLACK CARDIOLOGISTS, PUBLISHED BACK SHORTLY AFTER THE HEALTH CARE — AFFORDABLE CARE ACT WAS ENACTED IN 2010. AND WE FOCUSED ON SOME PRINCIPLES FOR CONTINUING EFFORTS TO ELIMINATE RACIAL AND ETHNIC DISPARITIES UNDER HEALTH CARE REFORM AS MORE PEOPLE GAINED ACCESS TO COVERAGE. WE OUTLINED FIVE KEY POINTS WE THOUGHT WERE ESSENTIAL TO CONTINUE THE PROGRESS TOWARDS HEALTH EQUITY IN THE UNITED STATES TO PROVIDE INSURANCE AND ACCESS TO HIGH QUALITY CARE FOR ALL AMERICANS, SECOND TO PROMOTE DIVERSE WORKFORCE, THIRD TO DELIVER PATIENT-CENTERED CARE. FOURTH MAINTAIN ACCURATE AND COMPLETE RACE-ETHNICITY DATA. WE CAN EXPAND WITH BROADER LENS ON DISPARITIES TO FOCUS ON GEOGRAPHY, AND SEXUAL AND GENDER IDENTITY AND GENDER AND SOCIOECONOMIC FACTORS BECAUSE WE NEED GOOD DATA IN ORDER TO TRACK WHETHER WE'RE MAKING PROGRESS ON ALL THE IMPORTANT ISSUES WE'VE DISCUSSED A THE THIS CONFERENCE. FINALLY WE NEED TO SET GOALS, ACHIEVED EQUITABLY. I WOULD MAKE THE CASE THAT IT'S ABSOLUTELY ESSENTIAL LIKE WE HEARD FROM THE LAST PANEL TO BRING HEALTH SYSTEMS AND MORE BROADLY TO BRING COMMUNITIES INTO THIS DISCUSSION AS WE'VE SEEN IN EXAMPLES I PROVIDED FROM NEW YORK CITY AND CHICAGO TO MAKE IN A CASE AND TO ACHIEVE THOSE GOALS THAT ARE SO IMPORTANT TO OUR SOCIETY. SO TO WRAP UP, I LEAVE YOU WITH THREE KEY RECOMMENDATIONS FROM THE EXAMPLES I PROVIDED TODAY. FIRST, WE SHOULD MONITOR RACIAL, ETHNIC AND SOCIOECONOMIC DISPARITIES AND RATES OF PREVENTIVE SERVICES NATIONALLY AND BY STATE UNDER THE AFFORDABLE CARE ACT WITH THIS MAJOR CHANGE WE'VE SEEN IN EXPANSION OF COVERAGE. SECOND, WE SHOULD TRY TO LEARN FROM LARGE SCALE COMMUNITY INTERVENTIONS THAT PROMOTE EQUITY, MANY DRAWING ON SPECIFIC COMPONENTS AND TYPES OF INTERVENTIONS WE'VE DISCUSSED AT THIS CONFERENCE. AND THIRD, WE SHOULD TRY TO DEFINE AND DISSEMINATED PROCESSES THAT ENABLED MEDICARE ADVANTAGE PLANS TO ELIMINATE DISPARITIES IN PREVENTIVE SERVICES AND EXPAND TO OTHER ELEMENTS OF OUR HEALTHCARE SYSTEM. THANK YOU FOR YOUR ATTENTION. WE HAVE A FEW MINUTES FOR QUESTIONS FROM THE PANEL OR OTHERS. [APPLAUSE] >> WHAT KIND OF CONTROLS WERE IN THERE TO LOOK AT THE EFFECT EFFECT OF ENROLLMENT INTO THE MEDICARE ADVANTAGE, YOU HAVE TO CONTROL FOR SELECTION BIAS AND SO FORTH. >> SURE. THAT WAS A BIGGER ISSUE PRIOR TO 2006, WHEN THE MEDICARE PROGRAM BEGAN INSTITUTING CLINICAL RISK ADJUSTMENT WHICH CALLED HIGHER COEXISTING CONDITIONS, HCC SYSTEM. WHAT'S BEEN FOUND IN STUDIES OVER THE DECADE OR SO AFTER 2016 IS THAT SELECTIVE ENROLLMENT OF HEALTHIER ENROLLEES DECLINED SO WITH RISK ADJUSTMENT, ALLOWING PLANS TO BE MADE MORE WHEN THEY CARE FOR SICKER ENROLLEES, REDUCED INCENTIVES AND THE CLINICAL PROFILE OR SEVERITY OF ILLNESS OF PEOPLE ENROLLING IN MEDICARE ADVANTAGE HAS COME MUCH CLOSER TO WHAT WE SEE, ALSO AS PROPORTION OF MEDICARE ENROLLEES HAVE GONE INTO MEDICARE ADVANTAGE DOUBLED OVER THE PAST DECADE, WE'RE SEEING THEM TO BE A MUCH MORE REPRESENTATIVE GROUP OF MEDICARE ENROLLEES, SO WE STILL NEED TO PAY ATTENTION AND TO THE EXTENT POSSIBLE TRY TO CONTROL FOR SOME OF THOSE HEALTH DIFFERENCES WITHIN THE STUDIES, BUT YOU RAISE A GOOD POINT WE NEED TO BE AWARE OF AS WELL. >> THANK YOU. THANKS FOR YOUR PRESENTATION. I'M THINKING FOR ANY PROGRAM OR INSURANCE THEY SHOULD WORK FOR THE PATIENT OR THEIR FAMILIES, BUT I'M THINKING NOT SOCIAL PROGRAM WHERE THE INSURANCE OR SOCIAL BENEFIT, MEDICARE, MEDICAID, ANY SOCIAL PROGRAM LIKE SOCIAL BENEFIT, ALSO MEDICAID, HOUSING ASSISTANCE OR PROGRAM BENEFIT, I DON'T THINK THEY ARE RELATED FOR THE TARGETED RECIPIENTS OF POPULATION, INSTEAD THEY USE AS EXCUSE SO THEY TAKE ALL OF GOVERNMENT FUNDING SO THE BENEFIT TO A FEW. SO I WONDER IF YOU HAVE THIS TYPE OF STUDY BECAUSE IF WE WANT TO PROMOTE PEOPLE'S HEALTH OR WEALTH OR PROSPERITY OR THEIR WELL BEING WE MUST INVESTIGATE THIS SO BE SURE TAXPAYERS MONEY GO TO FUNDING FOR THE BENEFIT OF THE GENERAL PUBLIC, NOT THE FEW DIVERT BENEFIT A FEW. >> THANK YOU. I THINK YOU RAISE A POINT TOUCHED ON THE LAST PANEL, IMPORTANT ROLE OF SOCIAL DETERMINANTS OF HEALTH, AND SORT OF THE ROLE OF SOCIAL SERVICES THAT PEOPLE WITH SIGNIFICANT HELD CONDITIONS NEED TO COMPLEMENT. THERE'S BEEN SOME GREATER APPRECIATION IN HEALTH CARE ORGANIZATIONS, EVEN IN THE PAYMENT SYSTEM, MEDICARE ADVANTAGE PLANS NOW HAVING FLEXIBILITY, SOME BEGINNING TO AUTHORIZE MEDICAID HEALTH PLANS TO FOCUS ON SOME OF THE OTHER SOCIAL NEEDS SUCH AS TRANSPORTATION, SOCIAL SUPPORT, HOUSING AND NUTRITION SUPPORT. I THINK WE'RE JUST EMBARKING ON EFFORTS TO IMPLEMENT THOSE NEW APPROACHES TO MEETING NEEDS, PARTICULARLY PEOPLE WITH SEVERE CHRONIC HEALTH CONDITIONS, AN IMPORTANT ROLE FOR RESEARCHERS AND LEADERS AND COMMUNITY STAKEHOLDERS TO WORK TOGETHER TO UNDERSTAND WHAT ADDED VALUE DOES THAT FOCUS ON SOCIAL SERVICES BRING AND SOCIAL DETERMINANTS OF HEALTH AND WHAT IMPACT DOES IT HAVE ON MANY OF THE UPSTREAM FACTORS THAT CONTRIBUTE TO HEALTH DISPARITIES IN OUR COUNTRY, THAT IF WE WAIT TILL PEOPLE NEED SIGNIFICANT MEDICAL CARE, IT MAY OFTENTIMES BE TOO LATE TO ADDRESS SOME OF THE MAJOR DISPARITIES THAT AFFECT PEOPLE'S QUALITY AND LENGTH OF LIFE. SO I THINK YOU RAISE A GOOD POINT THAT IT WILL BE IMPORTANT FOR FUTURE STUDY. >> I WANT TO THANK DR. AYANIAN, MEMBERS OF THE PANEL AND SPEAKERS. FOR THOSE ONLINE OR HERE, YOU STILL HAVE TIME TO GET COMMENTS IN, GO TO THE PATHWAYS FOR PREVENTION WEBSITE, COMMENT ON THE REPORT OR THE CONFERENCE. THE PANEL IS NOW GOING TO GO ADJOURN AND WE'RE GOING TO START WRITING. WE'RE HOPEFUL WITHIN A WEEK OR TWO OR SO WE WILL HAVE A REPORT TO BE PAIRED WITH THE SYSTEMATIC REVIEW, NOW OPEN FOR COMMENT, YOU CAN COMMENT ON THAT ONLINE, EITHER THROUGH THE AHRQ WEBSITE OR PATHWAYS TO PREVENTION WEBSITE. THERE'S LINKS THAT WORK. BUT OUR PAPER WILL BE POSTED FOR PUBLIC COMMENT FOR FOUR WEEKS AS WELL DURING THE SUMMER. AND THEN WILL BE PUBLISHED IN THE FALL PRESUMABLY IN PARALLEL AGAIN IN THE SAME ISSUE OF ANNALS OF INTERNAL MEDICINE WITH A SHORTER VERSION OF THE SYSTEMATIC REVIEW. AGAIN, I WANT TO THANK EVERYBODY HERE, THANK THE FOLKS ONLINE, AND OUR COLLEAGUES FROM OHSU WHO DID A VERY NICE JOB WITH THE SYSTEMATIC REVIEW AND THANK THE COLLEAGUES FROM NIH FOR HOSTING THIS CONFERENCE. THANK YOU VERY MUCH.

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