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Dr. Peter Margolis, M.D., Ph.D., Co-Director, Center for Health Care Quality, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio contributed this in-depth interview on August 5, 2009 about his life work to improve medical care for children, support for families, and operational efficiencies for health care staff.
Collaborative Health Care Transforms Systems of Care Delivery for Children
Introduction
I’m Peter Margolis, and I’m Co-Director of the Center for Health Care Quality at the Cincinnati Children’s Hospital Medical Center. I am a general pediatrician and epidemiologist. The work that I do is focused on transforming systems of care delivery for children. |
We work in many different parts of the country with many different types of settings, everything from hospitals to primary care practices to communities, states, early child care centers, social services, trying to help create better systems of care that produce better outcomes for children. This is part of Cincinnati Children’s Mission to improve care and transform care delivery for children. The way that we operate is by forming and bringing together groups of clinical sites generally to work on specific problems.
What are you most passionate about?
[00:01:38] My own passion comes out of my experiences as a pediatrician recognizing how hard it is for individual physicians to produce the kinds of outcomes that we’d like to produce for children without being part of a supportive system. I’m very interested in how to create theinfrastructure, the things that surround one on one medical practice to help people improve. That’s work that we’ve done for probably close to twenty years now.
[00:02:29] Some specific examples of the kinds of things we’re pursuing passionately now include trying to connect subspecialty pediatricians who take care of kids with chronic illnesses together better so that they can share knowledge about how to create more effective care delivery systems. We’re also very passionately interested in population health; not just taking care of the people who come in the door but also creating ways to affect the health of entire communities. Early childhood education and
outcomes and behaviors are a big area of focus; better use of drugs and other therapeutic devices is another focus, and we’re also interested in developing innovative ways of providing care so we are starting to look at ways of using social networking platforms to enable patients to communicate better with each other, provide better social support for each other, also, potentially to communicate better with physicians, so that the interaction between patients and physicians is not based so much on episodes of care, but it is more continuous over time. Some of the social networking platforms offer an opportunity to do that.
[00:02:29] Some specific examples of the kinds of things we’re pursuing passionately now include trying to connect subspecialty pediatricians who take care of kids with chronic illnesses together better so that they can share knowledge about how to create more effective care delivery systems. We’re also very passionately interested in population health; not just taking care of the people who come in the door but also creating ways to affect the health of entire communities. Early childhood education and
outcomes and behaviors are a big area of focus; better use of drugs and other therapeutic devices is another focus, and we’re also interested in developing innovative ways of providing care so we are starting to look at ways of using social networking platforms to enable patients to communicate better with each other, provide better social support for each other, also, potentially to communicate better with physicians, so that the interaction between patients and physicians is not based so much on episodes of care, but it is more continuous over time. Some of the social networking platforms offer an opportunity to do that.
Below: Listen to the complete interview with Dr. Margolis,
What would you like people to know, think, feel and do?
[00:04:07] The kinds of things we’d like to see people and society do is to put greater investment into the development of network based approaches to care delivery. Probably the best, a couple of really great examples in medicine already exist for this concept. Probably the best example comes from children’s cancer, so there, pretty much every child with cancer in the country is involved in a large network of care providers so that the care a child in Idaho gets really looks pretty much identical to the care of the child in New York City. That comes from the fact there’s an infrastructure that enables protocols and treatments and best knowledge to be disseminated very rapidly to everybody who provides care for patients with cancer. The particular problem in children that we have is that there are very few children with serious chronic illnesses in any place. So that, as a clinician, if you want to make sure somebody’s getting the best possible care, it’s really impossible to do it based on just the information from your own center. There may be just too few children to really study and evaluate the effectiveness of the various treatments. So, by linking people, linking care providers, and physicians up across multiple sites, it provides the sample size, the number of patients you need to really study and evaluate what is working and what isn’t. That also provides a way; the standardization of care actually provides a way of improving care. A lot of patients fall through the cracks because of a lack of communication; doctors and nurses working as hard as they can but not being able to deliver the best care because of the limitations of the system. So, those are the things we like people to know about.
What do you see for the future?
[00:06:16] This whole issue of how to improve care delivery is extremely hot right now with the emphasis on healthcare reform, the need to develop better systems of health care delivery. I think there’s growing interest in the potential of understanding how network effects, at all levels – both at a social level as well as a molecular level are important in determining health outcomes, so I think this area is only going to grow.
What category of the Innovation Framework do you primarily invest your time and attention? Brainpower? Networks? Quality, Connected Place? Dialogue and Inclusion? or Branding Stories?
[00:06:53] I think the things we work most on are creating a technical and social platform for networks to form and develop so that when we work in a particular area we identify a number of sites who want to work together, we provide them with a framework and structure for linking specific activities that they’re doing in delivering health care to the outcomes we are trying to achieve, so for example when we’re working with ICU’s (intensive care units) on reducing bloodstream infections we may identify particular care activities like how they insert IV’s or catheters into the body, or how they clean them and maintain them, or how they monitor their performance, we provide them with that framework as a way of enabling them to, a word I use is “calibrate” so that they have a set of common words and tools and way of looking at the task at hand so that they can actually communicate with each other. That is part of the technical platform.
What secondary categories are you interested in?
[00:08:22] Then there are ways of communicating, which again, I think you call “inclusion and dialogue”, so we provide them with, they may come together several times during the year: face-to-face meetings, we include social components in the meetings so they get to know each other on a personal level, we support their ongoing interactions through conference calls, email, there is usually a website that they can go to where they can interact. We also stimulate interaction by feeding back data to them about their performance so they can see whether or not their actions are related to the outcomes they are trying to achieve.
Which category would you like to collaborate with next?
[00:09:03] The area that we’re finding that we need to get into more is that we’ve been taking an approach that’s really kind of science and data focused and we’re realizing that we’re in order to get this style of working to spread, we’re going to need to start to communicate in stories and connect sort of the day-to-day work of delivering care to the emotional aspects of what we’re trying to do and why people went into medicine and that sort of thing.
Images © Copyright Alice Merkel. All Rights Reserved.
What research areas interest you? Why?
[00:09:36] Let me give you an example of networks. I had mentioned before that we’re working on the subspecialty care of children’s chronic illness. We currently have networks forming of physicians to work on inflammatory bowel disease, intensive care emergency medicine, and the treatment of pain in children, supporting children with severe cardiac problems who are undergoing surgery and recovering from surgery. Each area, each topic, is it’s own network of anywhere from fifteen to forty clinical sites working together.
Our hope is that we could expand the participation to get virtually all care sites working on a particular topic and so for example, for pediatric ICU’s, that would be about 350 ICUs across the country, for inflammatory bowel disease it’s probably about 250 care sites that deliver care for children with that condition.
[00:10:56] I think our expertise developed over the last twenty years has been really in developing and running distributed projects, large-scale efforts that depend on collaborative partnerships among groups. Our major research now is learning how to scale up what we’ve been able to do at a scale of twenty to forty sites at once to a much larger scale potentially involving thousands of sites at once.
Our research is really on a variety of different dimensions. One dimension has to do with using specific methods: in our field we use quality proven methods which have not been used widely in medicine as a way of rapidly adapting new ideas to clinical care. On a methodological side, we’re interested in understanding the contextual factors that enable specific teams to succeed in being able to improve care. So, what we observe, is that some sites that participate in these networks are much more successful in proving outcomes for kids than others and that may have to do with the amount of resources they have, the kind of leadership that’s at their center, the team dynamics, they may have the expertise that the team has the knowledge about the application of quality improvement methods, or the kind of data management system they have. So, we’re interested in actually starting to study that systematically. In order to do that, we have to have the relevant observations that take place at the clinical site, not at the patient level, they need to have a lot of clinical sites involved in the network in order to do the studies. So, that’s one area of pretty intensive research.
[00:10:56] I think our expertise developed over the last twenty years has been really in developing and running distributed projects, large-scale efforts that depend on collaborative partnerships among groups. Our major research now is learning how to scale up what we’ve been able to do at a scale of twenty to forty sites at once to a much larger scale potentially involving thousands of sites at once.
Our research is really on a variety of different dimensions. One dimension has to do with using specific methods: in our field we use quality proven methods which have not been used widely in medicine as a way of rapidly adapting new ideas to clinical care. On a methodological side, we’re interested in understanding the contextual factors that enable specific teams to succeed in being able to improve care. So, what we observe, is that some sites that participate in these networks are much more successful in proving outcomes for kids than others and that may have to do with the amount of resources they have, the kind of leadership that’s at their center, the team dynamics, they may have the expertise that the team has the knowledge about the application of quality improvement methods, or the kind of data management system they have. So, we’re interested in actually starting to study that systematically. In order to do that, we have to have the relevant observations that take place at the clinical site, not at the patient level, they need to have a lot of clinical sites involved in the network in order to do the studies. So, that’s one area of pretty intensive research.
[00:13:09] Another area of research is working on the patient side to get to hold more practices, more clinical sites into active efforts to improve care. And that’s how we’ve gotten into social networking, the ideas of social network. So, connecting patients with each other, connecting patients with doctors, increasing the demand side on the patient’s side. And we’re starting to look, as I mentioned, at the use of social networking platforms as a way of making that happen. And that’s also lead to this interest of you being here, which is the use of open source methods and in some ways to summarize it, we need more Linux and less Microsoft in medicine. Traditionally, researchers have been taught to kind of hold on to their ideas and what we’re learning is what’s appealing about open source is that there may be another set of incentives that are going to be necessary in order to drive academic productivity, particularly in medicine.
[00:14:26] We try to share as much information as we can in lots of different ways with others that’s a feature of academics that’s our job to share information, we do it through publications, presentations, we do it on websites, and again, we’re starting to try to share more with the public, with public oriented websites.
[00:14:41] I think virtually every project that we do is done collaboratively with other organizations and other individuals. So, the leadership of every project includes people with a variety of different skills, we may have a clinical expert, somebody who’s an expert in inflammatory bowel disease, we might have a QI (quality improvement) expert like myself who’s expert in the technical components, we always establish partnerships among various organizations, we have strong partnerships with a number of the certifying boards of medicine as well as the professional organizations. We realize that that’s key to being able to do this work effectively.
[00:15:39] I think the kinds of connections we’re finding we need are more connections with the public and more connections with policy makers, who I think are less familiar with this kind of style of work. I think we have not taken advantage of the public’s interest in ensuring that the scientific knowledge that’s generated by the kind of work we do actually gets translated into improved health of the population, which is in fact, what our tax dollars are going towards.
[00:14:26] We try to share as much information as we can in lots of different ways with others that’s a feature of academics that’s our job to share information, we do it through publications, presentations, we do it on websites, and again, we’re starting to try to share more with the public, with public oriented websites.
[00:14:41] I think virtually every project that we do is done collaboratively with other organizations and other individuals. So, the leadership of every project includes people with a variety of different skills, we may have a clinical expert, somebody who’s an expert in inflammatory bowel disease, we might have a QI (quality improvement) expert like myself who’s expert in the technical components, we always establish partnerships among various organizations, we have strong partnerships with a number of the certifying boards of medicine as well as the professional organizations. We realize that that’s key to being able to do this work effectively.
[00:15:39] I think the kinds of connections we’re finding we need are more connections with the public and more connections with policy makers, who I think are less familiar with this kind of style of work. I think we have not taken advantage of the public’s interest in ensuring that the scientific knowledge that’s generated by the kind of work we do actually gets translated into improved health of the population, which is in fact, what our tax dollars are going towards.
Images © Copyright Alice Merkel. All Rights Reserved.
What networks are you building? Why? How?
[00:16:22] We probably have about twenty networks in development right now. So, actually, that’s what we’re just learning how to do, is to do a bit more use of formal network mapping tools, so that’s a set of expertise that we need. We understand that there’s, I don’t know if you’re aware of this, there were a series of articles in “Science” this week, many of them published from Indiana University who do network mathematics. I think that’s a set of skills we don’t have right now.
What criteria do you use for mapping knowledge networks?
[00:16:59] So, in terms of how do we map, how do we use networks? One of the advantages that I think we have in medicine is that we often have pretty concrete outcomes that we’re after. I mean, it can be even living or dying. So, when you collect data at a site level, we take advantage of the variation across sites in their performing and achieving outcomes. We all think that doctors do it right all the time and it turns out there’s a lot of variation across centers in the outcomes they can produce. So, one of the ways that we can use a network, take advantage of the network, is that by measuring the outcomes that different sites are producing, you can identify those sites that are outperforming everybody else and those are the groups that have knowledge that others don’t have. Probably the best example of this that has come up in my career, was a project that we did on cystic fibrosis a number of years ago focused on improving the quality of care for kids with that condition. At the time, there were data about the life expectancy of kids with CF (cystic fibrosis) at different care centers, but they were not available to the research community, that was kept as private, so when we were starting the project, one of the pulmonologists that we knew, who was involved with the leadership, and I were talking about where we could go look to find really good outcomes. So, we just sat down one day and Googled – I asked him, where’s the best place in the country –and so we did a Google search for the University of Minnesota’s CF Center and it turned out there was a graph on their website showing the average life expectancy for kids at the University of Minnesota was fourteen years longer than the national average. That kind of information was instrumental in helping us identify the specific care activities with verifiable results, the tacit knowledge that individual centers have that we needed to surface so that other centers could adopt it.
What is the next enterprise opportunity that you see? Why?
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[00:19:32] We think there’s a very big opportunity to create, we have had to create, to use networks in a new way. In medicine, as I mentioned, there have been research networks, there are also improvement networks, those are centers who work on improving care.
When you bring together the research networks and what you might call “learning by doing” networks, you get the, use the opportunity to also identify and create innovation about how to do care delivery, so there are a lot cool discoveries coming out of medicine that may have to actually be translated into practice that’s going to require new ways of delivering care. So, the way we’ve done this in the past in medicine is that academics have assumed the guys in the lab have assumed that if they write their results up that somebody would read it and figure out how to put it into practice. What we’re realizing is that you really have to have a different care delivery system, so people earlier in the research trajectory, the ones who are making the breakthrough discoveries need to be in communication with the people who are designing care delivery systems so that they can accommodate the new discoveries. Sort of like Intel working with Hewlett Packard so that the Hewlett Packard people prepare their computers to accept the new capabilities for the next new Intel chip. |
How much time would you like to spend on this opportunity, from idea to execution?
[00:21:09] How long will it take to get innovation networks spawned in medicine? How long would I like to spend on it, or how long will it actually take? I’d like to spend three to five years on it; I think it’ll take twenty years.
Whose insights and guidance do you/would you engage?
[00:21:24] I think one place that we’re starting to look now is to look to all these experts in networks, network people like Peter Gloor, Von Hippel [Eric von Hippel] and Thomas Malone at the MIT Center [for Collective Intelligence]. We’re working with the Science Commons. We’re starting to work with economists at the University of Chicago and we’re also working with creative people out of Los Angeles who are good at telling stories. We’ve engaged some creative movie talent in developing our stories.
What benchmarks and measurements do you use in your work?
[00:22:07] Okay, so I talked a little bit about the benchmarks and measurements: the biggest measurement is the improved care, improved health outcomes for the patients that we see.
Images © Copyright Alice Merkel. All Rights Reserved.
What next steps do you envision to pro-actively respond in education, economic and workforce development?
[00:22:15] One of the opportunities in Ohio is that there are eight children’s hospitals in Ohio, we’re very interested in the potential for Ohio to be, what we’re calling a collaboratory, that engages all the children’s hospitals in working together to make children in the state some of the healthiest in the country. We also think there’s also the opportunity to work at a population level with primary care practices throughout the state to again demonstrate what’s possible if you scale some of the results we’re accomplished up to full scale and impact health in the entire state. It seems like there’s willingness and passion within the state to start to make that happen, there is willingness in the government across the children’s hospitals at the level of the pediatric health care providers and among family physicians who also take care of children, so we think that’s a really cool opportunity. So, if you guys at I-Open in Cleveland want to do something that would be a great way to get involved.
[00:23:35] So education and workforce development’s obviously a big piece of what we do at an academic medical center. We are actually starting a treatment program for fellows in various medical specialties, as well as nurses, pharmacist, allied health professionals to learn these methods and apply them in their various venues. Really, at the moment, we think there are only two or three programs in the country that are focused on creating the skills sets that enable people to learn to do this in healthcare.
[00:23:35] So education and workforce development’s obviously a big piece of what we do at an academic medical center. We are actually starting a treatment program for fellows in various medical specialties, as well as nurses, pharmacist, allied health professionals to learn these methods and apply them in their various venues. Really, at the moment, we think there are only two or three programs in the country that are focused on creating the skills sets that enable people to learn to do this in healthcare.
What next steps do you envision to pro-actively respond to the powerful topics affecting communities and their regions, such as: climate change, green job creation, water, land, energy, technology, and health care?
[00:24:13] So, the content focus is what we call ‘quality improvement’. It’s similar to your cyclical framework of knowledge building or learning by doing; it’s really an application of scientific method in real time to enable people to change care systems. That’s the focus; it’s the science of essentially engineering care delivery systems to implement knowledge, reliable. It’s not something that in the past we’ve assumed that if doctors had the right knowledge they could do the right thing. What we’ve learned over the last twenty or more years are that knowledge isn’t enough, we need to know how to do it. The tools and methods of quality improvement are very important for that ‘how to’ knowledge. So, it’s not only knowing what to do, it’s knowing how to do it. You might think of our fellowship as almost creating health care systems engineers who learn how to get knowledge into practice.
[00:25:28] There are probably two or three other places that are focused on this: the VA (Veterans Administration) has something they call the VA Quality Scholars Program, it runs at about ten or fifteen VA Centers. The VA itself is starting to use this approach.
Dartmouth Center for Clinical Effectiveness is one of the leading places; the other place that I think is doing some training in this area is Intermountain Health.
[00:25:28] There are probably two or three other places that are focused on this: the VA (Veterans Administration) has something they call the VA Quality Scholars Program, it runs at about ten or fifteen VA Centers. The VA itself is starting to use this approach.
Dartmouth Center for Clinical Effectiveness is one of the leading places; the other place that I think is doing some training in this area is Intermountain Health.
Who would you like to be connected to that you are not?
[00:26:03] So, connections, for example, the person who’s leading our fellowship today is up at Dartmouth talking to them about how to share and integrate our curricula. We have established connections with the VA and a looser connection with Intermountain Health, although we do work with them.
[00:26:27] Sure, I mean our curriculum is not so much about network development as it is about quality improvement methods. We have a formal training process that includes experiential learning of actually making changes in care delivery, and a sequence of courses that we offer here that goes over the science and the methods of improving care delivery. We have an intermediate course and an advanced course focused more on research, coupled very strongly with learning by doing.
[00:26:27] Sure, I mean our curriculum is not so much about network development as it is about quality improvement methods. We have a formal training process that includes experiential learning of actually making changes in care delivery, and a sequence of courses that we offer here that goes over the science and the methods of improving care delivery. We have an intermediate course and an advanced course focused more on research, coupled very strongly with learning by doing.
Images © Copyright Alice Merkel. All Rights Reserved.
How will your research/business serve the sustainability of communities and their regions 50 years from now?
[00:27:12] Our goal is to create a sustainable way of continuously improving the practice, so what we’re trying to do is to build sustainable systems so that physicians come to view participation in an ongoing effort to constantly improve practices as a central part of their job.
Closing questions:
[00:27:37] When you incorporate patients and their families with health care providers, how do you do that, online? Are they also participating, or do you really address the health care provider nodes?
Our major focus up until now has been the health care provider nodes. We often include, on some of our projects we include families, parents, and kids on the teams that are redesigning care. So, some of the best projects actually have families participating in the design activities and the tests. One of my colleagues runs a center on chronic illness innovation, and there are a number of parents who participate on the design teams, they do the experiments themselves, they cook up this stuff themselves. One of their projects is using, working with adolescents to design a set of text messages for kids with asthma that amount to reminders to the kids, but the kids actually design, what they’ve done is work with the kids. Certain adolescents like to have certain kinds of text messages as reminders, so some adolescents prefer to have ones that are demanding, “Take your medicines, dammit!” “It’s time to take your medicine.” Or, others want a more, touchy, feely approach, “Maybe you should take your medicine” or, “This would be a good time to think about taking your medicine.” We’re working with some cell phone companies to develop customized messages based on kid’s preferences for how they like to have reminders.
Our major focus up until now has been the health care provider nodes. We often include, on some of our projects we include families, parents, and kids on the teams that are redesigning care. So, some of the best projects actually have families participating in the design activities and the tests. One of my colleagues runs a center on chronic illness innovation, and there are a number of parents who participate on the design teams, they do the experiments themselves, they cook up this stuff themselves. One of their projects is using, working with adolescents to design a set of text messages for kids with asthma that amount to reminders to the kids, but the kids actually design, what they’ve done is work with the kids. Certain adolescents like to have certain kinds of text messages as reminders, so some adolescents prefer to have ones that are demanding, “Take your medicines, dammit!” “It’s time to take your medicine.” Or, others want a more, touchy, feely approach, “Maybe you should take your medicine” or, “This would be a good time to think about taking your medicine.” We’re working with some cell phone companies to develop customized messages based on kid’s preferences for how they like to have reminders.
Contact Information for Dr. Peter Margolis, MD, PhD
Peter Margolis, MD, PhD
Contact Information:
Peter Margolis, MD, PhD Professor of Pediatrics Cincinnati Children's Hospital Medical Center Center for Health Care Quality Cincinnati, OH 45229-3039 Rebecca Boerger, Administrative Assistant Center for Health Care Quality 3333 Burnet Ave., MLC 7014 Cincinnati, OH 45229 Email: Ph:
"Dr. Peter Margolis, MD, PhD: Collaborative Health Care Transforms Systems of Care Delivery for Children" is available at the I-Open Store in Transcriptions (PDF download) and Podcasts (.aif download).
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Keywords
Collaborative health care, networks, pediatrics, social networking platforms, quality improvement, medicine, education
Collaborative health care, networks, pediatrics, social networking platforms, quality improvement, medicine, education
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