Category: Social Determinants of Health

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Assessing the Impacts of Social Determinants on Population Health with Rob Fields, SVP, Chief Medical Officer Population Health at Mount Sinai Health System

Recommended Book:

The Little Prince

Best Way to Contact Rob:

robert.fields@mountsinai.org

Rob's Podcast:

https://soundcloud.com/robert-fields-424184141

Check out this Link:

https://outcomesrocket.health/podcast

Assessing the Impacts of Social Determinants on Population Health with Rob Fields, SVP, Chief Medical Officer Population Health at Mount Sinai Health System

Welcome to the Outcomes Rocket pod cast where we inspire collaborative thinking improved outcomes and business success with today's most successful and inspiring healthcare leaders and influencers. And now your host Saul Marquez

And welcome back to the podcast Saul here with a special guest. His name is Dr Rob Fields. He's Senior Vice President, Chief Medical Officer Population Health at Mt. Sinai Health System. He is really doing some fascinating work. His career began by opening a new practice at a residency focusing on using technology for quality improvement and serving the Latino population in western North Carolina. The practice was the first to use a patient portal on the first to achieve PCMH Level 3 in 2010 which is huge. In 2012, he spent a year teaching at a community health and family medicine residency at the University of Florida. He was recruited to come back to Asheville as the assistant medical director for primary care at Mission Medical Associates. As the ACO planning began in 2013, Mr. Fields but the quality steering committee and helped the initial planning of what was to become Mission Health Partners. He's done a lot for that community but also across his experience in health care to improve outcomes and it's a pleasure to have him here on the podcast with us to discuss what's on top of his mind. So Rob pleasure to have you on the podcast today.

Thanks for having me Saul.

It is a pleasure. So what is it that got you into the medical sector Rob?

Yeah I mean honestly my older brother. I have a brother who's 10 years older and at one point had wanted to go into medicine and that's how the idea first got in my head and then had some experiences in high school and volunteering and kind of got a sense that I was pretty sure I wanted to do primary care even then just kind of solidified you know you go through undergraduate have different thoughts but really always came back to medicine as something that was really met all my needs that need for a service and a need for to be renewed my love of science and relationships and all that. So it is a thing to combine all the things I love. And it's been great, been a great career.

That's outstanding man. Yeah it's such such a great place to get all those wonderful things man and also help people in the process. And so as you've worked your your feel for technology as well as you know caring for patients. Tell us what a hot topic you believe needs to be on health care leaders' minds and how are you guys at Mt. Sinai taking care of that today?

Yeah. World is changing pretty dramatically. I mean I think one of the things I've learned over the last 10 years or so both actually starting with my journey and private practice all the way to working on system kinds of problems and in particular here in New York City is that the world is changing such that really the economics are changing though. Our systems, our government, our society, is running out of money to take to really handle health care and the way we've always done it. We need to think differently about how to do it in a particular way in a market like New York City where we have a lot of competition a lot of high branded internationally renowned institutions or really focused on on specialty care and the way the systems have always operated is really about trying to be come up with the newest and greatest thing that is actually a back to basics philosophy that the systems really need to adapt by going back to the basics of relationship-based care. Building Primary Care base is managing population trying to reduce cost and utilization in the hospital in many ways sort of the antithesis of the things that they were built to do. But I think all healthcare leaders that are looking at the way the finances are working around that and healthcare economics and seeing the writing on the wall or are trying to figure that out. How do you change our systems from delivering the kind of care they've been delivering to something that really goes back to and I think the basics of population health which are the basics of medicine, a strong primary care, strong relationships with patient and trying to positively affect behavior to get better outcomes.

Yeah now that's such a great point Rob and there's definitely a lot of heavy lifting that's happening right now and has turned to more value based care and I love to hear some of your thoughts and what you guys are up to over there at Sinai. And just to help improve outcomes and do things differently.

Yeah there are a couple of things or several things but maybe it's the basis you have to change the economics of the health system and the financing of the health system in order to change the operations right. So you can't disconnect the two so much that you try to change your operations in a vacuum. You have to be able to do your contracting and change your contracting to support the kinds of things that you want to do. So we have entered into value-based agreements with all of our payers in some capacity all the way from full arrest to just pay for performance and everything in between. So I think that's one thing that we started doing several years ago and the second is of course is establishing the right leadership and start to address the cultural issues within the institution to kind of move us towards value. But I think more concretely there are a couple of things. One is really working on primary care redesign. So if we agree that the foundations of Population Health are really about empowered primary care that provides the appropriate foundation then it can't be the primary care of the lot, 15 to 20 years. I think that led us to physician burnout, it led us to relatively low number of medical students deciding to do primary care. It just needs to change, we needed to improve or empower our workforce. We need to support them a lot more in a star building team based care infrastructure. So we've done that you're kind of starting to introduce the concept of integrated care with behavioral medicine with social work with clinical pharmacy. So we're starting on that process now for rebuilding primary care in redefining primary care. And then the other big thing among all the things we're working on that is really important is how we use our information systems and data and analytics to really fuel our operations and top health both in terms of measurement of operations and quality and efficiency but also prediction. Now how do we use all sorts of data to start to predict who is likely to have a better outcome and start to define our population. The idea being given in limited resources and in a place like Sinai your population is potentially infinite right you have people traveling from all over the place to come here. We don't have enough resources to cope to really deal with an infinite population. We need to use data and analytics to help define our population a little more discreetly and then organize our operations around that. So I think primary design and data and analytics have been bought by our two biggest investment.

Love that and that super clear focus on these two metrics and feel like is the key to to really drive some great results and maybe along the journey, you guys saw some some setbacks and some learnings. I feel like we learn more from those than than the successes. Definitely want to dive into the successes here by one hour before we get to those learn from maybe one of the setbacks that you and your team had and what you learned from it.

Sure. Yeah I'm in I'm still relatively new to Sinai but I think some of the challenges here are not unique to either their troop or other large health system. I think population health is soon to be in vogue thing right. Every system says we need to do pop health that are quote not really understanding what that is and often start on the same journey of trying to build primary care. I think where it gets a little law is really undervaluing the what we call the less discrete part. So what part makes primary care so impactful. So I think there's a general under appreciation for how important those relationships are to improving outcome. And we know that patients generally do better. They utilize less, they have better outcomes if they have a consistent and reliable relationship with a primary care physician and that isn't often reflected on profit loss statements or balance sheet. So a primary care practice so our primary care division which for most systems often loses money. I think there is a lot of other value there especially when we talk about you know population health model that has to do with having a reliable place for a sick patient to become someone that knows the patient, that knows their social contacts, that can have meaningful conversations that are not just a singular conversation but an accumulation of conversations over years in that relationship that is incredibly impactful but it doesn't generate our views. So I think our mistakes as a system have often had to do with resourcing decisions in primary care that are based on balance sheet and not about the overall value. What primary care brand. That's easy to do. I mean when you think about a division that might be losing money out of balance sheet then decide well we can't afford to resource it differently or build team based care model. I would argue you really can't afford not to, given the new economy and and it's beyond the balance sheet. I think that's a pretty common mistake across systems but I think that I've had experience with.

Wow that's so insightful and those are the tough calls that visionary CMO and CEOs leadership teams and general ad provider institutions need to be thinking about. You're definitely thinking about these things and I think it's key for others to really start sharing into that vision of hey you know it may not make sense on the balance sheet right now but if we take a look at the impact overall, what we could get out of this for patients and just the system that the health care that we're providing could be big. What would you say has been one of the proudest medical leadership experiences you've had to date?

From a personal standpoint who's actually maybe for the Sinai and even before a mission. I spent a year as you mentioned at the University of Florida teaching in the family medicine residency program and are my personal proudest moment as a leader was getting faculty of the year there and teaching residents about these kinds of topics and transformation and just having that connection with people. And I was only there for a year and it was a really powerful experience for me in terms of having those kinds of relations so I think that's certainly one of my proudest. I think certainly that I think in terms of pop health my proudest moment was being in my previous organization. When we we first were able to generate shared savings in our model. And I say that because it was somewhat of an untested model. We worked not exclusively but quite a bit on Social Determinants as the core of our operations and how we dealt with poor management of health. And I think we had uninvolved nationally with a CEOs and there are a lot of people that those that don't really believe that a social determinant model is really the way to go in managing populations. And so there were some naysayers out there and we were able to generate significant savings despite some significant headwind and that was certainly a proud moment for me that our model tested true and has delivered a result. And we're working towards the same things here at Sinai and I'm excited to be a part of it.

That's awesome. Well you know what, success definitely leaves a trail and I'm excited to see apply some of the things that have already worked for you and your previous teams to what you do at Sinai. Rob there's no doubt in my mind that you're going to succeed. So as you work to unravel some of the things that you've got going on what's an exciting project that maybe you want to share with the listeners?

Sure. Yeah. In taking on some of the social determinants work here at Sinai that the thing is I'm really excited about our how to use the data sources we have and use things like machine learning for example to be able to describe our populations differently and so we're able to now using our one of our analytics partners able to predict with a reasonable degree of certainty who in our population is likely to end up in the hospital unnecessarily in the next 30 days before. And so whereas most analytics talk about readmissions predictors and other types of I think more common metrics and predict use other common uses of predictive analytics. We're trying to think more upstream and predict the next unplanned admission to really try to have a more meaningful impact on patients and not only do we are we able to do that but we're able to do that with a little bit of information on these patients regarding their social determinants so we can actually tell based on more I would say less typical data sources. So like purchased data you know using big data to help provide social context for these patients so not only can we say hey they're likely to end up in the hospital in the next 30 days but they're likely to end up in the hospital and also have an issue with housing or transportation or finance. And that way our social workers and our nurses that are trying to manage the population have a greater degree of insight even before talking with the patient and can most appropriately helped them by closing those social determinants gaps. So it's really sort of an empowered approach to care management and proactive upstream thinking in terms of care management that I'm pretty excited about. Not to mention the opportunity to partner with our nonprofit than New York City to be able to really help close those gaps in a meaningful way.

Wow that's super exciting and yeah you know I had a guest who was about a year ago actually and he was talking about you know he had as part of his portfolio a Socio Determinants of Health test and the patient would take it on the tablet when they got to the doctor's office or the E.R. and based off of that it would give the care team an understanding of where they sat, what the risks were. And this is more like just a piece of the entire vision of what you're painting. But it seems like it's at its core I think like a lot of times it's tough for people to envision these things that you know you're just laying out for us. But the power behind what a system like this can do is pretty big for the health of people and for the way that hospitals manage populations. If if somebody's listening to this what Rob is saying is if it's resonating with you, Rob what would be the best way for them to get in touch with you to to start a conversation.

Probably by e-mail my e-mail's robert.fields@mountsinai.org that's probably the best way to start a conversation or to have a conversation about what we're working on. I remember working with somebody that worked with vulnerable populations back in Asheville who is credited with the quote that went something like You know it's hard to take care of your diabetes if you're living in a tent. And that to me is probably as concrete as it comes because you're right. I mean I think data and analytics and predictive analytics is kind of out there and some people get it and some people don't. But I think that line can easily resonate and whereas healthcare, I can write a million prescription. And that's what I'm trained to do. Somebody has diabetes it's done under control. I can write a thousand prescriptions for insulins or for other medications all day long and have zero impact because I've done nothing actually deal with the priorities that the patient has and just surviving the day. And I think ultimately when I think about what that the core pop health is trying to deal with those basic life needs that you have to deal with, otherwise you don't get to the right outcome and it just so happens that the way the financing of healthcare is changing that's more possible today than it might have been 10 years ago in the first purely fee for service environment.

That's a great way to put it. Rob and and definitely resonates with me. And folks if you need to rewind us in here again it's definitely one that I'll be rewinding and listening to again because Rob's definitely given us some great insight into population health and the things that matter and the promise that we're about to see around the corner with the changes in the economic infrastructure and health care. Getting close to the end here Rob, let's pretend that you and I are building a medical leadership course. And what it takes to be successful in healthcare. The one on one of Dr. Rob Fields. And so we're going to design a syllabus for questions lightning round style followed by a book that you recommend to the listeners. You ready?

I'm ready.

All right. What's the best way to improve healthcare outcomes?

Always keep the results in mind.

What is the biggest mistake or pitfall to avoid?

Don't substitute a process for a result. I think we go a good job of creating processes. But again we lose sight of the result that we're intending.

Love that. How do you stay relevant as an organization despite constant change?

Keep your, be true to your mission. Always. I think it starts there.

What is one area of focus that drives your organization?

I would say culture and I think this should be true of all organizations. Think you've got to get the culture right and that should drive everything else to do.

What's your all time favorite book that you'd like to recommend to the listeners on the syllabus?

Oh man. Lots of great books but I'm going to kind of stick to the basics and I'll recommend The Little Prince. I think there are a lot of truths about life in that children's book.

Nice.

I think hold true to that today and I credit my older brother for introduce me to that too.

That's awesome. Kudos to you older bro. And yet you know I've listen, I've heard that recommendation once before so now Rob with your recommendation it's definitely climbed up on my must read list so appreciate you for sharing that. And that listeners, you want to get a hold of this syllabus that we just crafted for you along with a transcript of our interview, just go to outcomesrocket.health/fields as in Rob Fields and you'll find it there. Before we conclude I love Rob if you could just share your closing thoughts. And then the best place where the listeners could follow you or learn more about your work.

Sure. Maybe a closing thought is that the thing I'm most excited about in the new economy is that it turns out that doing the right thing by patients turns out to be the least expensive way to provide care. And then when those things align I think good things can happen. I'm excited there and again probably the best way to get me is via email. robert.fields@mountsinai.org and we also have our own podcast that we Mount Sinai partners, Apple podcasts, and Google podcasts as well. That's helpful.

Outstanding. We'll definitely have to check that out Rob and we'll provide a link to the podcast that they offer on the show notes as well. So if you want to check out this is just the tip of the iceberg ladies and gentlemen. If you want to dive deep into Rob's thoughts and what they're doing over there, check it out. Just go to outcomesrocket.health/fields and you'll see a link to their podcast down there so you could dive deeper. Rob this has been a true pleasure. Really appreciate you taking the time with us today and yeah hopefully we could get you back on in about a year or so to hear how things have gone.

Sounds great. Thanks Saul. Appreciate your time.

Thanks for listening to the Outcomes Rocket podcast. Be sure to visit us on the web at www.outcomesrocket.com for the show notes, resources, inspiration, and so much more.

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End of Life is a Human Endeavor, Not a Medical Issue with Dr. Shoshana Ungerleider, Founder at End Well

Hey Outcomes Rocket friends, thanks for tuning in to the podcast once again. As a leader in health care, you have big ideas great products, a story to tell, and are looking for ways to improve your reach and scale your business. However there's one tiny problem. Health care is tough to navigate and the typical sales cycle is low. That's why you should consider starting your own podcast as part of your sales and marketing strategy. At the Outcomes Rocket, I've been able to reach thousands of people every single month that I wouldn't have otherwise been able to reach if I had not started my podcast. Having this organic reach enables me to get the feedback necessary to create a podcast that delivers value that you are looking for. And the same thing goes if you start a podcast for what you could learn from your customers. The best thing about podcasting in healthcare is that we are currently at the ground level, meaning that the number of people in healthcare listening to podcasts is small but growing rapidly. I put together a free checklist for you to check out the steps on what it takes to create your own podcast. You could find that at outcomesrocket.health/podcast. Check it out today and find a new way to leverage the sales, marketing and outcomes of your business. That's outcomesrocket.health/podcast.

Welcome back once again to the outcomes rocket podcast where we chat with today's most successful and inspiring health leaders. Today I have a very special guest for you. Her name is Dr. Shoshana Ungerleider. She's the founder at End Well. She's a physician, philanthropist and speaker. She received her medical degree from Oregon Health and Science University in Portland and completed residency at California Pacific Medical Center. She's got a lot going on right now. She's passionate about improving how people are cared for throughout the continuum of life. She started the Ungerleider Palliative Care Education Fund to support innovative programs that further palliative care. And she's also a starter of the company. As I told you End Well, very focused in this piece but on top of that, she's also a producer. She executive produced a film by the name of Endgame, a short documentary on hospice and palliative care. It received Academy Award was with Academy Award directors Rob Epstein and Jeffrey Friedman. But she also funded extremists. It's a short documentary about end of life decision making in the intensive care unit and this film was premiered at Tribeca Film Festival and was nominated for Academy Award nominated for two Emmy Awards. So as you can see here, this physician frontline also producer entrepreneur is very passionate about this space and it's with big pleasure that I welcome Shoshanna to the podcast. Welcome.

Thank you so much for having me.

It is a pleasure. Now Shoshanna did I leave anything in your intro that you want to share with the listeners.

Gosh you covered a lot. I guess the only thing that I would add is that my favorite hobby is singing karaoke.

Nice, I love it. Any favorite songs?

Oh man there's so many. I love Whitney Houston, she's a crowd favorite.

Love it. I love it. Yeah it's a great one. I love the karaoke. Obviously, very focused in this niche of end of life. What would you say, just going back to the root of it all. Got you into the medical sector?

It was funny, I studied as wife at 10 different majors in college. I was kind of all over the place everything from Spanish, to fine arts, to women's studies. I finished college with a degree focused on marine biology and actually thought I was going to pursue a Ph.D. there and I realized that very, very end of college that after spending a few months at the marine lab on the Oregon coast that I was not going to be happy studying little tiny microorganisms floating around in oceans. I really wanted to work with people and so I decided to put the premed route. So I ended up back in school and then many years later in medical school.

Nice. So you made a really great choice right, because obviously you've contributed a lot. And you're enjoying what you're doing. Shoshanna what do you think is a hot topic that needs to be on every medical leaders agenda today. And how are you and your organization tackling it?

Well a topic that I care the most deeply about is improving the end of life to make it a more human centered experience. So we have 10,000 baby boomers turning 65 every single day in this country.

Wow. Everday?

Every day. And actually the latest estimates are even higher. So even if we were to have massive breakthroughs in longevity science never in our history with such a large number of people die in such a short time span from natural causes. Right. And to further complicate this causes of death are now largely chronic conditions can require care for years and years. And I think with the work that I'm doing with the End Well which is a project which is a nonprofit is we're coming at this from a few different angles. You know we started in thinking about medical education reform to train clinicians in how to have conversations with patients about prognosis, about goals of care, about palliative medicine fundamentals. I mean we continue to support that but we also realize that a broader societal shift internees that take place. And I firmly believe that dying is not a medical issue it's a human issue. So we've created a media platform and we support an annual international symposium which convenes people from the world of tech, of healthcare, of policy, education, patient advocacy, the media arts and faith communities to really create an interdisciplinary network and try to develop human-centered solutions for the end of life experience. So we're kind of I like to say we're bringing in the creative experts, the technical experts and the life experts into one room.

Love that. And you bring a really good distinction. You know it's it's end of life. It's not a medical condition it's a life thing. It happens. So what message would you give to the folks listening about end of life and how they address this?

Gosh it somewhat depends on you know where you're coming from in terms of the conversation. But to me I think it first starts with personally reflecting on what matters most to you as a human being, as sort of how you live your life and then have a conversation about that with the people that you love. We know that critical conversations are not taking place to make sure that the care people get is care that they really want. And I'm talking health care and care otherwise. And so I think the more that people can be thinking about this and talking about it, gets them closer to making sure that those things are aligned for them.

It's a great great message there Shoshanna. Can you give the listeners an example of how End Well is creating results and doing things differently to improve outcomes?

Absolutely. So End Well is a nonprofit. And one thing I've learned is this, we're really, really siloed in our approach to problem solving around the end of life experience. I think doctors talk to other doctors and then you have the hospice people talking to other hospice people. Of course insurers speak to insurers and the policy makers speak to policy makers and nobody seems to be talking to patients. And while we are all in agreement that our health care system is broken, the majority of what we propose as solutions is to rearrange or just to fine tune what we already have. I think we've really internalized the idea that specifically death is a medical issue. So we keep looking for medical solutions. And I think what's unique about End Well is that we're really focused on bringing diverse voices a real interest professional group of people together to listen and to learn from each other and our symposium which this year is December 6th in San Francisco is to really create a cultural shift that supports new collaborations, new systems, protocols and even products that foster new and existing networks of support. And this really hasn't been done before in this particular arena and we've been successful in terms of the metrics that we're looking at. So End Well 2017 was our inaugural event. We sold out 3 months beforehand and had several hundred people on our waiting list to attend. We just that blew our minds at this topic that people really wanted to dive into. Our hash tag on Twitter #endwell17 reached over ten million Twitter impressions and 20 seats in 15 countries in a matter of hours. We had CNBC NPR's On Being San Francisco magazine all cover our event. So that shows us just in terms of reach that the people are really wanting to engage in this content related to end of life. And so we're going to keep going.

That's awesome. Now thank you for that Shoshana. And folks if end of life is on your mind you definitely need to check out the conference that's coming up in December. It's the endwellproject.org. If you look up endwellproject.org you'll find information there. It's coming up it's in San Francisco. Definitely one that you'll want to miss. You won't want to miss especially if you're wanting to surround yourself with the thought leaders in this space and and to Shoshana's point right. Knock down those Shiloh's or connect the silos at least to be able to make some strides in this space because it's definitely needed.

Give us an example Shoshanna of a time when you had a setback. I feel like we learn more from these setbacks. What did you learn from that setback?

Absolutely. Well you know I think what I want to share is maybe not necessarily a setback but something that early on we realized. I first started off my career around philanthropy thinking about medical education reform. What I knew was residency training and that there were major gaps or maybe we'll just call them opportunities for training providers in communication skills in palliative care fundamentals. And so I thought well, if we can train all healthcare providers in how to have these really important conversations with patients in a more effective manner and if they have an understanding of palliative care that will improve outcomes. And I think that that's very true but I really quickly realized that scale and sustainability were going to be huge issues. Thinking about the many many programs around the country each have their own ways of funding up thinking about curriculum of thinking about these issues frankly. And if I'm somebody that you know has bigger goals for change and I want to have this happen in my lifetime, right. So I really shifted my focus my time my energy my resources to tackle some of these issues from the consumer side and I realized that that was what I'm betting on it was going to be more impactful. So I've gotten much more involved in documentary film as a vehicle for sharing this information and sparking conversation and creating the End Well platform really is focused on culture shift.

Yeah you know and Shoshanna I love a love that you saw that right. You mean you're like OK I'm gonna aim at these institutions, these educational institutions and quickly just saw that. Wait a minute, I want to scale this and I don't see it happening. So you made a quick shift and went to the consumer and I love that you did that and did it in such a creative way. I mean you went to the documentary space I mean what sparked that idea?

Well the idea was already happening. So you know it turns out that a good friend of mine a friend and colleague Dr Jessica Zimmer And I were having coffee and she mentioned she is an ICU doc and also practice palliative medicine. And you know we're having coffee and she said listen, did I ever tell you they're filming a documentary in the ICU about end of life and I said no. Like what do you mean. Like that sound incredible. So she connect me with the director. And it spent several months actually already filming at the Highland Hospital in Oakland and he sent me a five-minute rough cut. I was totally blown away by what it should, you know film is not something that I had studied in school or even knew much about but I just when I saw those that really brief footage I just thought gosh like this is a story that needs to be told and he's captured it in such an amazing way and I have always felt that we need to let people into what it's really like to be seriously ill in a setting like the ICU so that they understand you know maybe what they're signing up for or maybe they don't want that or at least to empower people with some information so that they can make that decision for themselves about what they might want. Should that issue arise and so I funded that film and never in a million years that I think that it would take off like it did. I think we just got really lucky and filmmaker Dan Kraus just did an amazing job.

That's awesome Shoshanna. And listeners think of yourself as a coffee table right now. You're sitting here with Shoshana. with me. You're hearing this. This topic of end of life. We're connecting silos right now as we speak. So don't wait. This is an opportunity, don't wait and do something about it right, if you're looking to make make something better happen within the space of end of life. Do it now. So Shoshana you pivoted. You had some great, great success. What would you say one of your proudest medical leadership experiences or moments that you've had to date?

Gosh, I don't know if this is a medical leadership experience but getting to go to the Oscars was pretty unbelievable.

It's pretty cool.

Extreme is which is on Netflix. It was nominated last year. So that really blew my mind. I was also named Woman of the Year by the women's healthcare executive.

Congratulations.

Two months ago. So that was really a wonderful more healthcare focused experience. But it's been a wild ride the last few years. That's for sure.

That's awesome. And you know the message here listeners is like Shoshanna, right. She was mission focused, she was outcome-centered. And there's so many ways that you could get the word out and share your passion and your solution. It could be a medical device. It could be a process. It could be a documentary in this case who knows you may be sitting next to Shoshanna at those awards next time, right. But just do it. And so Shoshana, what would you say right now in the midst of all the things that you've got going on, great things that you've got going on is an exciting project or focus that you want to talk to us about?

Yes. The Our second film a different team of filmmakers I executive produced called end game which you mentioned earlier about hospice and palliative care and that was done by Academy award winning directors Jeffrey Friedman and Rob Epstein. Just came out on Netflix and we're we're actually launching a national impact campaign focused on education related to the film both for medical professionals and for the general public. So we're hosting screenings across the country with a curriculum to help spark these important conversations related to advanced care planning to discussions of mortality and really what it means for all of us to live well until the very end. So I'm really excited about that or be rescreening it around the country over the next six to nine months and people can actually host their own screenings so you don't need us. You can actually just log in and get some folks together to watch it and talk about it.

Now this is super exciting. So for the andwell film. Is this something that listeners that want to know more, where can they go for this?

Absolutely. There's a couple places, but probably the most straightforward is the endgame documentary website. So the film itself streams on Neflix so you just type in Endgame on your Netflix accounts. But if you want to read or check out the resources for the documentary that's on our documentaries website which is endgame-documentary.com.

Awesome. So simple check it out on your Netflix or end game dot com slash documentary?

No it's actually endgame-documentary.com.

Oh got it, endgame-documentary.com. There you have it folks. And what we'll do to is will we'll provide you links to this film on the show notes to the podcast. So make sure you check that out. So we're getting close to the end here Shoshana, let's pretend you and I are building a medical leadership course on what it takes to be successful in medicine today. It's the 101 of Dr. Shoshana Ungerleider and so I've got four questions lightning round style for you, followed by your favorite book that you recommend to the listeners. You ready?

Yep.

All right. What's the best way to improve healthcare outcomes?

Well I think aligning incentives to achieve the quadruple aim which is improving patient experience, creating better population health, lowering the cost of care all while increasing the joy and well-being of providers.

Love that, what's the biggest mistake or pitfall to avoid?

Well I think the best way to avoid mistakes or pitfalls is to constantly ask yourself is what I'm doing today serving my overall goal or my mission? I think it's easy to get distracted and off track constantly reevaluating that is really important.

It's a great, great tip there. How do you stay relevant as an organization despite constant change?

Gosh I think there's so many ways to think about this. For me in terms of focusing on culture change I think figuring out how to best leverage social media and staying current which we don't always do the best job of in health care you know on LinkedIn there's 250 million monthly active users Twitters 330 million and that as of early this year Facebook at 2.19 billion monthly active users. So I think leveraging if we're thinking about culture change leveraging the world of social media.

Love that. What's one area of focus that should drive everything in an organization?

Well I think I can tell you what what we're focused on we want all care, healthcare or otherwise to be aligned with people's goals and values of how they live their lives and our end goal as a nonprofit is actually to go out of business or to shut our doors because we're no longer needed. That's the end goal.

Love that. So what would you say your favorite book is Shoshana?

I have several but the one I would recommend is Being Mortal if you haven't already read it by Dr. Atul Gawande.

Love that. Folks, check out all the resources provided by Shoshana here the syllabus that we just put together go to outcomesrocket.health/endwell and you can find all that there as well as a transcript of our discussion today. Shoshana, before we conclude I love if you could just share a closing thought with the listeners and the best place for they could follow or get in touch with you.

Sure. You know I'd like to challenge listeners out there to think about reframing our conversations in healthcare. So what if the entire health care system was geared toward asking patients one question and that question is what are your goals and values of how you want to live your life and then tailoring all care based on the answers to that question and whether it's about treating high blood pressure diabetes or talking about serious illness and end of life. I think this is a way to shift our thinking and move forward. And you can thank you. You can reach me at shoshanaungerleider.com or if you can't spell that which I know it's hard on Twitter @shoshiumd. I'm on LinkedIn, I'm on Facebook, I'm on Instagram haven't yet figured out Snapchat but I'm available.

I love the listeners they have it. Shana has provided several ways, several channels to get in touch with her and her work. Take action, do your part to make this end of life process better for your patients, for your loved ones. And I think in this interview, we've provided multiple ways for you to take action. So whether it be Shoshana's documentaries, the upcoming documentary or just checking out her conference. Do something about it. It's definitely a great opportunity for all of us to tackle, so Shoshana just want to say a big thank you to you for sharing your mind your heart with us and we're really excited to keep up with your work.

Thank you so much. It was great to chat with you.

Hey Outcomes Rocket friends, thanks for tuning in to the podcast. Once again as a leader in health care you have big ideas great products a story to tell and are looking for ways to improve your reach and scale your business. However there is one tiny problem. Health care is tough to navigate and the typical sale cycle is slow. That's why you should consider starting your own podcast as part of your sales and marketing strategy at the outcomes rocket, I've been able to reach thousands of people every single month that I wouldn't have otherwise been able to reach if not started my podcast. Having this organic reach enables me to get the feedback necessary to create a podcast that delivers value that you are looking for. And the same thing goes if you start a podcast for what you could learn from your customers. The best thing about podcasting in healthcare is that we are currently at the ground level meaning that the number of people in healthcare listening to podcasts is small but growing rapidly. I put together a free checklist for you to check out the steps on what it takes to create your own podcast. You could find that at outcomesrocket.health/podcast. Check it out today and find a new way to leverage the sales, marketing and outcomes of your business. That's outcomesrocket.health/podcast.

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Recommended Book:

Being Mortal Illness, Medicine and What Matters in the End

Best Way to Contact Shoshana:

LinkedIn: Shoshana Ungerleider

Twitter:  @ShoshUMD

Instagram:  shoshstagram

Email:  shoshanaungerleider.com

Mentioned Link:

End Well

endgame-documentary.com

Episode Sponsor:

Outcomes Rocket - Steve Sisko

Rethinking Healthcare IT with Steve Sisko, Healthcare Data Technology & Services Servant at Healthcare Data, Technology & Services Group

Thanks for tuning in to the Outcomes Rocket podcast where we chat with today's most successful and inspiring health leaders. I want to personally invite you to our first inaugural Healthcare Thinkathon. It's a conference that the Outcomes Rocket and the IU Center for Health Innovation and Implementation Sciences has teamed up on. We're going to put together silo crushing practices just like we do here on the podcast except it's going to be live with inspiring keynotes and panelists. To set the tone, we're conducting a meeting where you can be part of drafting the blueprint for the future of healthcare. That's right. You could be a founding member of this group of talented industry and practitioner leaders. Join me and 200 other inspiring health leaders for the first Inaugural Healthcare Thinkathon. It's an event that you're not going to want to miss. And since there's only 200 tickets available you're going to want to act soon. So how do you learn more? Just go to outcomesrocket.health/conference. For more details on how to attend that's outcomesrocket.health/conference and you'll be able to get all the info that you need on this amazing health care thinkathon. That's outcomesrocket.health/conference.

Welcome back once again to the outcomes rocket podcast where we chat with today's most successful and inspiring health leaders. I thank you for tuning in again and I welcome you to go to outcomes.health/reviews where you add rate and review our podcast and especially today because the guest that we have today, our outstanding guests. He is a major contributor to Health. His name is Steve Sisko. He is a health data technology and services servant. He's been in the game for over two decades assisting healthcare payers risk bearing provider organizations and software vendors to define, create, deploy and transform their software platforms products and technology ecosystems. He's got extensive knowledge across many I.T. services as well as health services. He also runs the blog called the shimcode.com blog. It's health care data technology and services blog where he posts a lot of his predictions lists on what he believes are relevant to today's health I.T. environment. So with that being said he also does so much more so I want to open up the microphone to Steve to fill in any of the blanks that intro. It's a pleasure to have you.

Hey Saul Thanks for having me too. I hate to say like actually about 35 years in I.T.. But you're right the last 20+ years. Yeah three decades right. Yeah. I'm a young 57. You know I got four kids so they keep me young. So I've been in the health care I.T. and services in various capacities for about 23-24 years I started in 93. You know I've got a long history on social media and that's really helped me make a lot of connections, connecting with people I can lean on meeting new people such as yourself and also people that I can reach out to help out. You know when I need a boost. There's no better feeling than being able to help other people out with no strings attached so that's a little bit about my history.

Hey now that's really interesting Steve and we've had a chance to connect that couple of times and you definitely have an interesting story right, entrepreneur where your company sold it and have stayed in the game since all in health. What got you interested in health to begin with.

Well to a certain degree sort of luck I suppose you know where preparation meets opportunity. But I had been working commercial paper trading for Chicago bank in the early 90s and people that remember 1991 was sort of one of the recession heroes. I got a call out of the blue from a company that was one of the first radiology benefits management firms actually Medicon at the time yeah. They're now AIM's specialty health and yes so I was working for them seven days after they called me.

Wow.

Yeah. So.

Move fast.

Well it's funny because all my best opportunities and I think this goes probably for a lot of people come when you're not looking for them. But back then when I started with them you know they had 14 employees and 18 months later they had 300 plus. And I was the I was hired as the I.T. director with one contract land guy. But anyhow total immersion back than yeah. Back then the health care system you know was was all about managed care people that renumber you know the 90s and there weren't a lot of tools and core systems out there. Back then at least affordable ones. So coming up on 24 years later we've come a long way.

That's for sure. Longway in technology and policy and definitely and most providers are doing so. Steve you've got the history and that's really interesting because you put up some some really interesting less listeners if you haven't had a chance go to shimcode.com That's where Steve puts together his lists on collections of data and technology and other things are relevant to health. So if you haven't had a chance to check that out. So Steve you gather a lot of pertinent information for health leaders today out of all of it. What would you say needs to be top of mind for health leaders today?

Yeah well this is certainly the time of year where all these top of mind things come. You know you mentioned this list of lists that I have out there. But HIMMS is coming up and you know it's conference season but you know keeping in mind that I'm largely on the risk side you know the health plan side sole financial administration quality and measurement are my areas of focus. But I've also had a few years on your provider side you know so things like clinical services order entry procedures precision medicine that I don't have a lot of background in those. But what I would say one of the top things is hands down social determinants of health I'd like to say block change so I'll say it everyone wants their work done that in bitcoin right. So right now my kids buying bitcoin on his credit card. Oh ok so working. You know I think social determinants of health. You know I mean I've been really working on that as my side hustle for a while. And I could share more about that if anyone's interested. But you know I think social determinants of health and also the idea of analytics and our group everything into analytics you know artificial intelligence, natural language processing all these things but basically tools and methods to help gain insight. You know we've got all this data now we've got all this need but we need the insight both you know predictive and prescriptive not just retrospective like we've traditionally had. So particularly in the area of leveraging unstructured and semi structured data. So and actually that sort of fits back into my idea that social determinants of health are a hot topic and that really spans not just just the you know the health plans and the employer groups and the sponsors or the payers but also the providers and then really outside of that areas of service provision that are not typically associated with medical procedures per se. If you can't get to the doctor's office because you don't have a ride that's not a medical issue per se but it's certainly going to impact your health care outcomes and if you don't refill your prescription for whatever reason you can't afford to copay you can't get a ride to pick them up. You're confused about when you needed to do that. These are all things that fall into the realm of social determinants of health so I'm convinced that this is an area everyone needs to focus on.

Absolutely and define a hot topic that came up before Steve. Yeah I mean why don't you talk to us a little bit about how your side hustle is leading to maybe implementing some.

Okay so I travelled a lot for years and in fact about two years ago this coming May I was up in Portland for about close to six years straight. I mean very little time back here in a suburb of Phoenix where I live but I had a lot of downtime in the evenings in the weekends because I would always come home because of the overhead. So one of the things I worked on was a tool and continuing to work on this idea of measuring functional status of individuals so we can't measure we can't determine outcomes if we can't define the metrics and the measures that are available to help us measure those outcomes or results. So there's a lot more than just again the physical procedural aspects but you know you have what's your environment like what are your support relationships what are your the products and the technologies that are available to you. What are you do you live in a food desert. So historically I've been involved with diagnosis codes that was actually to start my first foray into blogging was ICD 10 and because that's what I was working at the time so of course I write about what I'm interested in. So social determinants of health need to be measured and there's no standard way of measuring these things so we have to. Everyone talks about population health but what's a population a population is a a group of individuals. So you have the roll up from the bottom. So what I've been working on there's actually a standard set of classification of functionality in disability it's going to be big with ICD 11 yes. So this is something that you know I have a strong background in I.T. and product management, data modeling, design specifications requirements, so I've been working on a complete set of what I envision as a way that companies could jumpstart their measurement and outcomes measurement needs with a tool so actually a set of API used to be clear and you know I've been working on this on and off and this scary at once I should say the exciting thing and somewhat scary, depressing thing is. 90% of people are talking about this and historically I've always sort of been you know this sounds sort of probably put myself on the back here and it hurts to do that but I've seen things a few years in advance of when they happen or widespread deployed I should say. So I'm convinced that this idea of measuring social determinants of health where we take a baseline as to people's functionality across a whole range of aspects not just physical or or mental or behavioral but they're living in their social networks are really big things like that so I'm pretty excited about it and I'm at a point where I identified a lot of the patent and the other legal and licensing and you know I just I'm trying to develop a set of API that might be used by a wide range of systems be they health plan, or provider or vendor or whatever. So there's a couple of firms out there that specialize in API you know pockit doc and no eligible API and a couple of these other companies so I think this idea of provide an API is sort of a flexible approach where I can pivot if things change.

Yeah. That's pretty cool. And without a doubt listeners we have an array of things that in health do not have a standard measurement. And like Steve's mentioning to us social determinants of health are one of them it can be a big lever to improve outcomes. Just recently we had a guest, Justin Barad. Dr Justin Barad talked to us about standardization needs for orthopedic and cardiac surgeons right using VR for that. What else is out there, listeners that is not standardized yet and what could you do to use technology or just process to help with the standardization of that? Steve, really really super interesting.

Yeah and you know I've always had this idea that the government got to completely bass ackwards with the giant meaningful use. You know they had everyone put in the software in advance of actually defining the standards and the use cases and the communication protocols so you know certainly you know fire the h all seven standard and use cases are really important because one of the areas I've spent a lot of time in and you know my LinkedIn profile sort of bears this up is integration and interfaces so oh yeah you know you've seen one standard, you're seeing one standard because everyone codes them therefore and everyone uses this segment or this loop to put something different and so being able to sort of reduce the variability among the so-called standards is really important.

Absolutely. And in your vision Steve can you share with the listeners a way that standardizing social determinants of health would improve outcomes.

Yeah well OK so so we have to measure things I mean what's an outcome really it's the difference between a baseline or one stake in the ground and then the second stake in the ground and hopefully that second stake in the ground is in a positive forward manner but not always right. So the idea is is that we have assessments of people some of these assessments I can assess someone without them ever knowing it. Right. I mean this is unfortunately well fortunately and unfortunately very common. We know what people buy we know where people go we can infer things from their activities and that but what we need to do is there is you know four or five major areas of these you know body functions of course is one. But then what are their activities and what do they participate in and what do they do. Right. They're a long distance runner who just eat great food and goes to church every day or something right oh they're going to live forever right. But they're a crack addict who who is in a box and drinks Jack for breakfast right. Well they might not live so long. All right. So there's these activities and participation. So which are of course influenced by environmental factors and which include not just your current environment but your historical environment. And then you have body structures and things that are different in body function. So then you could go in there and take measurements where people lie. So these will be prioritized based on individuals or populations. But then you go in and this system that's actually out there and I'm sort of hesitant to actually tip this. But anyone who's listened this far can easily determine what I'm talking about. But it's been out there since like 2011-2012. And what I'm saying is is the new release of the International Classification of Diseases ICD 11 is going to incorporate a lot of this stuff. So but what I'm thinking is is that we need to have a separate set or some complementary set that companies can use to measure things. So when when they bring on a new member they have an employee they do an assessment and then they work with their person to determine okay you know where you live. What do you need help and what would make your life better? You know do you need some sort of legal services? Do you need some sort of education and training? Do you need certain types of vitamins or food or this or that. So I think being able to codify things people get upset Oh you can code everything and S.P. t's are a billing system not a medical system I get that you know ICD codes. Does the diagnosis codes are billing and use for that kind of stuff. Yeah to a certain degree they are but not always and that's what we have. So I think some new way or some complimentary way of being able to measure people's life situation because we all have I mean we all and this stuff some of this stuff is fixed and it's a one time thing and they can go up and down some of it's variable. We moved into neighborhoods. Things happen. We have deaths in the family we have. We win lotteries that change things all kinds of stuff comes around to impact our our well-being and the social determinants health of health are critical they really are.

Steve. Really great insights that you've made here. You know a couple of weeks ago we had a guest Matt Park is from Dacadoo. You guys go outcomesrocket.health/park works with this company at Zurich Dacadoo. And they measure they have a health score. So they use body, mind and lifestyle. They could bring in the Steve component and do social determinants of health to come up with something really interesting.

Yeah there are some companies out there you know and I've heard of this Dacadoo you know our healthify, here in Phoenix. There's a number of firms out there that are entering and living in this space. But my idea is is that there's really no one firm that's going to do it all because it's really a combination and it takes a village. As much as I am all for the individual and and self-reliance. Yeah sometimes it takes a village. OK so let's deal with that let's use that village. So I think that some sort of a means of allowing multiple different parties to contribute and to share their role and individual and a population's health. But being able to collect it on a longitudinal holistic basis not just my little vertical slice.

No totally makes a lot of sense and a great share definitely stimulating thoughts that you've got going on here. Steve and now I'm excited that you're sharing it with our listeners. So give us an example of a time when you had a setback or fail and what you got out of that moment.

Only one?

We just have time for one.

No man, I've had you know I've had a lot of instances where I let my pride and the opinion or comments of others get in the way of fully completing a project or deliverable you know you'll you'll get comments from senior people who might not really understand the opportunity or naysayers. I let them get to me and I an attitude so I'll show you I'm not going to finish this right. So I pretty much gave up on correctly or you know adequately finishing a project just because someone or me. And it ultimately it reflected poorly on me and maybe that's what their goal was and I help them succeed. So you know I've had 30 something years trust me I've had a lot of mistakes. I mean one of the scary or funny ones are most costly ones I ever did a sort of hate the repeat this but when I was just starting in IT, I was working for the Czechoslovak Society of America in Chicago. It was fraternal organization but anyhow I wrote some software and I swapped the previous and the current values in these certificates that they sent out for paid up life insurance and it costs about 100 grand. And they sent them out and then I discovered the error. No one knew.

Oh boy.

And I had to come in and tell the people that this happened and it just so happened that about half of them are right because the previous and the current values were the same but nonetheless they had to redo it and it was a big deal. So anyhow you know. So that was an instance where I had to own up to something at a young age. And I did so anyhow.

And so what pearl would you take out of that. Right. You know you mentioned a lot of really interesting things if you had to leave the listeners with one pearl out of your experience what would it be.

Well follow through to the end and sort of along that lines. Perfectionism is very costly. I got a senior V.P. of a vendor that works with a client of mine that I'm on the phone a lot with is always saying perfectionism is the enemy of good enough or something to that effect. So definitely follow through but avoid being a perfectionist. You'll get to the end a lot faster.

I love it. Steve what a great message. So many of us care so deeply about the things that we do. But in the end we got a ship at the end, we have to ship our idea, our product, or service. Otherwise it won't touch the people that we want to touch.

Right.

Great share Steve. Tell us a little bit about an exciting project or focus that you're working on.

Well I mentioned the social determinants of health. So there's that you know that's self funded and a side hustle and that's just sort of you know out there. But one of the things is I'm creating right now I'm creating a set of for blog post series that each series will have about four to six posts so you know about 20 to 30 posts. And right now I'm at about post number eight and they cover the topics of opportunities in healthcare in 2018 and beyond. Primary areas of digital transformation and health healthcare. One of them is about a specific engagement advisory engagement methodology that this client offers and then just a series on digital transformation ideas in general not necessarily healthcare so. So I've got this blog post series I started out thinking 6-700 words a post. My last post that I finished yesterday was twenty five hundred. Although long form posts are good I guess for cases so I've got that so I'm writing a lot. I've also recently which was sort of on what it's over is I was helping a medical a real estate firm with collecting data on the earnings of the doctors and the special lists and other vendors within those facilities. So gathering up different sources of data and then trying to assess OK what's the viability of this building based on its occupants and the money they're making based on publicly available data. So that was pretty interesting a little bit outside of my recent experience but also right in line with my detailed knowledge of healthcare data. And then of course my technical abilities to map and design.

Yeah super interesting. You're always doing some cool stuff and it's interesting. Lessner it doesn't matter what avenue you take toward helping improve health. You can always find a way to leverage your talents to give to this. You know we had a guest Gavin Teo talked about health care so big. It's not really a vertical, it's an economy with...

Right.

Right, Steve.

Right spot for everyone.

Yes. So there is a spot for everybody. Every talent. Steve let's pretend you and I are building a medical leadership course on what it takes to be successful in medicine. The 101 of Steve. Oh yeah. And so what we're going to do is talk about what you believe will take to be successful medicine. I got four questions and followed by a book and a podcast that you recommend to the listeners.

OK. Yeah.

All right. What's the best way to improve health outcomes?

Well define exactly what your outcome is and how you'll measure it. Because if you don't know you know what it is how are you going to measure it. Keep things short and simple don't over-engineer.

What is the biggest mistake or pitfall to avoid?

Well I just mentioned it earlier. I mean avoid being a perfectionist you know. And also along that line, not letting your pride or your ownership of an idea or external largely oftentimes uninformed people or sometimes people with a hidden agenda get you down or distract you. The old saying write don't let people interrupt you while you're doing the people that say you can't do it while you're doing it. Don't let them interrupt you.

How do you stay relevant as an organization despite constant change?

Well I'm pretty much a one man band with some resources I use. And I can't speak for my clients but I try to stay relevant number one by reading you know voraciously. By participating in social media. By attending lots of webinars multitasking at times watch and listen to the Web in our time writing something. Real life events like the HIMMS conference two weeks from today. Eyup Insitute regional events HIMMS chapters things like that. And again I do a lot of writing and blogging so you have to research and read and put your thoughts down and putting your thoughts down definitely helps you thinking through.

What's one area of focus that should drive everything in a health organization?

Well services management. I think you know we have products and a lot of times those products aren't deployed right. They aren't leverage configured implemented sharing information freely not holding it back which hasn't always served me well but nonetheless it's the real me. So you got what you hear.

Absolutely. And what would you say a book and a podcast you recommend the listener, Steve.

Yeah you know this is corny but I really like to Think and grow rich by Napoleon Hill. I read that my late teens my mother in law recommended it and it has a lot of practical advice so I guess what some people might think some spiritual or higher power advice. But you know I've also recently read a book called Social Selling Techniques something about techniques for influencing buyers or something but social selling it's by a guy named Hughson Reynolds. But it gave me a lot of good insight into the idea of the changing channels and landscape through selling and then podcasting. There's a lot of great health care podcasts but I got to tell you I think Joe Rogan you know if you know who he is yeah I like Joe Rogan's podcast very informative very practical just very practical as you know. And just like no bullshit. And if you're offended by it then you probably have something wrong with you. I think though whatever.

Love it. Listeners go to the outcomesrocket.health/sisko it's Steve's his last name. You're going to find all the show notes, as well as links to the things that we've talked about with Steve, things to his blog as well as some of the pearls that he offered including the books and the link to Joe Rogan's podcast. Steve, this has been awesome. Can you just share one closing thought and then a best place where the listeners can get a hold of you?

You know do things you enjoy. Even if it means doing it for free sometimes to use a gambling term on the column you'll always be rewarded one way or another. Yeah. So you know I'm on Twitter as @shimcode you can check out my blog which you mentioned. And you know you can reach me at steve@shimcode.com and I don't really hide or block things out so if you're happy with me or if you're upset with me or if you're different you know where to reach me.

Outstanding. Steve, it's been fun to have you on. I always enjoy having a conversation I'm glad the listeners will be able this time. So appreciate you taking the time to do it.

Great. My pleasure. Thanks for having me.

Thanks for tuning into the outcomes rocket podcast if you want the show notes, inspiration, transcripts and everything that we talked about on this episode. Just go to outcomesrocket.health. And again don't forget to check out the amazing Healthcare Thinkathon where we could get together took form the blueprint for the future of healthcare. You can find more information on that and how to get involved in our theme which is implementation is innovation. Just go to outcomesrocket.health/conference that's outcomesrocket.health/conference be one of the 200 that will participate. Looking forward to seeing you there.

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Recommended Books/Podcast:

Think and Grow Rich

Social Selling: Techniques to Influence Buyers and Changemakers

Joe Rogan's podcast

Best Way to Contact Steve:

@shimcode

steve@shimcode.com

Mentioned Link:

http://www.shimcode.com/

Episode Sponsor:

Outcomes Rocket - Veronica Combs

Water, Air, Soil and Data and Their Impact on Your Lungs with Veronica Combs, CEO, Content Strategy Solutions

Thanks for tuning in to the Outcomes Rocket podcast where we chat with today's most successful and inspiring health leaders. I want to personally invite you to our first inaugural Healthcare Thinkathon. It's a conference that the Outcomes Rocket and the IU Center for Health Innovation and Implementation Sciences has teamed up on. We're going to put together silo crushing practices just like we do here on the podcast except it's going to be live with inspiring keynotes and panelists to set the tone we're conducting a meeting where you can be part of drafting the blueprint for the future of healthcare. That's right. You could be a founding member of this group of talented industry and practitioner leaders. Join me and 200 other inspiring health leaders for the first Inaugural Healthcare Thinkathon. It's an event that you're not going to want to miss. And since there's only 200 tickets available you're gonna want to act soon. So how do you learn more. Just go to outcomesrocket.health/conference. For more details on how to attend that's outcomesrocket.health/conference and you'll be able to get all the info that you need on this amazing health care thinkathon that's outcomesrocket.health/conference.

Welcome back once again to the outcomes rocket podcast where we chat with today's most successful and inspiring health leaders. I want to welcome you to go to outcomesrocket.health/reviews where you could rate and review today's podcast. Our guest is an amazing health contributor. Her name is Veronica Combs. She is the executive director at the Louisville Institute for Healthy, air water and soil. She's on a digital health project to help focus on asthma. She's looking to reduce this. She's doing a lot of really interesting things around these social determinants of health the environment in order to make health better. She's been involved with the organization for close to four years but previously she's also been a leader in many things that involve health. And so what I want to do is open up the microphone to Veronica and welcome you to the podcast.

Well thank you so much Saul I appreciate the chance to talk to you and share work. We are trying to change the way things get done down here in Louisville Kentucky.

And you guys are doing some really good things and so Veronica did I miss anything in your intro that maybe you want to chat with the listeners about.

Well by training I am a journalist and I worked in newspapers for a while and then I moved into the digital world and at my last job I was the editor of MidCity City News. It's a daily publication focused on the business of healthcare. The publication covers entrepreneurs and digital health and medical devices and when I was the editor we always said technology is going to change healthcare and revolutionize everything and this current asthma project that I'm working on was really a chance to test that and see if that were true or that were just hype. So I was glad to have the opportunity to see how digital health would work in a real world with patients and doctors and insurance companies and advocates trying to make people healthier.

So you hit the road with your thoughts and theories and it's been about four years. How do you feel the thoughts and theories are playing out.

So it you know help is a big complicated topic their parents and their payers and their providers. And it was what was unique about the project was that we brought people to the table who weren't always in the same room together. So this as a project geography was its organizing principle. So it was really Kentucky people with asthma self-insured employers trying to manage their health care bills providers trying to provide the best care for their patients and then people living with asthma trying to control their symptoms and understand their triggers. So you didn't always have the American Lung Association talking with the public health department or the Office of Innovation in Louisville at the Metro Government talking with some of the providers in town. So it was really a chance to see how each person saw their role as. And then also to sort of cast a new role this kind of collaboration that crosses sectors and really challenges people to rethink a little bit. I think turf is always an issue in healthcare. You know this is my role and I like it and I don't want it to change. I think that people are realizing that they have to change to keep up with everything that's going on in health care and are is going on with our society in general. So parents were probably the people that really understood the program. If your kid is at school and they have an asthma attack you want to know that. And for anyone with children it's not always easy to get out of there and what happened during a day so if you have an alert on your phone it says your child is using a rescue inhaler. That's really important information for you to happen if you have a record of that over time that you could share with the doctor that's even more important. So parents were one of the biggest proponents of our work. Doctor certainly saw the promise with the platform that we used from propellor health. There is a dashboard. So we had a respiratory therapist who worked on this project with us. And so she could see everybody in the program we enrolled eleven hundred people we tracked them for up to 18 months looking at their medication use looking at how the different seasons and temperatures affected their asthma. And so doctors can see the promise in having that information. Asthma attacks tend to build over a series of three or four days so if you can catch someone on day one they don't necessarily have to go to the hospital or the E.R. whereas if someone can't breathe on day three of an exacerbation then they're probably definitely headed for the E.R. and rightly so. So doctors could see the promise but then fitting this into their workflow is really a challenge. The program was funded by the Robert Wood Johnson Foundation and it was free to participate. All we asked for was sort of access to people to promote the program. So with doctors offices now we would handle all the enrollment. But doctors are very busy. You know they don't have much time with patients and so it was a challenge sometimes to fit into their workflow. At the other end of the spectrum we worked with self-insured employers. Asthma is worse in Louisville than it is around the country. Nationally the rate is about 8 percent whereas in rural role it's closer to 13 percent especially amongst a vulnerable populations.

I wonder why that is.

Well we are looking right on the banks of the Ohio River and we are surrounded by coal fired power plants. Our own here in Kentucky but also you know in Illinois and Indiana and Ohio and so we're kind of at the very bottom of a bowl. We don't have big tall beautiful mountains like Salt Lake City. But the hills around our city do the same thing which is basically trap pollution on top of the city. So if it's a really still hot day in the summer there's no wind to clear out the air. There's no rain to clear out the air. So we have what I like to say is we have sort of chronic low level pollution. It's not like Beijing. You could always see the building next door to you you're not in a fog but it's always this sort of just enough to be problematic. And there was recently a report that said there are 46 additional deaths every year and the level due to air pollution. And even for healthy people it can take up to a year off of your life. Know it's amazing. Yeah it's sort of a factor and environmental health factor that we think doesn't get enough attention. So part of the goal with the asthma project was to say to employers you really have to care about the air because it's affecting your health care costs. It's affecting attendance at school. It's affecting your your work your employees ability to get work done. So that's why we went to employers to try to bring them into the conversation and tell them why the air is relevant to them. Is always looking for new companies to relocate here and people have told me transplants have told me that they've visited a few times in each season because they've heard the air is bad and they didn't want to move to a place where they can't breathe. So it really is a factor. And as a project that we did at Louisville was designed to sort of quantify this risk and get people talking about the air outside and how it affects our health.

So listeners you know it's something to consider. Right. We're so focused on the four walls of the hospital. Let's start thinking about outside of those four walls. I know I always talk about this ad nauseum but is this so true. And the project that Veronica and her team are dedicated to is focused on just that. You know what is the quality of your air water and soil and what are you doing in your community to bring that to the next level. If you're an executive at a company what are you doing to do your part and as providers in a space what are you doing to do your part. And so Veronica this is super interesting and so when you now you're and you've been doing this project for some time now have you noticed some traction with the goals that you guys have been trying to meet.

So what we did was we took those data. So the technology's centerpiece of the project was a small sensor that sits on top of a rescue inhaler said metered dose inhaler. It's the kind that you compressed to get a dose of medicine. So the Mensur when you took a dose of medicine it record the time and the date it would send that information to an app on your phone trapped in location. So you had this sort of passively collected record of all every time you were having an asthma attack. As long as you're in the program and you know sensor so most of our participants agreed to share their data with us and anonymized version of course and so we were able to create maps of where asthma was the biggest problem in Jefferson County. We really wanted to get down to a neighborhood level. It's intimidating to think about cleaning up the air and all of Jefferson County. It's quite a large county but if you think about this neighborhood has a higher risk than that neighborhood then you should focus your resources to think about planting trees or reducing idling or working with industry to try to reduce emissions so we collected 250000 data points about medication use and because we have a timestep and a location Stant for each one of those medication uses we could associate environmental data with that snapshot in time that point in time where a person is having trouble breathing. So we could know the temperature the humidity the pollen levels pollution levels where in town the person was. And so we created these maps that show where people with asthma are at the highest risk of having an attack. And so the city the city gave us some funds to plant trees. We launched a new alert system with the city to warn people who have sensitive airways of bad pollution days. We've been working with some neighborhoods that are particularly at risk. One thing that was really interesting about the work was that it did change the conversation about air in Louisville. Most of the time when you talk about bad air people always think of the West and on the west end of Louisville there are about 20 chemical plants that date from World War 2 they make synthetic rubber components that go into synthetic rubber. So people always assume that there's bad air in the city it's there with this Asthma map we could show that lack of trees lots of paved services high temperatures all contributed to the risk of an asthma attack. It wasn't just the chemical plant the West and so that made it a broader conversation. One thing at the Institute has done is create a Twitter accounts for each of the EPA monitors around town. So if you could you could see where the air was like in West End versus the downtown business district versus the East End. And we actually got a few metro council members to start following news accounts and it was a revelation to the gentleman in the east then the more affluent part of town that he had air quality problems almost as often as the folks in the West. So it really has raised awareness and has given us I think more accessibility to some to the mayor to some of the decision making process. I can't say that we've won every battle that we've that we've fought but we have definitely changed the conversation and the city rewrote its comprehensive plan last year. We were able to use some of the Azmath data to inform some path and to make some recommendations. And that voice of environmental health backed up by all this data is not usually in those conversations you know about zoning or road building or things like that. So we were able to to use our data to really start policy conversations and get more people talking about these issues.

And that is super interesting Veronica. And so congratulations on getting that going and getting some traction. Sounds like you've had some wind sometimes you haven't won but overall you're definitely raising awareness and listeners it just brings to mind what are you doing to raise awareness. Oftentimes it's just bringing awareness. I mean how clever is that you know hooking up the information from the different areas of town and putting it out there on Twitter so that the conversation is had it's hard to ignore those things. And kudos to you and your team Veronica for having been so creative in figuring something like that. The social component of air. So what can we do as health leaders to apply these creative ideas to help impact outcomes in a really positive way. What do you feel Veronica is next. You've been on this project for a while. How much longer and what's next for you.

So we completed a related project in 2016 and we've just launched a new project again sort of inspired by this asthma data. One of the hot spots that showed up in town was out by the mall has two big malls that right next to one another. There's a ton of traffic you know. Everyone understands what it means when you say yes when Shelbyville road and I've been sitting here for ten minutes waiting to find a parking spot or waiting to turn into the mall. So as it happens so. So that showed up as a hotspot of asthma attacks like I said lots of traffic not many trees lots of pavement which makes the environment hotter which is a risk for a trigger for an asthma attack. And so as it happens right across the street from the mall right in one of these asthma hotspots was a Catholic school K through 8 Catholic school. And they had this big beautiful front yard perfect for planting trees. And as it happens the pope just as we were starting to talk about this project the Pope released his encyclical about how Catholics need to care for the earth because it's our home and because it's the only one we have and because it's just part of the faith and the way we show love for one another and for our planet and for creation so environment is at the top of mind for this Catholic parish. And so we asked them if we could use our front yard for a science experiment what we did was we measured the air quality in the front yard and we had an electric golf cart. We strapped some air monitors to it and we drove in great big rectangles around the front yard to measure particulate matter and nitrogen dioxide at the same time we recruited 60 students and 20 teachers to participate in a health study. And it was quite a big ask of the school. St. Margaret Mary Catholic school has been a fantastic partner for us in this work. The kids and the teachers had to give blood and urine samples and they answered health question about their overall health and their conditions and things like that. And so then we planted 80 mature trees in half of their front yard. So we actually found an old Christmas tree farm that the trees were too big to be Christmas trees but they were still big beautiful trees and pine trees actually do quite a good job of blocking pollution. So they are perfect for a project so aptly played it the trees we measure the air and we did the RAND Health study again and we found that the is the sort of wall of trees that we built that we planted in the front yard reduced particle pollution by 60 percent.

60. How much percent?

60 percent 60 percent. That's huge. Yes and this particle pollution is the kind that gets all the way into your bloodstream. It's so tiny that it can penetrate all your body's defenses basically and go basically deep into your lungs and then out into your bloodstream which is not good at all for your immune system. So blocking this kind of particle pollution is really really important so and the health study also showed some promising results. It was a small group of people so obviously it's not it's not a clinical trial and we can't say definitively but we've found that protective immune cell activity was higher after the trees were planted. What that means is that children were not fighting off this sort of low level constant attack of pollution and these protective immune cells were able to repair blood vessels and just keep the body in good working order. What that means from a health point of view in adults is that your risk of heart attack is lower. So reduce particle pollution. And it seemed at least initially to reduce the risk of heart attack. It has the potential to reduce the risk of heart attack. So we spent about eighty five thousand dollars to plant these trees and hopefully they will be there for many years to come. Again introducing data into some of these health conversations if we think about the cost of statins to reduce cholesterol reduce that risk of heart attack. Planting trees is quite a different solution like the potential has as much power as taking that. And it affects the whole community right whether you're taking patents you know you have to get a prescription and then actually take the prescription if you change in the environment you reduce pollution levels that affects everybody whether you're taking a stand or not.

Yeah that's absolutely a great example and back to the air quality and pollution. There's talk of if you can buy out the elderly in urban areas an air conditioner for five hundred dollars you could prevent a cardiac procedure during the hottest months of summer. So.

Right

What can we do for our communities to affect health in a positive way and Veronica is doing an amazing job with her efforts with the air quality in her community. What can we do in ours and such a great story. And how wonderful that the church and the Catholic school was able to align with you guys and participate in a very meaningful way.

Yes. That's why we really went to bring corporations into these conversations nonprofits. We really need partners that will step up and say yes I will help out with this or yes I will try this. We had seven employers in Louisville who participated in the asthma project metro level employees Humana Brown-Forman which is a spirits company here in Mobile if you like bourbon and you should know about Brown-Forman kindred is a long term care company. So what really we could not have done the work without those partners at a public health department was very involved. And so I think it really is it's a different way to look at health. When you bring all these people to the table and not necessarily say what can you do differently but certainly how can you contribute. How can you help change attitudes and come up with new ideas and just help us test some of these theories because you're not always going to pick the right theory but at least you're moving in a different direction.

For sure and you know one of the things that could happen is you just feel like what am I going to do. Like how am I going to make an impact with such a little stamp. And the reality is you got to start with a small stamp and work from there. So don't feel like what you're doing is not gonna make an impact. It starts small. Would you agree.

Yes. Yes I think standing up and volunteering and saying how can I help. I think that's what's so exciting about the digital health world is there. There are entrepreneurs and their doctors and nurses and pharmacists who are willing to try something different. I think it's easy to be sort of negative and say well we tried that already and that didn't work or well you don't understand what it's like to have diabetes so you couldn't possibly build an app that would work for me who has diabetes. So I think that it's really important to keep trying new things and to support entrepreneurs and innovators and say yes more than saying no. The institute I recently participated in a discussion about failures and how and I think that's even more important to talk about what didn't work because then you can save the other people from the pain of making the same mistake that you can you know make this sort of trial and error more a normal part of our work instead of having this high stakes of have to make the right bet every time. So there are consequences for making the wrong bet. But there are equally bad consequences for doing nothing or just being afraid to try.

And on that topic Veronica Can you share an experience where something didn't go your way and what you got out of it.

So one of the initial as you mentioned the institute is about four years old and our very first project was called was centred around the air quality egg. And one thing that we would like to do is to get people to understand the air in sort of their neighborhood. So right now there's one air quality score for all the whole Jefferson County. And it's a big county in that one score doesn't really reflect every neighborhood. It's too big of a number. We need a more fine grained analysis of what the air is like and at least my little corner of my quadrant of Jefferson County or my neighborhood. And so these air quality eggs were new technology low cost sensors. They had a Wi-Fi connection. So the idea was you would hang this on your porch and it would tell you what the air was like in your neighborhood. So we thought oh citizen science importing new technology you know getting more awareness. Well it turned out that the initial version the first version of their quality egg was trying to measure several pollutants and it was just way too sensitive. So it was telling people the air was bad when the air was fine and the institute has always tried to sort of be a neutral party where we were really about science and education and data and not necessarily a particular political point of view. So we've tried to maintain good relationships with the city and the people who are officially in charge of the air. And so as you can imagine us telling people the air is bad when it's not doesn't help our credibility.

Right. Right.

Enemies of the people who are officially in charge of the air. So that was kind of a stumble. But it did give us a lot of insight into the censors. It told us who in the community was interested in this data and then it really helped shape the asthma project because with different sensors and a broader scope of data now assess we could get to some of those we could get to what we wanted to get to which was a little more personalized take on the air quality in someone's neighborhood without relying on this technology that is too sensitive. So and like I said it opened a lot of conversations. We learned a lot and we felt like we were setting an example of not being afraid to be a pioneer. We planted a few arrows in the back for our air quality egg project but we learned a lot. And it certainly informed our work to help it be more successful as you went forward.

Yeah thank you for sharing that Veronica. It's just getting out there. Everybody it's getting out there and doing your part. You're going to make mistakes. You're going to have to tweak. You're going to have to recalibrate like Veronica and her team did with the egg. And so yeah it's all about getting out there and doing and reiterating so Veronica we're at the point of the interview where we build a leadership course syllabus on how and what to do to improve outcomes. That's the 101 of Veronica Combs. So I've got four questions for you. We're going to do the lightning round style and then we're going to follow that with a book that you recommend to the listeners. You ready.

Yes.

All right. What's the best way to improve health outcomes.

Listen to the person whose health you want to improve. Don't assume a blanket solution. I would focus in on a person and a particular disease sate and talk to that person as much as you can to understand what life is really like for that person's health and how he or she would recommend improving the outcomes.

And to take it a step further and focus it on the air quality. How do we improve air quality outcomes.

Well you could plant a tree in your front yard you can telecommute instead of driving to work every day. You can get an electric car. You could look into banned pools Louisville has a vanpool service that every time they add a new van it fills up. So if you can clean up the air and have a little more time to read or or catch up on e-mail in the morning that that's a win for you with the individual and the air.

Awesome listeners take note of those options and think about how you could clean your air. What's the biggest mistake or pitfall to avoid.

I think that one solution will fix all that I think health care is so complicated. You know there are pediatricians and their heart disease specialist and there are surgeons. I think that you really have to focus on some of the biggest challenges are focused on what's most important to your practice or to your health system and focus in on that and certainly take best practices but don't assume that what works for pneumonia patients will also work for heart disease patients and health care is just so complicated. I guess the short bishes never underestimate the complexity of the health care world.

How do you stay relevant despite constant change.

Being willing to learn and being willing to say I don't know. Being willing to question your assumptions and read I think is keeping up with what's going on and keeping an open mind. We'll hope you incorporate changes into your own work whatever that feel that might be in and understand where you may need to do more aware what you have is working well.

What's one area of focus that should drive everything in your organization.

I think it sounds like a cliche but listening to your customer. I think so often if you're a physician you've never used your patient portal or if you're an entrepreneur you may not have the disease state that you're focused on building an app or building a service for. So I think getting in there experiencing it yourself really changes your perspective for a while. I was keeping a running list of healthcare executives who would make these grandiose statements about how patients just need to try harder and their waiting would work and then those same executives went through a traumatic health care situation of their own cancer or an accident and suddenly they realize that it's really awful to be in the E.R. It's really hard to get your health care records so I think being willing to walk through your own customers experience will give you a deep level of insight that you won't have otherwise.

That's a great insight. What would you say your favorite book is that you recommend to the listeners on the syllabus.

Gosh favorite book. That's a hard one. I'm reading when right now. But you know I really like fast company and I read a lot of analysis online. I think that that helps me read more I guess to staying up with analysis and thought leaders in the spaces is really done more for me than any particular book so I tried to sabotage her question there but.

Sounds good. It's a good perspective. You know typically we do get a book title but yeah you know there's people in the space that are doing a lot of thinking why not dive into their thoughts any particular blogs or people that you follow that you want to recommend.

I try to sort of mix it up. I like to always be reading a venture capitalist blog. I like to read what a doctor has to say. I like to read what pharmacists have to say so I really I'm not particularly a loyal reader. I guess I like to mix up the people that I'm reading but I think consciously picking people from different sectors that maybe you don't know anything about. Again that just sort of informs your perspective and helps you see something from experience that you haven't had or see some see and experience that from a different point of view. And I think that really helps you strengthen your business in your offering and just the way you approach work in general.

Veronica I love that response very non-traditional just like you. That's that's just how you roll.

That's right.

Listeners don't worry about getting any of this down. All the show notes as well as links to Veronica's organization and the projects that they're working on are available at outcomesrocket.health/combs That's Veronica last name you could find all that there. And Veronica before we conclude I would love if you could just share a closing thought. And then the best place where the listeners could get ahold of you or follow you.

My closing thought would be to look at your work or look at your projects or look at your personal network and consciously and by someone into your circle or to lunch or to coffee that you don't know anything about their work or you don't know their perspective. Maybe that means looking for someone with a chronic condition or looking for someone who has worked in Pharmacy or medical devices or something. I really encourage you to go out and find someone that you don't know anything about their work and you would really become a student if you were asking them about their work and I find that if you're willing to buy a cup of coffee or buy lunch. Most people are happy to share their experiences and to offer advice and I think broadening your perspective will help you individually. But I think it also helps healthcare leaders really see everyone that needs to be at the table. So you know like I mentioned with the asthma work ringing people in the same room that aren't usually there together. It changed my perspective. It helped those participants see their work a little differently and we had the Nature Conservancy on our Community Advisory Board. I don't know if they ever talk about asthma but they certainly know about trees so connecting that to really set off a cascade of relationships that we wouldn't have seen before. So I think that I think that's really important for health care in general to invite someone new to the conversation that maybe you're not sure what they would have to contribute to but it never hurts to learn and ask.

Absolutely. And where would you say the listeners could get in touch with you or follow you.

Well the Institute for Healthy Air water and soil.org is our website and we have a blog there. We did participant report cards for the astral project and for the Catholic school project that I mentioned so you can find all the details that instituteforhealthyairwaterandsoil.org. And then I'm also on Twitter at @vmcombs and I'm on linkedin too.

So awesome.

Different places.

Beautiful. So listeners will have all the links to connect with Veronica if they have something she said resonated with you. Reach out and find out how you could collaborate. It's outcomesrocket.health/combs. Veronica it's been a pleasure to talk about air and the quality of air and just thinking deeper about the things that can affect us in our day to day. Our health that we usually don't consider so really really thank you for taking the time to be with us today.

Well I appreciate it for the chance to talk about our work. Thanks very much for having me.

Thanks for tuning into the outcomes rocket podcast if you want the show notes, inspiration, transcripts and everything that we talked about on this episode. Just go to outcomesrocket.health. And again don't forget to check out the amazing Healthcare Thinkathon where we could get together took form the blueprint for the future of healthcare. You can find more information on that and how to get involved in our theme which is implementation is innovation. Just go to outcomesrocket.health/conference that's outcomesrocket.health/conference be one of the 200 that will participate. Looking forward to seeing you there.

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Best Way to Contact Veronica:

@vmcombs

Linkedin - Veronica Combs

Mentioned Link:

http://www.instituteforhealthyairwaterandsoil.org/

Episode Sponsor:

Steve Miff is the President and CEO at PCCI.  He is a seasoned executive & growth champion with 20+ years experience driving revenue through the launch of innovative products and channel partnerships across the healthcare continuum, particularly in healthcare analytics and consulting.  He is a national thought leader with over 100 peered-reviewed and independent thought leadership publications.

Steve earned his Ph.D. and MS degrees in biomedical engineering and a BA in economics from Northwestern University. He has been an adjust professor of Biomedical Engineering for 5 years. He served on the Senior Board of Examiners for the Baldrige National Quality Program and on the Executive Quest for Quality Prize Board Committee for the American Hospital Association. He is on the Editorial Board for the Journal of the American Health & Drug Benefits and on the Advisory Board of NurseGrid, Inc.

Why Healthcare?  Steve comes from a family of physicians and he always wanted to give to patients in their time of biggest need with the use of analytics.

Hot Topic that should healthcare leaders agenda:  How do we deliver more personalized and precision medicine?  Analytics and integration of care with communities and social services so we can influence the social determinants of healthcare.
 
How have you created results by doing things differently?  The success we’ve had is due to the time spent with various stakeholders in technical, legal and administrative groups in order to get the system off the ground.  We address the human element and make specific models targeting specific indications (like pediatric asthma).
 
Setbacks that you learned from:  “Fail early and fail often.”  In 2008-2009 while at SG2 we built an algorithm for a value index that provided many useful metrics.  It was powerful, elegant in design, however, it did not take off.  Lesson learned:  If you build an outstanding product that is useful and elegant (a nice to have vs. a need to have) and if there is no incentives to change, the market will not adopt it.  Innovation must be grounded in solving real problems.
“Let’s not lose track of the fact that we are making progress.”
 
Proudest leadership moments:  Joining the PCCI team.  Really proud to reimagining the way we’re going to be addressing our healthcare problems.  Also super proud of the team at PCCI.
 
Exciting Project:  Doing things like using the Amazon Echo to help address issues with medication management and other things to reach patients in their home.  Working together with the support of Parkland Health is a great opportunity.
 

Steve’s 101 Course on Outcomes Improvement:

1.  What is the best way to improve healthcare outcomes?

Work upstream and concurrently address social determinants of health.

2.  What is the biggest mistake or pitfall to avoid?

Innovate but focus on real problems at the point of care.  Involve all stakeholders ina concept design.

3.  How do you stay relevant as an organization despite constant change?

Be both a listener and learning organization.  Stay connected to patients, providers, community, and government.  Focus on who you are and what you do best.

4.  One area of focus that should drive everything else is:

Start with your people.  Create a sustainable culture to help drive your mission.

Steve’s Recommended Books
 
Closing Thought:  The more we learn from each other and the more we collaborate the farther we’ll go.
 
The Best Way To Contact Steve:
 
Resources:
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