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: 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.
: 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.
: 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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