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
[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.
[00:10:56] 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.
[00:14:26] 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.
[00:19:32] 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.
[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.
[00:25:28] 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.
[00:26:27] 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.
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.
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
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Cincinnati Children's Hospital Medical Center
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