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Bill Klaproth (Host): Upper Chesapeake has worked diligently over the past few years to develop programs that aim to improve the overall health of the community and reduce the need for expensive hospital services. Wil me today is Dr. Nivatpumin and Colin Ward to explain what population health is, if it affects the way providers practice and the ways Upper Chesapeake has developed programs to improve the health of the community.

This is The Hero Podcast from UM Upper Chesapeake Health. I’m Bill Klaproth. Colin, let’s start with you. What is population health and how has Upper Chesapeake developed programs to improve the health of the community?

Colin Ward MHS, DrPH (Guest): Well we kind of loosely define population health as the identification of a group of people and that could be residents in an assisted living facility, or it could be cancer patients in Hartford County, or it could be kids in the Hartford County Public Schools. And we work to try and identify the barriers that they have to achieving their optimal health status, whatever that status may be, and we do that by usually partnering with different organizations across the county and across the care continuum. So, we’ve had success working with as an example, The Health Department and The Office on Aging and even our county EMS services to create programs that identify a challenge with a particular population and help us put a focus on an area of need for them. It might be a medical need. It might be a social need. It might be even about identifying that patient’s engagement level. How ready is a particular group of people to change a health behavior?

And so, in some cases, we are also working directly with businesses or faith-based groups on prevention activities. So, talking to church groups about what a cardiac healthy diet might look like. And so, we try and partner with folks all across the community and come up with programs that can really hit the right people with the right kind of interventions at the right time.

Host: So, hitting the right people with the right interventions at the right time. So, let’s keep the focus on the community. As people have become more savvy and searching the internet and using technology to help their care; Dr. Phil, how have your interactions with patients changed over the years because of this?

Philip Nivatpumin, MD (Guest): Yeah, it’s changed dramatically from when I started about 20 years ago. I mean patients with the internet have so much more information. They have a lot more expectations and that’s a good thing. They come in armed with a lot of data and there’s a lot of good objective data out there online and they want differing opinions, so they are not just coming to you, they are seeking other people and they have a lot of choices. They can go to multiple areas in the region and even around the country and they can access that data in real time, and they can bring it to you and kind of cross compare.

So, it really means that the physician has to embrace that, and the provider has to be open to that and realize just like we want choices when we buy something online or we go to make a travel arrangement and book a plane ticket; we love that from the consumer standpoint and so do our patients. And you know Doug telling them what Colin said about population health; providers are really having to think about – there’s a lot more to the health of our patients than just that 15 or 20 minutes in the room with us and their blood pressure or their disease or whatever. There is their home life, there’s their meals, there’s their socioeconomic status. So, we are having to learn about things like population health that we really didn’t understand, or we weren’t really educated about in our medical training and we have to really get upskilled on that in order to provide a better service to people and have better healthcare.

Host: Yeah, the internet certainly has changed a lot of things and disrupted many industries. So, speaking of interactions with patients, Colin, let me ask you this. How has the culture of clinicians changed then over the years as population health has become more prominent?

Colin: Well I think as Phil was referencing there, it has just been a greater awareness of how each physician or clinical provider’s decision making impacts a patient downstream. So, if we don’t get them this test today, are they going to have the transportation to get to that test tomorrow? And we’ve had cases where in the skilled nursing facility we are attempting to recognize much earlier who a candidate for telemedicine service might be to avoid an ED transfer.

We had a patient who we probably needed to cut this patient out of their home to bring them to the hospital and now our teams including EMS are saying wait a minute, if we cut a hole in this person’s home, then they are going to condemn the home. They are not going to be able to return after we provide the medical service. So, instead, let’s think about what services we need to bring to the patient in the home instead of creating a domino effect, creating another problem by literally cutting a hole in this patient’s home to extricate them.

So, we’re seeing a lot more thought process go into how each individual decision can have an impact on that patient downstream.

Host: That’s interesting and a really good point about the though process and how one decision may affect something else. So, Dr. Phil, let me ask you this then. How will innovation, since we are speaking about all these changes; how will innovation in healthcare affect what providers do in the future and how will their jobs change?

Dr. Nivatpumin: Well just like what Colin was saying is we need to understand that there is a lot of different things that go into affecting someone’s healthcare and their life and the what’s called social determinants of their health and providers are just one portion of that. So, one way that innovation is affecting things is that there’s such an explosion in data and biomedicine and pharmaceuticals and really, it’s beyond the scope of any one person or provider to really know everything. And so, just like Colin was talking about, we need to rely on nurses and social workers and people in the community and public health and other services. When we are actually in the exam room with a patient with say like cancer in my field; half of my time with patients now is just sitting at the computer, going over their three dimensional imaging, explaining and walking them through stuff and looking at best practices around the world together with objective data. Not just from say what was 20 years ago, which would just be like what do I think my subjective opinion.

No, it’s really, we have accessible data from tens of thousands of cancer patients with a similar situation like you. And so I think providers are really having to learn how to access all these different people in the healthcare system, learn how to interpret all this explosion of data and as we are seeing machine intelligence and artificial intelligence come and help us interpret this data; really to cultivate their own empathy as they sit with patients and explain that and sort of be like a copilot with the patient more than just the “captain of the ship” as it was in the past.

Host: So, it really is more of a partnership these days. Colin, let me turn back to you. Let’s talk about the Maryland Primary Care Program which is hoping to transform care in the community. How is Upper Chesapeake working to succeed in this new program?

Colin: Sure. The Maryland Primary Care Program is actually based on a national Medicare model called CPC Plus or Comprehensive Primary Care Plus. And in a lot of ways, it’s sort of back to the future where you have physicians that are supported in the practice with nurses and potentially social workers. But the idea is to look at each patient in a more holistic way, support them with physicians that are doing doctor things and nurses doing nursing things, addressing the social determinants of health that Dr. Phil was referencing in a way that allows patients to actively participate in their care.

And so, some of the transformation is about how we introduce a pharmacist into a primary care practice to really look at medication management for certain patients and make sure they are on the right course of treatment and make sure that they don’t have any duplications. And some of the innovations for that may be around technology. So, how do we introduce what’s called remote monitoring programs. These are devices that are wireless, and Bluetooth enabled scales where you can get a morning weight of congestive heart failure patients.

But the idea is that the physician in the primary care office and the patient all of that care is sort of revolving around those patients in such a way that you are heading off any potential worsening of that patient’s clinical condition.

Host: So, with the patient as a participant in their own care. Dr. Phil, what makes for a strong patient provider partnership during the care process in a time of transformation?

Dr. Nivatpumin: Well as Colin alluded to all the different changes happening at the local level and from a larger policy national level; with skill, the patient provider relationship with trust and with openness and with competence is really still what everybody wants. I think we see a lot of frustration that alluded to on the side of patients, with the cost of care access. Everybody has heard of that kind of thing, the Byzantine Complex nature of healthcare and on the provider standpoint, you are hearing more and more about people being burnt out. There’s an overwhelm with the electronic medical record and a lot of the administrative burdens and so I think the future has to be where we realize that one, we embrace it, that change is going to happen. We can’t put our heads in the sand either patients or providers or anybody in healthcare that the current situation is going to remain going into the future.

Number two is we have to realize if we look at other parts of the economy, like in again, transportation and how we buy things on Amazon.com, how we travel on Uber and those kinds of sectors of the economy; they have been transformed dramatically to be made more efficient, more personalized and deliver better service. And so, we in healthcare are delivering better health outcomes and that has to be the focus.

And so, in order to improve that patient provider partnership; I think it requires work on both sides. We need patients to do their part, really emphasizing more knowledge of their disease, taking a more active role in their condition, making better food choices and health choices and us understanding how to help them make those better decisions. And on the provider standpoint, we really need to embrace the future and realize that we need to deliver a better product that’s more objective and competent and standardized that will result in better or satisfying outcomes for people.

Colin: Phil reminds me that my food choices are terrible for a population health leader. So, I have to make sure I do a better job of listening to my doctor.

Host: Well, you know, it’s always a good idea to listen to your doctor Colin, especially Dr. Phil. So, Colin, let me stay with you. We talked about patients when it comes to innovation and care transformation. We talked about providers when it comes to innovation and care transformation. How has the board of Upper Chesapeake supported innovation and care transformation?

Colin: Well this is very difficult for a lay board to get their heads wrapped around because if we are successful in some of the things that Phil has described, we actually would have fewer patients coming to the hospital. And so, it’s not often that you hear the Chairman of the board of General Motors saying heh, we just built this beautiful wonderful new car, don’t buy it. And in a way, that’s what we are saying here. Is we’ve got a wonderful healthcare system that provides high quality care, you are going to get the best cancer treatment in the state here at Upper Chesapeake, but our goal really is to not have to have you ever need it or delay that need.

So, that can be a challenge. Our board has really embraced that. I’ve been here a little more than five years and they’ve been very supportive of our efforts to create new programs or experiment with care delivery systems. Sometimes they are asked directly to approve a project or a funding request. More recently, we’ve had education sessions. So, we had a sort of board innovation retreat a few months ago where we brought in someone to talk about what possibilities exist in healthcare and innovation specifically.

And Dr. Phil Co-Chairs a recently commissioned board work group on innovation to help us do two things really. Is to identify and implement innovative ideas that will help provide better or more efficient or lower cost care to patients. And also to help us create a foundation for a culture that values ideas and input from our frontline teams and hopefully it again, leads to better health and better care. This work group is just – it’s in the early stages but we really hope that we will be over the next few months able to demonstrate some early wins and really lay the foundation for future innovations here in Hartford county.

Host: So, Colin staying with you, it sounds like the board has been very receptive to this. has this been easy to sustain and is there anything you’d do differently?


Colin: Well not all the programs are going to work out of the gate. And I think this is where the board has been helpful is the understanding that if we try ten things that the likelihood is one of two of them are going to fall off or they are going to prove to not be successful. We have made strides with Telemedicine; we’ve made strides with our high risk programs for certain patients. Even things like the way that we process certain lab tests go from multiple days down to an hour to be able to introduce or purchase the technology that can really shorten that duration down significantly so that the clinician can make a more timely decision.

Those things have been implemented and they really almost always have a champion and so someone that is accountable in driving that program forward, understands the data, understands the pain points for the different folks and in some cases, you are trying to combine cultures. So, a Telemedicine program that links a skilled nursing facility with an acute care hospital at Upper Chesapeake; you have two different cultures that you are trying to merge and to the degree that you have a champion; you can really begin to blend the thought process down and you can blend the way that people consider the opportunity for patients to benefit from these programs.

And we’ve had success with Dr. Barreto and Tanya Appleby leading that Telemedicine program as an example and we have been really the only one in the state that has continued this skilled nursing facility Telemedicine program four years after the grant was initially awarded to us. So, it really boils down to having a champion, somebody that is going to be accountable to themselves and drive accountability of our team. And that’s really what the Hero culture at UCMC is all about.

Host: That’s really interesting. So, let’s wrap up. I’m going to ask you both each the very same question. I’m going to ask you to pull out your crystal ball now and gaze deeply into it. So, from a provider standpoint, Dr. Phil, what is the one change you expect to happen in the future that truly unlocks the potential of the healthcare system?

Dr. Nivatpumin: I think there’s maybe two that come to mind. One is there’s a revolution ongoing now related to DNA technology and genomics. I often tell patients that the first human genome sequence of DNA took 10-20 years, labs all around the world. It took three billion dollars to that first genome sequence. And then now it’s a few hundred dollars and it’s done on a tabletop machine the size of my computer and it takes a day.

And that’s only going to be cheaper with each successive year and that has resulted in things like in my field, in cancer, two to three hundred different drug indications for treatment in the last three years alone. Which is more than there was in the prior 15 years. And so this is only escalating. Things that were incurable, devastating ten years ago or 20 years ago when I was in training are now routinely curable and really just not a big deal. And so that is already underway.

That combined with the second innovation which most of us have heard about which is this machine intelligence, the kind of software revolution that’s underlying like facial recognition software and how we do Google searches just to give a brief example. Again, when I get patients, we get a biopsy, their cancer, they have genetic defects that we want to target; there’s thousands of these things that no human even if you are a genius working in a top lab at whatever university can interpret that. But we get these reports and machines have interpreted those and given us advice on what are the relative treatments available and clinical trials around the country that are available. And that’s already in place and so, that is only going to accelerate the combination of those two things, genomics and machine intelligence. And that to me is going to lead to a much better, more objective improvement in human health.

Host: That’s really exciting what’s happening in healthcare right now. All right Colin, step up to that crystal ball, gaze deeply into it. So, from a population health standpoint; what is one change you expect to happen in the future that truly unlocks the potential of the healthcare system?

Colin: Well I wish I was as sophisticated as Dr. Phil. But my answer is not going to be nearly as exciting. But I do think that there is an opportunity for healthcare systems, under the population health umbrella to get better intelligence about the people that can be helped or are ready to be helped. And by that, I mean, we historically have had a decent ability to diagnose a medical issue and understand medical risk and as Phil mentioned, I think that is going to become even more precise over the years.

We’re getting better at, but not quite there yet in terms of understanding the social determinant, so what could take a person from healthy to unhealthy is about their diet and their transportation access as opposed to anything else in terms of medication. But the third thing is that patients themselves are ready to be engaged or potentially not ready to be engaged. There’s a rationality to the way that they experience care.

And depending on where they are, they may not be ready to make the diet changes or exercise changes, or the lifestyle changes that Dr. Phil and his colleagues know are important for a patient. And so, I think over time, we’re going to get better at being able to identify patients by their needs and tailor medical or social or other support needs directly to those patients in a way that we’re starting to see with the precision of medicine.

Host: Very well said. Gentlemen, thank you both for your time today. I really appreciate it.

Dr. Nivatpumin: All right, thanks for your time Bill.

Colin: Great yeah, thank you.

Host: This is the Hero Podcast from UM Upper Chesapeake Health, a podcast for internal communications. Please visit www.umuch.org to learn more and check back for our next episode soon. And thanks for listening.