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Dr. David Nash on Population Health: Physicians Don’t Grasp It

August 6, 2018
by Rajiv Leventhal
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The renowned healthcare leader weighs in on where the biggest gaps and opportunities lie in the ever-evolving population health landscape

 

In late June, Thomas Jefferson University’s College of Population Health and Navvis, a St. Louis-based population health company, announced what officials attest is the country’s first private sector-supported academic chair in population health—The Navvis Professorship of Population Health at Thomas Jefferson University.

The professorship, funded by Navvis, will aim to support the work of a dedicated faculty member at the Jefferson College of Population Health. “The academic research will be national in scope, with the goal of improving intervention effectiveness in real-world applications. will focus on identifying methods and best practices to create systemic, effective and scalable improvements in health, officials stated in the June announcement.

David Nash, M.D., is one of the best-known pioneers in the world of population health management and related areas, and is the dean of the Jefferson College of Population Health. In a statement at the time of the professorship announcement, Dr. Nash said, “Establishing an endowed professorship devoted to the health and wellbeing of whole communities is an invaluable investment in humanity.” He added, “This professorship, the first collaboration of its kind between an academic entity and a private sector company, demonstrates a commitment to translating the scientific method into real-world practice. We are grateful for the support that will ultimately empower people to take charge of their health through research, education, and programs.”

In a recent interview with Healthcare Informatics, Nash discussed the importance of this professorship, while also touching on broader population health issues and the landscape at large. Below are excerpts of that discussion.

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What does the professorship represent in this current healthcare market and what do you see as its potential impact?

We think this is a paradigm shift and a watershed event, by having private-sector support for an endowed chair in our field. We believe this is the first ever [of its kind] in this field, making it really important. We will go recruit a major national scholar, hopefully a disruptor, who will help us bring this field to “2.0.” We have done a pretty good job; this month is the 10th anniversary of our college. And the Navvis professorship is the turning point for getting us to the very next level.

David Nash, M.D.

How would you describe what the population health landscape looks like, at a broad level, right now?

Let’s take population health management first. In population health management, the biggest issue at the moment now is the speed, or trajectory, in the movement from volume to value. We are in a valley, between two peaks—the peak of private practice fee-for-service and the peak of global payment. So the question is, how fast can we get out of this valley and make it from one mountain to the next? No one knows the answer, and that’s the scary part. We believe that based on the best available evidence, no matter which party you’re in, 60 cents of every Medicare dollar will be attached to an outcome measure in 2019. So we are moving inexorability from volume to value.

That said, this is not a done deal and it’s going to be a continued struggle, quite frankly. [Many] people are hoping to put a little steroid cream on this [problem] and assume it will be gone by the morning.

What are the pioneers doing in population health that those who are behind can learn from and replicate?

There are 10 schools of population health in the U.S. and we are tracking all of them, meeting and talking with their deans, in an attempt to raise all boats and help promote the field. There is tremendous energy in this arena. We have a text book, Population Health: Creating A Culture Of Wellness, that has been deployed in 80 graduate schools of medicine, nursing, public health, and health administration. And we are deep into preparing the third edition. We are still sculpting the field; we’re not done with the statue yet.

What are the biggest population health problem areas right now, as it exists today?

It’s a long list. Among the challenges is the lack of EMR [electronic medical record] connectivity, and the EMR in its current format is really an electronic chart. It’s not a source of information; only a source of data. The evidentiary basis of practice is still pretty modest. Eighteen percent of what we do is based on grade A evidence, and that in turn leads to inexplicable variation in what doctors do and inexplicable variation in price. This is a crisis. And then finally, medical error is the third leading cause of death in our country, regrettably.

Can EMRs, as they exist today, handle population health work, or are separate tools needed?

It depends on what camp you are in. We hope that Healthy Planet [Epic’s population health platform]—and the tools from its peer group from major vendors such as Cerner and Allscripts—will mature. In the meantime, there are a dozen add-on tools in play. We don’t have any research evidence to claim that one is more effective than another.

Do physicians and others have a common sense of what population health truly is? Can it mean different things to different people?

I honestly think they have no idea. They have never been exposed to it and they haven’t been taught this anywhere. They are learning as we go. The average well-trained physician in private practice has no real concept of any of this. As the payment system changes, their level of interest will increase. As we go from on the road from volume to value, their levels of interest will exponentially change.

We are still sculpting the new field. People are much more open than they were 10 years ago. Historically, we started the college two years before health reform when this vocabulary was largely unknown. We have come a long way. As you change the economic incentives, behavior will follow.

 


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Pediatric Asthma Care Management Program Extends to 7K Schools Nationwide

January 21, 2019
by Rajiv Leventhal, Managing Editor
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A regionally-established pediatric asthma care management program, which includes leveraging a student health record platform, is extending its reach.

Children's Hospital Colorado, the University of Colorado School of Medicine at CU Anschutz Medical Campus, and New York City-based pediatric healthcare technology company CareDox recently announced a new collaboration to scale the reach of the hospital's in-school asthma management program.

CareDox modeled this collaboration after the hospital's "Building Bridges for Asthma Care Program," which began in 2012, and is now offering its new care management platform to the more than 7,100 K-12 schools where the company's student health record platform and wellness services are already deployed.

By combining proven clinical protocols with widely deployed technology and wellness services operations, the three organizations “are poised to dramatically improve outcomes for pediatric asthmatics across the country,” officials of this partnership have attested.

The Building Bridges for Asthma Care Program is now deployed in 28 public elementary schools in Denver, Colo. and Hartford, Conn. The school program in Colorado was developed by Stanley Szefler, M.D., director of the pediatric asthma research program at Children's Hospital Colorado and the CU School of Medicine. Throughout the school year, school nurses train their students on asthma management, inhaler technique and other clinical best practices, and the students' absenteeism, physical activity and asthma control levels are monitored by nurses and communicated to their parents and healthcare providers.

In a study of the impact of the program published in the Journal of Allergy and Clinical Immunology, participants in the program experienced a 22-percent decrease in school absenteeism. Officials have noted that currently, approximately six million children under the age of 18 have asthma. It’s the top reason for missed school, totaling nearly 14 million days each year. Socioeconomically disadvantaged children and minority children are disproportionately affected by asthma. In these two groups, asthma is more often left uncontrolled, leading not only to absenteeism, but also disrupted sleep.

CareDox’s asthma care management program is already in use in the Clay County district schools in Florida, where there are more than 3,700 students who are known to have asthma. In addition to those students, CareDox leveraged medical data that resides on their student records platform to identify 345 additional students who are eligible for the program that weren't already known to school nurses and health officials as asthmatic.

In just three months, CareDox has already implemented the proven Children's Hospital Colorado/CU School of Medicine protocols to qualify about 1,200 students with asthma into the company’s asthma management program, of which 349 are eligible for CareDox's expanded care program for severe uncontrolled asthma.

The expanded care program includes four key components to address uncontrolled asthma among student populations, according to officials. One of these elements is the technology-enabled identification of new enrollees, which CareDox will leverage its student health record platform and enrollment processes for wellness services (flu and other vaccines, annual wellness checks) to screen for eligible asthma students.

"Children's Hospital Colorado and CU School of Medicine providers created the Building Bridges for Asthma Care Program to address the risk of health disparities and asthma-related absenteeism, as well as its related impact on academic achievement for inner city students," Robin Deterding, M.D., director of the Breathing Institute at Children's Hospital Colorado,  medical director of the Hospital's Center for Innovation and professor of pulmonary medicine in the Department of Pediatrics at the CU School of Medicine, said in a statement. “Building Bridges has proven that a school-centered asthma management program can have a positive impact on pediatric health and ultimately reduce asthma-related absenteeism within a school's population. Now by partnering with CareDox, we have the ability to drastically expand the program's footprint and reduce asthma-related absenteeism on a massive scale,” he added.

Like CareDox's existing school vaccination and annual wellness check programs, the company’s asthma care management program will be offered to eligible students at no cost to the student, their parents or the school district. CareDox partners with public and private health insurance to support the program, officials stated.

 

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Kaiser Creating Evidence-Based Complex Care Models

January 17, 2019
by David Raths, Contributing Editor
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Work aligns with recently published ‘Blueprint for Complex Care’

The National Center for Complex Health and Social Needs recently published a “Blueprint for Complex Care” to develop a collective strategy for promoting evidence-based complex care models. Recognizing that many patient issues have root causes that go beyond the medical, the Blueprint seeks to identify best practices for breaking down silos between the social care delivery system and healthcare.

Perhaps no health system has devoted as many resources to complex care as Kaiser Permanente. Its Care Management Institute, a joint endeavor between the Permanente Medical Groups and Kaiser Foundation Health Plan, has established Complex Needs as one of its national quality initiatives. It has named regional complex care leaders, created common quality measures across regions and established a complex need research arm called CORAL. (Kaiser Permanente has eight Permanente Medical Groups and regions, more than 12.2 million members, more than 22,000 physicians and 216,000 employees.)

In a Jan. 16 webinar presentation, Wendolyn Gozansky, M.D., vice president and chief quality officer, Colorado Permanente Medical Group and national leader for complex needs at the Care Management Institute, described Kaiser Permanente’s efforts and used some personal anecdotes to explain their goals.

She said Kaiser Permanenteis working on the concept of developing core competencies and tools to support a longitiudinal plan of care for patients with complex needs. “These are the folks for whom the usual care is not meeting their needs,” she said. “How do you recognize them and make sure their needs are being met?”

Gozansky gave an example from a patient she had just seen the previous wekend. This women had fallen and broken her hip. She had several chronic conditions, including significant asthma, yet she was not on an inhaled steroid.

“One concept I love from the Blueprint is that this field is about doing whatever it takes to meet the needs of the person in front of you,” she said. In speaking to the woman, she came to understand that singing in a church choir was the most important thing in her life, and the inhaler medication was making her hoarse and unable to sing.  She was fairly isolated socially except for church. “My goal was to get her rehabbed and leverage the patient-defined family that is supportive. Her goals are to sing, so we need to do what is possible to get her back to that. We have to capture that information, put it into a long-term plan of care. The goal is not to get her out of rehab but to get her singing in choir.”

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The health system has to work on care that is preference-aligned. The woman is not on a steroid inhaler but her care is preference-aligned. How does the health system assure that everyone knows they are doing the right thing?

Gozansky said the beauty of Permanente Medicine is that its setup involves an employed medical group focused on value, not volume. They can interact with health plan partners in delivery of new systems of care. “It is a virtuous cycle about value and person-centered care. This is what our complex needs team is trying to understand.”

She described the journey so far: In 2015 there were pockets of work being done across the eight Kaiser Permanente regions. In 2016 they established complex care as a national qualitiy iniative. “We knew we were not meeting these patients’ needs. We had to figure out the right way to do that.” They also realized that most of the previous research on the topic involved examples that were not in integrated systems such as Kaiser Permanente. “We had to figure it out in an integrated system,” she said.

 In 2017 they started working on cross-regional learning — for instance, taking a program from Colorado and trying it in Southern California. Then they sought to align quality measures. In 2018 they got funding to create CORAL, the complex needs research arm.  

The Care Management Institute has created a “community of practice” on complex care to break down silos within the organization and bring together research, operational and administrative executives. They also want to work with external stakeholders to make sure what they are developing is scalable, Gozansky said.

Mark Humowiecki, senior director of the National Center for Complex Health and Social Needs, also spoke during the webinar. He said one of the goals of the Blueprint was to get a clearer definition. Some people get confused about terms such as “hotspotting” and complex care, he said. He said there is a recognition that these patients’ needs are crossing traditional silos, so “there is a need to connect care for the individual but also at the system level.”

The goal, he added, is to create a complex care ecosystem by developing in each community system-level connections between social care delivery and healthcare, which in the past have operated too independently.  The five principles are that complex care is person-centered, equitable, team-based, cross-sector and data-driven. One of the Blueprint’s recommendations is to enhance and promote integrated cross-sector data infrastructures.

 

 


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NIH’s All of Us Program Teams with Fitbit for Data Collection

January 16, 2019
by Heather Landi, Associate Editor
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The All of Us Research Program, part of the National Institutes of Health (NIH), has launched the Fitbit Bring-Your-Own-Device (BYOD) project. Now, in addition to providing health information through surveys, electronic health records, and bio-samples, participants can choose to share data from their Fitbit accounts to help researchers make discoveries.

According to All of Us research program officials, the project is a key step for the program in integrating digital health technologies for data collection.

The All of Us Research Program, established by the White House in 2015, aims to advance precision medicine by studying the health data of 1 million diverse Americans over the next five years. One aim of the project is to include groups that have been historically underrepresented in research. As of September 2018, more than 110,000 people have registered with the program to begin the participant journey, and more than 60,000 have completed all elements of the core protocol.

The participants are sharing different types of information, including through surveys, access to their electronic health records and blood and urine samples. These data, stripped of obvious identifiers, will be accessible to researchers, whose findings may lead to more tailored treatments and prevention strategies in the future, according to program officials.

Digital health technologies, like mobile apps and wearable devices, can gather data outside of a hospital or clinic. This data includes information about physical activity, sleep, weight, heart rate, nutrition, and water intake, which can give researchers a more complete picture of participants’ health.” The All of Us Research Program is now gathering this data in addition to surveys, electronic health record information, physical measurements, and blood and urine samples, working to make the All of Us resource one of the largest and most diverse data sets of its kind for health research,” NIH officials said.

“Collecting real-world, real-time data through digital technologies will become a fundamental part of the program,” Eric Dishman, director of the All of Us Research Program, said in a statement. “This information, in combination with many other data types, will give us an unprecedented ability to better understand the impact of lifestyle and environment on health outcomes and, ultimately, develop better strategies for keeping people healthy in a very precise, individualized way.”

All of Us participants with any Fitbit device who wish to share Fitbit data with the program may log on to the All of Us participant portal at https://participant.joinallofus.org and visit the Sync Apps & Devices tab. Participants without Fitbit devices may also take part if they choose, by creating a free Fitbit account online and manually adding information to share with the program.

All of Us is developing additional plans to incorporate digital health technologies. A second project with Fitbit is expected to launch later in the year, NIH officials said, and this project will include providing devices to a limited number of All of Us participants who will be randomly invited to take part, to enable them to share wearable data with the program.

The All of Us research program plans to add connections to other devices and apps in the future to further expand data collection efforts and engage participants in new ways.

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