Advancing Health Podcast

Advancing Health is the American Hospital Association’s podcast series. Podcasts will feature conversations with hospital and health system leaders on a variety of issues that impact patients and communities. Look for new episodes directly from your mobile device wherever you get your podcasts. You can also listen to the podcasts directly by clicking below.

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After launching in November 2022, it took ChatGPT just two months to become the fastest growing consumer app in history — proof of the rapid adoption of AI technology. In this conversation, three experts from the American Hospital Association discuss the game-changing applications of ChatGPT and AI for health care data analytics, and some of the potential pitfalls.


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00;00;00;01 - 00;00;34;20
Tom Haederle
After launching in November 2022, it took ChatGPT just two months to become the fastest growing consumer app in history, gaining over 100 million users at an unprecedented rate. ChatGPT is perhaps the most prominent example, but certainly not the only one, of how artificial intelligence — or AI — is rapidly changing the world and the health care field along with it.

00;00;34;22 - 00;01;08;10
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. These days, our ability to process and analyze enormous volumes of data in new and innovative ways is evolving at warp speed. And AI is at the forefront. What are the implications for health care? Where is all of this going? In this podcast, three experts from the American Hospital Association discuss the game-changing practical applications of ChatGPT and AI for health care data analytics, and the potential pitfalls.

00;01;08;12 - 00;01;20;09
Tom Haederle
Host Stephen Hughes is director of health IT policy for the AHA. Brian Klein-Qiu and John Allison are both associate directors of health analytics policy. Let's join Stephen, Brian and John.

00;01;20;11 - 00;01;47;09
Stephen Hughes
Let's step back for a second to talk about how we got here. With less than 15 months ago, the world changed when ChatGPT kind of just crashed through the room, right? And all of a sudden added AI to the zeitgeist, catching a lot of us off guard. Now, as we know, AI has been in the health care space for decades right? There's diagnostics and in revenue cycle and in several areas, there's been tremendous advancement and practical application.

00;01;47;15 - 00;02;11;00
Stephen Hughes
But ChatGPT really accelerated and changed the way we think about it. It's changing the regulatory conversation around it. It's changed the way that every CEO and every board now is thinking about it. So we step back for a second to talk about what you guys do in data and analytics. There is a Brian and a John that works in some form or another for most health systems, right?

00;02;11;01 - 00;02;39;07
Stephen Hughes
We call them different things. It might be performance improvement team, it might be data analytics team. You know, it might be part of the strategy team. But one way or another, most health systems, whether they're doing it internally or thinking about it through partnerships or consultants, are looking at how they use data, how to analyze data, and how do they either improve patient outcomes or make themselves more competitive, make themselves more efficient.

00;02;39;10 - 00;02;51;26
Stephen Hughes
So Brian and John, let's talk a little bit about what you guys do, and then we're going to talk a little bit about how you guys were using AI and how it was valuable to you and how I think it'll be useful to our members.

00;02;51;28 - 00;03;10;27
John Allison
So, yeah, I'm John Allison. I think the most succinct way to describe what I do, at least the way that I approach my job is, my goal is to really tell compelling stories about hospitals, to advocate well for them. And one of the tools in my toolbag to do that is data, right? There's a lot of it out there.

00;03;10;29 - 00;03;28;10
John Allison
Being able to understand it, being able to make sense of the anecdotes, for example, which is oftentimes really how you're learning, is you're hearing from members or other hospitals being able to kind of convert that into something that's maybe more compelling. It's really important.

00;03;28;12 - 00;03;46;11
Stephen Hughes
Right. I think you guys would agree that health care is unique among all sectors in terms of just the sheer volume of data, right, that you have. I talked at the beginning about, you know, finding use out of that data. But there's a lot of noise inside, right, because it's just by the nature of what we do.

00;03;46;11 - 00;04;08;09
Stephen Hughes
By the nature of patient care, there's just a tremendous volume of data that's captured. And Brian, could you talk a little bit about the the different languages around data? One of the challenges here is that it's you know, it's like there's all this data and there's like several different languages that are being spoken in terms of how that data is understood and analyzed.

00;04;08;16 - 00;04;34;19
Brian Klein-Qiu
Yeah, absolutely. So the most common data analysis or data science languages are going to be your typical languages like Python or R. For historical institutionalized reasons, SAS still kind of has a large, large stranglehold over health care policy data. So, for example, most Medicare claims, a lot of these files they come in SAS formats. It's still kind of the lingua franca in our industry.

00;04;34;21 - 00;04;53;04
Brian Klein-Qiu
That's kind of a challenge because there's not a lot of SAS programmers these days, and that's kind of a hard, hard barrier to access for people to be able to interact with claims data. When you add in the fact that a lot of these data analysts, data scientists, they're not specifically gearing up to work in health care policy the way that John and I work.

00;04;53;12 - 00;04;59;08
Brian Klein-Qiu
What that means is you're going to get a lot of great analysts and programmers who have no prior experience with SAS.

00;04;59;11 - 00;05;08;13
Stephen Hughes
Now, fast forward a little bit. So, Brian, when you came in, tell a little about the story of like you've had a little bit of SAS background, but...

00;05;08;16 - 00;05;09;21
Brian Klein-Qiu
Actually it's opposite.

00;05;09;21 - 00;05;10;12
Stephen Hughes
Oh it's the other way around.

00;05;10;14 - 00;05;12;15
Brian Klein-Qiu
I have a lot of SAS background.

00;05;12;17 - 00;05;13;04
Stephen Hughes
Right, right, right.

00;05;13;11 - 00;05;36;02
Brian Klein-Qiu
I have not touched Python and R in maybe five or six years because I've been living in the SAS world. So when I joined AHA in July 2023, I'm part of the new health care policy data team and our manager I think in week one or two he sits me down and says, "Hey Brian, there's this really complex data project that John is handling right now.

00;05;36;06 - 00;05;58;15
Brian Klein-Qiu
Can you take a look at all of the complex great code that John's been writing and try to contribute to it?" And if this was July 2022 before ChatGPT came out, I would have had to tell Aaron, "So, you know, Python's on my resume. But the thing about that is I'm still going to need three weeks to make sense of what John's writing."

00;05;58;15 - 00;06;01;02
Stephen Hughes
And maybe a class. And maybe do a lot of Googling.

00;06;01;02 - 00;06;32;08
Brian Klein-Qiu
John's going to have to see me down. But because it's July 2023 and not 2022 ChatGPT is out. And I can tell Aaron, yeah no problem. So John hands me off the code base that he's been working on. I feed literally everything that's not sensitive into ChatGPT. And because I have experience with programing languages, I knew Python in the past, I'm able to pick it up pretty easily with the help of ChatGPT explaining to me what these specific lines do, what the overall structure is and all of that.

00;06;32;11 - 00;06;38;26
Brian Klein-Qiu
So literally from day one, I'm able to plug in and contribute to what John's been handling for I don't know what, the last six months?

00;06;38;29 - 00;06;53;12
John Allison
Yeah, I mean, I would say not only contribute to it, but just like make it better really quickly. Like I remember some of that code you were sending to me and as we were working on and I was like, wow, this is a really good idea. Like, I hadn't thought to do it this way.

00;06;53;12 - 00;07;13;04
John Allison
And, you know, and I think probably the thing to like underscore there is for data analysts, ChatGPT is really quickly becoming a must have in your quiver. It might be the quiver. It is so important for data analysts in terms of like in the toolbag you reach into when you're doing your job.

00;07;13;07 - 00;07;34;22
Brian Klein-Qiu
Oh absolutely. Health care policy, you are working with really a diverse array of languages. But you kind of develop an expertise in one and you kind of just have to make do with whatever knowledge you can get to parse through all the other projects. For example, claims are going to be mostly in SAS files. If you do data and analysis or processing

00;07;34;25 - 00;07;53;04
Brian Klein-Qiu
a lot of people like to use Python for that. But if you look at the claim prices for like how consumers actually prices claims, all those source files are in Java. So if you can have a tool like ChatGPT that can help you process these very different languages easily, that's an incredible boost to productivity.

00;07;53;07 - 00;08;12;22
Stephen Hughes
And there's a couple of important points here. And one, to extend the metaphor of languages out. You know, effectively you have a Rosetta Stone, right? That's understanding these languages. We have two different languages we started with, so we're extending the metaphor out. We've got, you know, Mandarin and English. Now if you're adding Java on top, you're adding, okay, French, right?

00;08;12;29 - 00;08;23;20
Stephen Hughes
We keep adding more and more languages, more and more expertise, more and more time. And someone who's not familiar with something...so ChatGPT effectively was acting as that kind of universal translator.

00;08;23;27 - 00;08;43;17
John Allison
What ChatGPT does is it says, okay, so maybe maybe you weren't as strong at learning programing languages or Java or whatever it is. ChatGPT's going help you get there in a way that I would have said... you talked about weeks to get caught up. That's because you had some experience with some of these languages before.

00;08;43;19 - 00;09;07;19
John Allison
For someone who doesn't you're talking years, right? And so that's where most of the data analysts that would be listening to this or that are if you're a health system C-suite, that would be working for you. Fifteen years ago, ten years ago, even five years ago, it probably took them years and years and years of not only learning the language but getting really comfortable in it, learning how to use it to become the data analyst that they are.

00;09;07;20 - 00;09;09;00
John Allison
It takes years.

00;09;09;02 - 00;09;27;27
Stephen Hughes
So there's this concept of upskilling, right? I know this is a concern with with CEOs everywhere in health systems now that are thinking about, you know, applications and investment in AI. And it's an important piece because a lot of again, let's go back to 2022. It's you know, the AI is coming for our jobs.

00;09;28;00 - 00;09;55;19
Stephen Hughes
You know, there's the crisis, right? We've now gone to this idea of it's not taking jobs. It's making individuals better at their jobs. It's you know, like in our case, like in the AHA's case, rather than having to hire two more Brians or a John and two more Brians, right. I'm now able to take Brian and John and upskill them to a point where I'm getting much more productivity out of two individuals by upskilling.

00;09;55;25 - 00;10;21;13
John Allison
I think with something like ChatGPT that years of like building up this experience and skillset to be able to tackle the problem has really been ameliorated. And to the extent that if I'm an analyst and I'm working at the AHA, which I am, and there's a question, a big question that we have something we want to answer on a topic that maybe not all people have talked about yet, and there's some data out there, but it's just huge.

00;10;21;14 - 00;10;47;18
John Allison
We don't understand it. Instead of me thinking, well, that's a waste of my time. I shouldn't be actually trying to answer that question. Instead, I'm thinking, okay, with ChatGPT, I feel reasonably confident that I can take something that's currently incredibly difficult to understand and I don't have a ton of background in. And I can still ask this big question from the data and reasonably expect to get an answer and not take years to do it.

00;10;47;20 - 00;11;16;04
John Allison
That's just hard to underscore how game-changing that is, at least from my perspective. Whereas before I would have asked a really good question about my data, like what is what is driving this this trend that we're seeing in health care and hospital utilization and things like that. And while the datasets might have been available to me, a lot of them aren't, by the way, but the ones that are publicly available, I might have just shied away from asking questions like, well, I don't have the next ten weeks to devote to this.

00;11;16;06 - 00;11;18;25
John Allison
And nowadays I would say that's a week at most.

00;11;18;27 - 00;11;33;18
Stephen Hughes
But then the other part of which I think again, would resonate with with most health systems is this idea of like they've got a lot of data, that's not the problem. They've captured all kinds of data, it's just in all different places. You have a lot that's in the HR. You have a lot that may have predated the HR.

00;11;33;20 - 00;11;57;06
Stephen Hughes
That you've been hanging on to for, you know, for years for regulatory reasons, but are you actually making a use out of it to create, again, better outcomes, other business opportunities? Who knows? And then sometimes again, there are disparate sources, right? What if you acquired another health system that has a different EHR. You acquired a practice or partnering with a practice, and they've got again, it's a different EHR, or god forbid, paper.

00;11;57;09 - 00;12;18;00
Stephen Hughes
How am I bringing this all in? Or what tools am I bringing in? And in most cases, those answers are going to be, I have a very hard time doing that internally, right? I'm going to have to you know, I'm going to have to either move all of this to some cloud-based service which costs, security risks associated with it.

00;12;18;02 - 00;12;40;09
Stephen Hughes
Time. When am I going to get value back out of this as opposed to, hey, this is my data and now I can take a very narrow approach to my data and solve problems and get value out of my data with my staff inside a health system, right. Which is going to cut the security risk problem. The cost concerns, the do I bring in consultants?

00;12;40;09 - 00;12;49;18
Stephen Hughes
Do I you know, all these other issues? I can actually start solving these problems internally because I have tools like, you know, GPT.

00;12;49;25 - 00;13;26;02
John Allison
Probably something to underscore is if you're looking for an application of AI and you're like, well, I'm not a huge health system. I don't have these resources to spend on these more clinically-based AI applications or maybe even some sort of, you know, chat bot thing, things that maybe are more business-oriented, consumer-facing potentially. A really low, an area of a lot of low-hanging fruit for the use and practical application of AI tools like ChatGPT is going to be data analysis, frankly, and some people might find that boring, other people might find that exciting.

00;13;26;04 - 00;13;52;08
John Allison
I think that's important to contextualize, it's something that ChatGPT does pretty darn well compared to a lot of the other things that it does. It's going to help you think through data problems comparatively pretty, pretty well. And I would say if you're looking for a place to kind of grow your hospital or your health system, whatever it is that your business you're working in, it'd be to be thinking about how to apply these tools to data problems.

00;13;52;08 - 00;14;10;08
John Allison
If your analytics department, your data analysis teams, the people that are helping with decision support, business intelligence, whatever it is, that's the group out of anyone in an organization that I would think would be leading the charge, in a very I hate to use this word because we're in D.C., but in a very grassroots way.

00;14;10;15 - 00;14;15;28
John Allison
You're not being told to do it. It's very organic. This is making me better at my job.

00;14;16;00 - 00;14;45;19
Stephen Hughes
And yes, it starts in data. But I think that, you know, your insight there, John, is good. And I think it's applicable really to even outside of data analytics, right? The idea that the use case came out organically by need. So it's, and I think if there's a lesson there and there's marching orders to then take out, you know, really any level of management in the health system that maybe listening to this all the way up to senior executives and board members is, worry less about trying to shoehorn a solution into the organization.

00;14;45;21 - 00;15;01;19
Stephen Hughes
It's go down to the practitioners, right? Go to your people in the front lines, go to your experts and ask them about how they could use it. And that's where I think you're going to get the most effective, you know, examples and the most effective tools are going to emerge from that.

00;15;01;22 - 00;15;11;13
Brian Klein-Qiu
It's true that this is an incredible tool and you can solve so many issues and increases productivity so much in the hands of somebody who is competent and somebody who is...

00;15;11;13 - 00;15;34;16
Stephen Hughes
In the hands of someone who is competent. Right. You have to have a baseline, competent person to start with that you're upskilling as opposed to...what you're not doing with ChatGBT or really with AI in general. And this is you could extend this metaphor out to the kind of the absurd level of you're not going to turn somebody who didn't go to medical school into a radiologist because they're using an AI tool to look at diagnostic images.

00;15;34;16 - 00;15;55;28
Stephen Hughes
You get you start with a radiologist, add the AI on to that and they get much more productive and much more effective at picking up abnormalities in a mammogram. Just like you take someone who's got good or at least a basis with understanding data languages and good analytical skills, add AI, they're going to be much better at doing decision support.

00;15;55;28 - 00;16;01;03
Brian Klein-Qiu
Exactly. And the criteria for evaluating who's good at analysis has changed with AI.

00;16;01;06 - 00;16;17;21
Stephen Hughes
I'm glad you brought this up, too. So we're not just sounding like that we're a bunch of just ChatGPT and AI cheerleaders, right? There's always a downside with technology. So let's talk a little bit about the quality measures. So how do we do that with ChatGPT and data analytics? How do you apply that safety criteria?

00;16;17;21 - 00;16;19;10
Stephen Hughes
What are the tests or what are the outcomes?

00;16;19;10 - 00;16;40;22
Brian Klein-Qiu
Yeah, that's a good question and that's you hit on a really, really crucial thing because that's something especially in fields like health care systems or health policy in general, there's not a lot of that kind of thinking. A lot of people a lot of organizations, a lot of agencies are not concerned with how do we know that these numbers are right, how we know that these algorithms are correct and we see how many mistakes CMS makes all the time.

00;16;40;24 - 00;17;01;19
Brian Klein-Qiu
It's not limited to CMS. All agencies and companies do that. But one thing that I find shocking and that we need now more than ever is there's no emphasis in the interview process for a lot of these places on how do you sense check your numbers in a project. It's all what are the results of the projects? Give me examples of projects you've done and it's never

00;17;01;26 - 00;17;25;13
Brian Klein-Qiu
how did you know that your project was correct? Explain to me your benchmark process. Explain to me how you were able to contextualize the numbers you got. The answers to those questions are much more indicative of how meticulous someone is and how analytical someone is. Than them being able to list five languages on their resume and say, okay, I created this algorithm and it gave me this many charts.

00;17;25;20 - 00;17;25;27
Brian Klein-Qiu
Here you go.

00;17;25;28 - 00;17;40;08
Stephen Hughes
So would you be saying in a way that the way to actually make sure that you're you're using GPT safely and effectively is to actually double-down on your people hiring process.

00;17;40;10 - 00;17;43;13
Brian Klein-Qiu
Or instill a culture. Instill a culture that is much more...

00;17;43;13 - 00;17;44;16
Stephen Hughes
Get very human centered.

00;17;44;16 - 00;17;46;01
Brian Klein-Qiu
Yeah, right, right.

00;17;46;06 - 00;18;01;04
Stephen Hughes
Interesting. So to ensure quality it's make sure that you're being careful about your your hiring practice,s right, and instilling a culture of quality and you know high levels of ethics in those who are using the applications.

00;18;01;11 - 00;18;15;14
Brian Klein-Qiu
The number one thing you can do if you've already hired a person to improve the culture of checking the quality is just literally ask, how do you contextualize these numbers with other entities' numbers? Can you think outside of GPT, are you right externalizing everything you do?

00;18;15;19 - 00;18;39;15
Stephen Hughes
I love that. To actually ultimately control quality in GPT or tools like GPT think outside of GPT and in the end AI is a piece of technology. Really what we should be thinking about in health systems is a thoughtful application of technology. This is just one more thoughtful application of technology. Overall, I think it's connecting back to what Brian was saying, which again connects us back to the human-centered nature of this.

00;18;39;21 - 00;19;02;05
Stephen Hughes
You know that ultimately the quality control check for, you know, use of AI in data analytics and decision support is do you have a culture of quality, right? Do you have a culture of peer checking around what you're doing? You know, ultimately to get the most out of AI, across the system, across health care, is encourage a culture of innovation and creativity, right?

00;19;02;05 - 00;19;13;06
Stephen Hughes
Know the tools are out there. Encourage people not to be afraid of it. Go look at it and suggest things. You be amazed what you might find. Well, guys, I think that's all the time we have. I really appreciate it. John, Brian, thanks so much.

00;19;13;09 - 00;19;14;16
Brian Klein-Qiu
Thank you. Pleasure to be here.

For hospitals and health systems of every size and location, it’s critically important to adapt to the needs of their communities. Over the years, SBH Health System has shown its adaptability, evolving with shifting demographics and social determinants of health. In today’s conversation, Joanne M. Conroy, M.D., CEO and president of Dartmouth Health and 2024 Chair of AHA's Board, talks with David Perlstein, M.D., president and CEO of SBH Health System, to discuss how the organization is proactively improving the health and well-being of its patient population and community.


 

 

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00;00;00;25 - 00;00;34;02
Tom Haederle
You may not think that a rural health care system in New Hampshire and a major independent hospital in the Bronx, New York, share many of the same concerns, but they do. For care providers of every size and location, it's critically important to identify and adapt to the needs of the communities around them, since no two are exactly alike. In this month's Leadership Dialogue Series podcast, that shared concern for meeting the needs of patients and families where they are  - for being responsive - has given Dr. Joanne Conroy, CEO and president of Dartmouth Health in rural New Hampshire and AHA's 2024

00;00;34;02 - 00;00;51;22
Tom Haederle
Board Chair; and Dr. David Perlstein, President and CEO of SBH Health System in the Bronx, a lot to talk about.

00;00;51;24 - 00;01;18;22
Tom Haederle
Welcome to Advancing Health, the podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. SBH Health, formerly known as St. Barnabas Hospital, opened in New York in 1866 as America's first chronic care facility. Over the years, St. Barnabas Hospital has demonstrated a great ability to evolve to meet shifting demographics and address social determinants of health, as we hear in today's discussion.

00;01;18;24 - 00;01;42;27
Joanne M. Conroy, M.D.
Good afternoon and thank you everyone for joining us today for another Leadership Dialog discussion. I'm Joanne Conroy, CEO and President at Dartmouth Health and I'm currently the chair of the American Hospital Association Board of Trustees. I'm looking forward to our conversation today as we focus on how our fields can influence and drive improvements in the overall health and well-being of our communities.

00;01;42;29 - 00;02;10;12
Joanne M. Conroy, M.D.
As hospital and health systems leaders, we certainly need to strive towards delivering high quality health care. But we all appreciate the fact that a lot of what we do has to do with the health of the communities outside the walls of our facilities, and we need to be just as passionate about improving the health and health status of the people in the regions we serve as the rural health care system, serving New Hampshire and Vermont.

00;02;10;15 - 00;02;44;28
Joanne M. Conroy, M.D.
We have a unique opportunity at Dartmouth Health to focus not only on care within our walls, but also our communities. And we have a group that focus on rural health equity that has identified some frightening statistics that if you live 15 miles away, you often live 15 years less on average than other communities. It is critically important that we identify how we can shift the environment that our patients live and work in in order to have the best lives possible.

00;02;45;00 - 00;03;09;12
Joanne M. Conroy, M.D.
You know, it's interesting. I've got a fabulous colleague that's joining us today, Dr. David Perlstein. And David and my communities are similar and different. We all have issues associated with poverty. We have issues that are associated with housing and the lack or the availability of housing as well as transportation. But it's very different in the Bronx than it is in rural New Hampshire, Vermont.

00;03;09;14 - 00;03;31;11
Joanne M. Conroy, M.D.
But a lot of things that we can learn from each other. Now, I want to spend some time talking about David Perlstein who shares our convictions that hospitals and health systems have to provide value to their communities. And you only need to look up SBH Health to really appreciate what they have done over the last... David, it's been almost eight years,

00;03;31;11 - 00;04;00;12
Joanne M. Conroy, M.D.
you joined in 2016... where they've really made an impact on that community. David is the president and chief executive Officer of SBH Health System, which is formerly known as St. Barnabas Hospital, located in the Bronx. This system includes a teaching hospital and ambulatory care center, a behavioral health facility, among many other health services that are provided for a very multi-cultural community.

00;04;00;15 - 00;04;39;05
Joanne M. Conroy, M.D.
He's a pediatrician by training and joins St. Barnabas initially as a director of pediatrics before serving as the CMO and then stepping into the CEO role in 2016. He continues to be clinically active and has spent the majority of his career promoting better health and better health care in the Bronx. He has a special interest in this social determinents loss of health and has written and lectured nationally and is also past chair of the AHA's Committee for Clinical Leadership, which is an advisory body that helps guide the association's policy positions on clinical matters.

00;04;39;05 - 00;04;43;19
Joanne M. Conroy, M.D.
So David, welcome and thank you for joining me.

00;04;43;21 - 00;04;54;28
David Perlstein, M.D.
Thank you. Great to be here. Great to be here. And it's great to meet you also, finally. I've heard a lot about you and my sister and her family actually live in Concord, so yay.

00;04;55;00 - 00;04;59;11
Joanne M. Conroy, M.D.
Maybe she gets some of her care from our ambulatory care facility.

00;04;59;11 - 00;05;02;00
David Perlstein, M.D.
And it would be hard to believe that she doesn't.

00;05;02;03 - 00;05;19;22
Joanne M. Conroy, M.D.
So our viewers love to know a little bit about our guests before we jump into all the great work you're doing. So can you tell us a little bit about your path and what is actually influenced the work that you're championing now at SBH Health?

00;05;19;24 - 00;05;51;24
David Perlstein, M.D.
Yeah, So I was a reluctant doctor and I come from a family of doctors. So I'm one of those guys that believed that no way where my genes or my or the influences on my family were going to instruct what I became in the future. And believe it or not, I mean, generations, my grandmother, my grandfather, my great uncle, and they were all in different types of care, but they all were very involved in the system.

00;05;51;28 - 00;06;12;01
David Perlstein, M.D.
Some of them were academic, some were not. My grandfather, who is a is a pediatrician also, was a co-founder of the American Academy of Cerebral Palsy. And so he recognized very early on that kids with CP had normal intelligence in many ways, and they were being treated as if they were not normal. You can't escape that. My father was a neo-natalogist.

00;06;12;03 - 00;06;37;08
David Perlstein, M.D.
My grandmother, I mentioned, grew up in also in Chicago and graduated from Rush in the 20s and was the first female president of the Dermatologic Society in Chicago. So these are folks that were doing pretty amazing things, though. I was getting ready to go to law school and I had an epiphany. That's really, I think, the best way to say is I realized I couldn't escape the drive.

00;06;37;08 - 00;07;02;22
David Perlstein, M.D.
I couldn't escape the need to do good now. So I took a different route than all of my relatives. I actually was already married and had a child when I started medical school. That informs you in a different way, right? You're basically approach the whole medicine thing and patients very differently than you do when you're when you're in your low twenties and suddenly decide, you know, I finished college and I'm going to become a doctor.

00;07;02;25 - 00;07;27;05
David Perlstein, M.D.
And I will tell you, it had a huge impact on what I wanted to do with my life. Once I got out and I chose pediatric kicks because I didn't have patients for adults at the time. And I realized that, you know, when you're taking care of kids, you always have to maintain a certain level of openness. You just have to and you have to be very aware of whatever bias you have.

00;07;27;05 - 00;07;47;15
David Perlstein, M.D.
But also, I'm somewhat of a child anyway, so it made sense. And I came back to New York because we left my wife and I left New York. We went to Cincinnati where my parents were, and that's where my dad practiced at the University and Children's Hospital. And then we came back here and I attended Cornell, the residency at Cornell before it was New York Presbyterian.

00;07;47;18 - 00;08;06;12
David Perlstein, M.D.
And then I thought I would do some specialty care. I was positive I was going to be a cardiologist and was accepted to this joint program that they just started between New York Presby Columbia and New York Presby Cornell. And then they asked me to stay on and be the chief. And so I spent an extra year being a chief.

00;08;06;12 - 00;08;30;29
David Perlstein, M.D.
And then three months into that, I realized, I can't keep doing this. You know, my kids are going to be in their thirties by the time I finished my training. And I took a deep breath and decided primary care. And I joined a boutique, Upper East Side practice taking care of very rich people. At that time, this was in the in the late nineties we had just introduced child health plus. And we didn't take any insurance except for two.

00;08;31;00 - 00;08;50;17
David Perlstein, M.D.
One was to be able to care for the Cornell faculty and the other was to be able to care for Cornell staff. So I took Blue Cross and I decided to also open up my practice to CHIP. And I remember the first time I had a CHIP patient come in. It was a Mexican woman, young Mexican woman with two kids in her stroller.

00;08;50;17 - 00;09;21;14
David Perlstein, M.D.
And and I saw her took care of it. And my partner said, can I talk to you after this, after the patient left? And she literally said to me, you really shouldn't bring those people here. And then I was gone in a month. That ended that relationship. And I was lucky to fall into an opportunity at St. Barnabas because St. Barnabas had had just founded their own Medicaid managed care plan, because Medicaid managed care had been coming to New York and they needed it.

00;09;21;16 - 00;09;46;25
David Perlstein, M.D.
I was hired actually, as the as the director of Ambulatory pediatrics. I served as a vice chair. We were given the funds to actually build the department and ultimately, you know, brought in a residency. I mean, it was really a lot of fun, a lot of work. But we were doing it for a really to be able to have pediatrics available, both on an outpatient inpatient side in the hospital, in a community that actually is filled with women and children.

00;09;46;28 - 00;10;04;27
David Perlstein, M.D.
And then I had a big mouth. I kept seeing things that didn't work and I kept suggesting things. And then I became a member of the medical board and then I became a medical director. I ran quality. You know, I followed that weird path of you do something, and they say, Well, try this. I became a chief medical officer.

00;10;04;27 - 00;10;38;13
David Perlstein, M.D.
And then in 2016, as you mentioned, I became CEO. But I've always approached everything I've done with the lens of taking care of children and communities. And because of that, it just has given me a different credibility, I would say. And we are a physician-run organization. It's not a it's not a new thing. But I think that the the idea behind how we got to the point where we were even open to doing some of the things that we were doing has to come from the fact that if you're taking care of children, public health has to be part of the discussion.

00;10;38;16 - 00;11;03;13
Joanne M. Conroy, M.D.
We know you've had an incredibly purpose-driven career and incredibly fortunate for the people who receive their care at St. Barnabas and now SBH Health System. There are some organizations that are really just grounded in purpose, and yours is one of them. I can name a few others in the country that are just that is their North Star.

00;11;03;15 - 00;11;29;14
Joanne M. Conroy, M.D.
It does change how you make decisions and how you use your resources. Now, you did some things at SBH Health. Educate me. I don't know if you did it before or after the rest of the world, but a lot of things. Your kitchen...don't you have grass or like some farm thing on the roof of one of your facilities?

00;11;29;17 - 00;11;56;14
Joanne M. Conroy, M.D.
You've invested in fitness facilities. Yeah. That, you know, everybody was all in on these and that late, you know, 2006 to 07 or 08 and I think it was to attract people. But I have a feeling that you got into it for a different reason. So talk a little bit about how did you shift from delivering care, which I'm sure St. Barnabas was all about.

00;11;56;14 - 00;12;03;03
Joanne M. Conroy, M.D.
How do you deliver that care to actually how do you care for the community outside the walls? Because that is a shift.

00;12;03;05 - 00;12;29;29
David Perlstein, M.D.
Yeah. So before I go, any deeper, you have to understand the history of St. Barnabas, right? The history of the hospital, the history of SBH health system. It's an independent community hospital. No affiliation with any religious organization. It was founded by an Episcopalian in 1866 as the Home for the Incurables. It was close to the current campus, but it was not on the current campus, and it was the first chronic care facility in the country.

00;12;30;04 - 00;12;50;19
David Perlstein, M.D.
It was the second in the world. The first one, opened in England a year earlier. And it was really for, you know, wealthy patients who were in the in the city to recover from TB. I mean,  that really is, I think what the majority of the work was about. Listen, we're in the Bronx and the Bronx changes over time.

00;12;50;21 - 00;13;25;15
David Perlstein, M.D.
So at some point in the late 1800s, a hospital was actually built on the site that we are currently at right now, continued with the name The Home for The Incredibles and the whole place was funded by all of those wonderful names that, you know, the Vanderbilts and the Astors and the Spalding's and and they were actually funding a lot of the care at that point so that people didn't have to pay in order to get the care they needed.

00;13;25;17 - 00;13;52;19
David Perlstein, M.D.
But at some point, you know, the community starts changing, the needs start changing. There's a split between kind of chronic care and and acute care that's occurring. The hospital is getting old. Throughout the teens and the twenties, there was a continued move towards delivering two types of care and ultimately a new building was built in the thirties, I believe, and the name was ultimately changed to St Barnabas Hospital in 1940s.

00;13;52;22 - 00;14;23;13
David Perlstein, M.D.
And then they also rolled that they basically built a nursing home at the same time. So they split the services between acute and chronic. But again, it's being done because the community needs change/ It was an old Italian and Irish and Jewish neighborhood originally and then that changed over the years. You know, certainly the seventies saw a huge change, but even before that the neighborhood was already changing and we had to redefine who we were going to care for and how we were going to care for them.

00;14;23;15 - 00;15;10;06
David Perlstein, M.D.
And we've done that pretty well over the years, though it's amazingly challenging in a place like like the Bronx, because there were a lot of just demographic changes that occur because of immigration patterns. So even at the time that I've been at Barnabas since 1999, you know, we've gone from primarily a Puerto Rican like and African-American community that we care for to a transition to kind of a Dominican and then we saw a transition to a Mexican, we saw a transition to the Albanian and Yemeni, and now we're seeing West African population and a very large, much larger South and Central American population that are now moving into the Bronx.

00;15;10;08 - 00;15;29;16
David Perlstein, M.D.
You now have to be aware of all the cultural norms. You have to train your staff on how to do it. You have to talk to people. You have to be in the community saying, what do you need? What do you want? And so it's amazing that we're still standing. I will tell you, I mean, you you have to know is that I just, you know, said all these things about Barnabas.

00;15;29;18 - 00;15;54;05
David Perlstein, M.D.
But we are 95% government payer and 88%, I would argue, is funded by the Medicaid system because we have mostly dual eligibles, because we're a poor report community. And that's how we even allowed ourselves to be open enough to move down the road because no matter what we do, no matter what decisions we make financially, we're not going to make a profit.

00;15;54;07 - 00;16;14;14
David Perlstein, M.D.
Our costs are pretty much set by our union partners and our revenue is set by the government. And I don't control for that. I had a board for many years when I first was chief medical officer and moving into a CEO. I had a board member kept saying, Well, you know, you're going to lose X number of dollars.

00;16;14;14 - 00;16;19;13
David Perlstein, M.D.
You have to cut out of the budget. And you had to do the model for them and said, Well, it doesn't work.

00;16;19;18 - 00;16;20;06
Joanne M. Conroy, M.D.
Yeah.

00;16;20;09 - 00;16;38;28
David Perlstein, M.D.
You know, what am I going to cut? We're going to cut psychiatry out when I stop seeing behavioral patients, even though the community, trust me, needs behavior. Am I going to cut addiction medicine out because it really doesn't cover the cost of care? No. You know, I'm a health care provider. I don't make widgets. You know, I don't make cars.

00;16;39;00 - 00;17;05;24
David Perlstein, M.D.
I exist at the at the health and pleasure of the community. So if you come into it thinking this is an opportunity to do something different in order to move the community in the right direction, to give them the tools and the ability to live more productive lives, to be happier like everybody else, it really makes it possible to move into the things that you were talking about in terms of the opportunities to build a wellness center.

00;17;05;28 - 00;17;28;06
David Perlstein, M.D.
And so that was what primed our ability to even do this. The other thing that primed our ability was the waiver. The first New York State waiver. They got the district delivery system reform, incentive payment program, Medicaid adjustment. And it really changed the way we were supposed to deliver care. Moving New York from a volume based system to a value based system.

00;17;28;09 - 00;17;57;16
David Perlstein, M.D.
That was a program that was that started in 2015. And then expired in 2020. And of course, what happened in 2020, COVID. So everything kind of just stopped. But we were fortunate because during those early years, as we were trying to move towards value, we stared at our empty lot across the street from the hospital that had been held for I can't tell you how long with the idea the board would build a new hospital

00;17;57;16 - 00;18;20;01
David Perlstein, M.D.
one day. It became clear that that is not what we needed to do. And in fact, in 2014, we did change our name to SBA Health System because, you know, the majority of our care was no longer being delivered in a hospital setting. It was really being delivered outside the walls. But I'll tell you about the moving from, you know, volume to value.

00;18;20;01 - 00;18;54;00
David Perlstein, M.D.
It enabled us to look around at what the social determinants, what the needs of the community were. Housing became a huge issue, we knew that. Food insecurity, a huge issue, and we found a really good partner. We found a developer who was mission-driven, who agreed with us to build 314 units of affordable housing on our land, and we donated the land in exchange for this because, you know, they could have built, I guess, co-ops and condos and tried to make as much money as they could.

00;18;54;00 - 00;19;19;00
David Perlstein, M.D.
We just wouldn't have given them the land, then. But in exchange for building out these 314 units, we also demanded that at least 50% of the units were held for the community. And we also worked with a group to make sure that 95 units were actually held for previously homeless individuals. We were moving people off the street and into stable housing that had support. In exchange for all that

00;19;19;00 - 00;19;43;03
David Perlstein, M.D.
we we actually got them to build a shelter for us, a 50,000 square foot space that was a shell. And we did get state funding, a $22.6 million to build it out. And that's our wellness center. And in that place we have women's and children's programs on the first floor and our urgent care because we were thinking we could decant the E.R., which by the way, hasn't worked.

00;19;43;05 - 00;20;13;06
David Perlstein, M.D.
And then we thought, all right, we were able to design a program that we thought, could it start to address those things that made it hard. It's a food desert up there, right there, just bodegas. So we actually had a Greenmarket that was put in and it with almost like a health food market. But on the first floor, our primary care programs for women and children, including WIC, OBGYN, women's imaging, and it's all co-located and it's a beautiful large space.

00;20;13;09 - 00;20;40;19
David Perlstein, M.D.
The idea was we really didn't want to hold people in a waiting room area, but we wanted to create a space where a family, if they were waiting for their family, they could have places to sit that were open. So it never looks busy until you go back and see people moving around. But we thought it was time to build a respectful place for patients to be seen and not just design something around profit.

00;20;40;21 - 00;21;04;18
David Perlstein, M.D.
So the programs you talked about  - the second floor  - are the the programs we're most proud of, which are the the teaching kitchen, the medical model fitness center. And yes, we have community space and studio space. And then on the roof there is a we have a farm. We partnered with Project AIDS and they manage the farm. That's where our our food comes from for the for the kitchen.

00;21;04;20 - 00;21;14;13
David Perlstein, M.D.
And we have a Greenmarket in the lobby. And then we also have been busy doing these great programs for the community. So, you know, it is possible.

00;21;14;15 - 00;21;38;24
Joanne M. Conroy, M.D.
It is, you know, getting the board and the community to appreciate that you actually have to move upstream to keep people healthier. And it was kind of the confluence of opportunities from state funding as well as kind of new programs that allowed you to have those resources to do something really different. You were sure that you could actually make a difference in the lifespan.

00;21;38;24 - 00;21;47;14
Joanne M. Conroy, M.D.
So have you been kind of following the data there, or is it really is it incredibly difficult to do that?

00;21;47;17 - 00;22;00;23
David Perlstein, M.D.
We are, right. So so we're just starting to actually have data that's meaningful. We're just able to now start to meet with payers to make deals because this is expensive and, and nobody wants to pay for it.

00;22;00;25 - 00;22;01;12
Joanne M. Conroy, M.D.
Yeah.

00;22;01;15 - 00;22;26;15
David Perlstein, M.D.
Because it takes a long time to change behavior. But the, the argument really comes down to, you know, if I can impact a patient and keep them out of the hospital, I've saved somebody's money. I certainly have decreased the trauma associated with being admitted. I would say the biggest mistake I've made in my career and the biggest positive thing I've done are the same thing. Just before

00;22;26;15 - 00;23;00;10
David Perlstein, M.D.
I became chief medical officer, I would walk through the ED and I'd look at the census and I'd see all these one day stays and two day stays of people who did not need to be admitted. And I set up a system that basically changed how we evaluated patients for admission. I put in the resources to treat people or get people into services on the outpatient, and we decreased our admissions from about 40% of our 90,000 a year ED to about 13%.

00;23;00;13 - 00;23;01;21
Joanne M. Conroy, M.D.
wow. That's fabulous.

00;23;01;26 - 00;23;08;08
David Perlstein, M.D.
It is and it's not. It is because it's the right thing to do. It's not because where do you get paid?

00;23;08;10 - 00;23;09;21
Joanne M. Conroy, M.D.
When they're in a bed.

00;23;09;23 - 00;23;24;08
David Perlstein, M.D.
So we killed us. Right. And luckily, as a pediatrician, I can say, look, we're doing the right thing. This trip is here, right? This is going to be permanent. We now have a track record of being able to do this. Well, we're going to get funded the right well. And I would tell you, the state's been really good to us.

00;23;24;15 - 00;23;43;14
David Perlstein, M.D.
We have received funding in order to keep our programs going. But the reality is, as a pediatrician, I could I could say, you listen, you know, what else do you want to do? And if you talk about social determinants and you've got to go back to the patient always. If I'm somebody who doesn't know where my next meal is going to be, I don't know where I'm going to sleep tonight,

00;23;43;17 - 00;24;05;24
David Perlstein, M.D.
am I going to fill my prescription to control my blood pressure? And if you have your blood pressure medication, you're going to remember to take it every day? Absolutely not. So ironically, it's kind of like SBH, right? We've talk about social determinants and saying, you know, it's almost like a Maslow's hierarchy. How can I be strategic when I'm basically have a negative margin all the time?

00;24;05;27 - 00;24;28;18
David Perlstein, M.D.
I don't know what my income is going to be in the next year. And so the reality is it also serves us because I don't know these things and profit can't be a goal for me. I can make the decisions around maximal social good. I can make decisions around doing the right thing. It's no different than anything else, right?

00;24;28;18 - 00;24;32;09
David Perlstein, M.D.
I already told you I can't cut myself to break even.

00;24;32;11 - 00;25;02;21
Joanne M. Conroy, M.D.
One question about actually integrating the community because your community has changed a lot and all the expectations that you may have developed for Hispanic and African-American predominant communities and now that are sub-Saharan African and Eastern European, how do you actually integrate all of those voices in terms of how do you identify the social determinants and how do you create programs that they'll use?

00;25;02;23 - 00;25;26;24
David Perlstein, M.D.
It takes trial and error. One of the things that we found is that you find the commonality. And honestly, the commonality amongst these folks are one: they want to have better lives. All of them. And all of them struggle with poverty and all of the associated problems that come with being poor. So we try to to really gather folks together around that commonality.

00;25;26;26 - 00;25;42;11
David Perlstein, M.D.
It's just like when you're taking care of certain populations that don't want blood products. Do you just say, forget it, I don't want to see you? Or do you work with the populations? Do the best thing you can in order to serve their needs. You do the latter, of course, because you're a provider, you're a health care provider.

00;25;42;14 - 00;26;09;29
David Perlstein, M.D.
So I would say that we struggle, but we also celebrate the differences internally because the hospital is also an anchor institution. Anywhere else we're a large institution. We have about 3000 employees and and a budget of almost 600 million. It's not a tiny place except in New York. It is. But I will tell you, our community makes up our staff.

00;26;10;01 - 00;26;35;13
David Perlstein, M.D.
So for many years we would celebrate each different group and we would find folks within those groups who wanted to run programs and we would develop these celebrations that would go on for a week. And it brought community members in. And it also highlighted that we were recognizing our differences while coalescing around the greater good.

00;26;35;15 - 00;27;00;13
Joanne M. Conroy, M.D.
You know, what you've done there is simply inspirational. And again, as we started the conversation, there are a handful of institutions across the country that are really mission driven and the way that SBA health system is And I want to thank you. You're doing such great work on behalf of your patients and the Bronx community. And I think we could probably talk for another 45 minutes about this.

00;27;00;13 - 00;27;22;08
Joanne M. Conroy, M.D.
But I want to be mindful of everybody's time. So on behalf of the AHA and Dartmouth Health and all of us in health care, I'm going to thank you for joining me in this discussion today. I would like to talk to you about your grandmother. My grandmother graduated from Smith in 1918, so they were the same generation and incredibly impactful.

00;27;22;08 - 00;27;35;00
Joanne M. Conroy, M.D.
And also I wanted to be a religion and philosophy major and I ended up in chemistry. So, yes, parents have an unduly strong impression on you actually decide to do as a career.

00;27;35;06 - 00;28;01;11
David Perlstein, M.D.
So yeah, I'll give you one last thing that before before we...my son is a is a Michelin chef who during COVID and he's in his thirties and he's been in that industry for a long time, very successful. He's now going to go and do a post back to get to go to medical school. And my daughter is in Anschutz in nursing school.

00;28;01;13 - 00;28;07;24
David Perlstein, M.D.
And these are two kids that I never thought would do this. So, you know, I guess there is something in the genes.

00;28;07;27 - 00;28;23;20
Joanne M. Conroy, M.D.
Well, you are a testimony that having a purpose driven career is actually very rewarding. And they've seen that in you. So thank you, David. On behalf of the AHA and everybody that's listening, I'll be back next month for another leadership dialog.

This special series explores the medical complications that can accompany pregnancy, successful prenatal and postpartum treatment programs, and how hospitals and health systems are addressing the social needs of new mothers. Pregnancy is a major stressor on a woman’s body, with cardiovascular conditions being one of the most prevalent complications and leading causes of maternal mortality.  In this episode, learn how Orlando Health is reaching outside its walls to support heart-healthy pregnancies and postpartum periods for new mothers.  


 

View Transcript
 

00;00;00;20 - 00;00;25;29
Tom Haederle
While the impending arrival of a new baby is an occasion for joy, pregnancy is also a major stressor on a pregnant person's body. Cardiovascular conditions are one of the most prevalent complications of pregnancy and one of the leading causes of maternal mortality.

00;00;26;02 - 00;00;51;21
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. In this podcast, the AHA’s Julia Resnick, director of Strategic Initiatives, explores how Orlando Health is reaching outside its walls to create the conditions for a heart healthy pregnancy and postpartum for new parents.

00;00;51;23 - 00;01;15;18
Chinedu Nwabuobi, M.D.
My family and I moved from Nigeria when I was 16. And I always tell people this, which is, you know, growing up, unlike in the United States where I tend to see a lot of joy surrounding pregnancy, surrounding births. I grew up in a place where when a woman was pregnant, there was joy associated with it. But when it got closer to the time for delivery, there was a lot of fear.

00;01;15;20 - 00;01;40;10
Chinedu Nwabuobi, M.D.
There was a lot of uncertainty. There was a lot of prayer groups being brought together to pray that a woman makes it out alive. I lost my lovely aunt while she was having her seventh child from postpartum hemorrhage, which was very devastating. A lot of people in the U.S., when they think of pregnancy, they obviously, you know, most times think about how I'm going to go have the baby, come back home.

00;01;40;13 - 00;01;48;03
Chinedu Nwabuobi, M.D.
But the truth is that, unfortunately, anybody can lose their life in the pregnancy.

00;01;48;05 - 00;02;11;26
Julia Resnick
That was Dr. Chinedu Nwabuobi, grounding us in the medical risks inherently involved in pregnancy. He is a maternal fetal medicine physician at Orlando Health Women's Institute Center for Maternal Fetal Medicine. I'm Julia Resnick, director of Strategic Initiatives at the American Hospital Association. And this is Beyond Birth in advancing Health Podcast. Today, we'll be focusing on matters of the heart.

00;02;11;29 - 00;02;40;24
Julia Resnick
Not only is February Valentine's Day, it is also Heart Health Month, a month dedicated to raising awareness of heart, health and cardiovascular conditions. Today, we will be exploring cardiovascular health during and after pregnancy and what hospitals can do to help create the conditions for a heart healthy pregnancy. So why heart health? Pregnancy is a major stressor on the body, and particularly on the heart  - complicating up to four in 100 pregnancies.

00;02;41;01 - 00;03;04;14
Julia Resnick
Cardiovascular issues continue to be one of the most common causes of maternal morbidity and mortality. One-in-three pregnancy related deaths in the U.S. are due to cardiovascular problems, and people who are black, American, Indian or Alaska Native are at higher risk of heart conditions during pregnancy and have a much higher risk of dying during pregnancy or soon after.

00;03;04;17 - 00;03;26;22
Julia Resnick
Hospitals know that creating the conditions for a heart, healthy pregnancy and postpartum period is key to improving outcomes. In this podcast, we'll be exploring how Orlando Health is reaching outside its walls to meet the needs of moms who are at risk of experiencing cardiovascular issues. You'll hear more from Dr. Nwabuobi, as well as Dr. Lori Boardman, chief quality officer at Orlando Health

00;03;26;22 - 00;03;46;09
Julia Resnick
Winnie Palmer Hospital for Women and Babies. Peggy Burgess, founder and CEO of the Center for Change and Crystal Wilson, a new mom who participated in Orlando Health's telehealth hypertension program after giving birth. We'll start with Dr. Boardman’s overview of Winnie Palmer Hospital and the population they serve.

00;03;46;11 - 00;04;11;14
Lori Boardman, M.D.
Winnie Palmer is really sort of almost iconic nationwide, and it has been that way because of generally the large volume of patients that we take care of here. So in the last fiscal year of full data that we have, we delivered 14,550 patients under one roof. We take care of 142 neonatal beds and their occupancy runs around 80 to 90%.

00;04;11;15 - 00;04;35;28
Lori Boardman, M.D.
So not only do we have a large patient population of persons who are delivering, but we have a lot of sick babies as well. So we have a lot of babies born early and a lot of babies with complex needs. So Winnie Palmer Hospital is a standalone women's hospital, it's an 11 story building. It houses a Labor floor of about 28 delivery rooms and houses, three floors for postpartum care.

00;04;36;00 - 00;04;53;18
Lori Boardman, M.D.
We have a floor dedicated to the NICU which again is large, and you get lost wandering around it because of the number of beds and pods involved. We have a triage area for taking care of those patients coming in with emergency needs and all the volumes in these sites are quite high.

00;04;53;21 - 00;05;04;20
Julia Resnick
Dr. Nwabuobi who you heard from at the beginning, specializes in perinatal cardiovascular health. I spoke with him about the prevalence of heart conditions during and after pregnancy.

00;05;04;23 - 00;05;41;02
Chinedu Nwabuobi, M.D.
About several hundred women die each year in the United States because of pregnancy related complications, right. Like no death is too little. So several hundred, that's that's too many already. And that's I can imagine with some of the numbers I'm seeing nowadays, probably higher now. The most recent report we have in the United States, as far as pregnancy associated mortality rates, and this is covering from 2007 to 2016, is pointing out that data is actually about 16.7 deaths per 100,000 live births.

00;05;41;04 - 00;06;09;13
Chinedu Nwabuobi, M.D.
And the top cause of that turns out to be cardiovascular disease, about 26.5%. So on a national scale, that is already quite an alarming number. The volume continues to increase. But when you look, we are talking about chronic hypertension, which is a cardiovascular complication. You're looking at about 8.6% in our African-American patients. You look at about 4.7% Hispanic patients and is Hispanic of any race.

00;06;09;19 - 00;06;42;12
Chinedu Nwabuobi, M.D.
And you're looking at about 6.2% in all non-Hispanic white. And then when you bring in something like actual preexisting cardiac disease, about 5.1% in our African-American patients, let me just say black patients as a as a whole, non-Hispanic blacks by about 3.9% in our non-Hispanic white and about 3.1% in our Hispanic patients of any race. So, again, these are numbers that continue to rise over time, but it's both a local and a national problem that needs all hands on deck.

00;06;42;15 - 00;06;52;27
Julia Resnick, M.D.
And you kind of touched on this, but are there certain populations that are particularly at risk for both maternal mortality and maternal morbidity due to cardiovascular issues?

00;06;52;29 - 00;07;24;07
Chinedu Nwabuobi, M.D.
I'm glad some of these things are starting to get national attention as far as like the media is concerned. But this is something that continues to marvel a lot of us, which is the fact that even among the black race, when you correct for education, where you correct for socioeconomic status, that a patient who is of a black race continues to have up to fourfold the amount of risk of maternal mortality, including cardiovascular causes of death when compared to the other races.

00;07;24;13 - 00;07;48;29
Chinedu Nwabuobi, M.D.
So that's definitely a fact. Something else that we continue to see to be a population that is at risk for some of these complications are women who are aged 35 and above. You know, I tell a lot of my patients, I joke with them when I say, you know, well, age is just a number. But in this case, it's not just the number because, as you know, your age goes beyond just having knee pain or aches, getting out of the bed

00;07;48;29 - 00;08;10;20
Chinedu Nwabuobi, M.D.
now. It really actually counts your chances of making it out of your pregnancy healthy, and the baby, you know, healthy as well. So age is a factor that we need to pay close attention to. And then there's also the factor of patients who do not have prenatal care and I think the angle of looking at this is probably thinking about access to care.

00;08;10;22 - 00;08;35;01
Chinedu Nwabuobi, M.D.
Most people do not just ignore care completely. There are several factors that limit them deciding that they will get up, go see a physician, go see a midwife, go see whoever that provides their prenatal care to get care beyond the fact that they are noncompliant. Right. Some people have issues with transportation. Some people do not even have a place to live.

00;08;35;03 - 00;09;06;25
Chinedu Nwabuobi, M.D.
Some people are probably a juggling two or three jobs to make ends meet and not able to make that appointment. Sometimes we do not have the best clinic hours to actually accommodate all of these patients with some of the things going on in their lives. It's very multifactor, but again, it comes down to that lack of access. So these three populations with the black race, the age and limited access to care can definitely exacerbate the issue of cardiovascular complications and pregnancy.

00;09;06;27 - 00;09;20;09
Julia Resnick
It is clear that some people are more at risk of experiencing cardiovascular issues during pregnancy than others. To target their efforts and address those inequitable birth outcomes, Dr. Boardman and her team dug into the data.

00;09;20;11 - 00;09;51;28
Lori Boardman, M.D.
There's a lot of disparities and we can talk about a number of them that we see in our data. This just mimics nationwide data, and we know that black women in particular are disproportionately affected by severe maternal morbidity and mortality. And we know that they, no matter what their background is, no matter how much education they've gotten, no matter how much money they make or where they live, they all have a similar pattern of unfortunately, being more likely to have a severe maternal morbidity event in their lives.

00;09;52;00 - 00;10;15;29
Lori Boardman, M.D.
And you see it on television. Serena Williams can't get it done. Nobody can. So what we did and what I've done for the last decade is, is create some dashboards that really allow us to look at different things. So we have a whole set of dashboards around severe maternal morbidity. One is just outlining and knowing what those severe maternal morbidity events are.

00;10;16;02 - 00;10;41;24
Lori Boardman, M.D.
So our most common forms of severe maternal morbidity tend to be sepsis, which is a severe infection, tend to be renal failure, and then also tend to be more of those hemorrhage events. So we do follow those. And the biggest one probably is now hypertension or hypertension related causes. So we look for those rates and we are able to calculate that.

00;10;41;24 - 00;10;59;26
Lori Boardman, M.D.
But we also want to have a way to identify those patients who are at greater risk for having a severe maternal morbidity event. And one of those is to use something called the comorbidity index. So we've been able to collect that information at the time of delivery so we have a good idea what our patients are struggling with.

00;10;59;29 - 00;11;21;07
Lori Boardman, M.D.
For example, if we look at the black population, that population comes in with a preexisting history of anemia and almost half of those patients. We know there's opportunity there to follow them more closely. We know that when we looked at our patients coming back after they've been here for delivery to be readmitted to the hospital, the most common cause was hypertensive disorders.

00;11;21;10 - 00;11;46;20
Lori Boardman, M.D.
So using that as a way to move forward, we also knew we were in the middle of a pandemic and a lot of people weren't coming into the hospitals or going to practices. So we use the telehealth platform to have a program that we established while those patients were in the hospital, they delivered. If they had any kind of hypertension problem or they had even had a history of chronic hypertension before they came in, we wanted to follow them

00;11;46;20 - 00;12;07;12
Lori Boardman, M.D.
when they went home. It did really well. And then a lot of providers were, well, skeptical of the program. But then when they saw the results, everybody jumped on board. So at this point, we have everybody involved with our postpartum hypertension program. That means that when those patients go home, we want them to be teed up as much as we can to go home in a healthy way.

00;12;07;12 - 00;12;28;12
Lori Boardman, M.D.
So the institution started doing something called "meds to beds" so that you would go home with your prescription in hand. If you had to be on something for your blood pressure, you were given it so that you didn't have to go to a pharmacy and try to get it delivered to you or have to go through anything. So most patients were able to go home with a prescription.

00;12;28;14 - 00;12;48;24
Lori Boardman, M.D.
We recruited them before they left the hospital. Our retention rate from recruitment was over 90%. So every month we had about 300 patients and we would have close to almost all of them would be in the program. Initially, we wanted to do day two after you got home and then a day five visit, because most of our readmissions were in that first week.

00;12;48;26 - 00;13;10;11
Lori Boardman, M.D.
But we found out very quickly that we needed to do one the day after you went home. So we caught more people doing that. We were able to engage with them in the platform like we're using. So I'm looking at you and we're having a conversation. We use the platform to not only ask them about their blood pressure, but also to ask some other related questions.

00;13;10;13 - 00;13;40;27
Lori Boardman, M.D.
We screened all the women for depression and anxiety. We screened everybody for social determinants of health and social drivers of health and we also talked a lot about breastfeeding because we know that black women are much less likely to breastfeed, so to provide them the support to do that before the patient went home. Everybody went home with a cough and a monitor and then they were given education about how to know when there's a sign or symptom that you're having that needs to be addressed.

00;13;41;05 - 00;14;00;16
Lori Boardman, M.D.
Who to call. If the blood pressure was sort of in the middle range, you would call the provider. If it wasn't, they would come to the hospital. And for most patients, and particularly for those patients that struggle probably with social support and transportation, they couldn't believe that they could do all of this in their kitchen or their bedroom or wherever they wanted to be.

00;14;00;18 - 00;14;23;02
Lori Boardman, M.D.
And it just took off that load of having to worry about who's going to drive you. We could even do some of those social determinants, social drivers of health like hunger and food, getting them delivered directly from one of our community partners and they can drive that stuff to their home so they can have fresh vegetables and other perishable and nonperishable items.

00;14;23;04 - 00;14;32;13
Lori Boardman, M.D.
So when I would even be recruiting them, people would cry. They just couldn't believe that this kind of program would exist.

00;14;32;16 - 00;14;35;03
SFX
Baby cooing

00;14;35;05 - 00;14;54;16
Julia Resnick
Crystal Wilson delivered her third child at Winnie Palmer last year. During the course of her pregnancy, she learned that she had previously undiagnosed cardiovascular issues. After giving birth, her provider knew her heart was at risk for future complications. Enter the perinatal hypertension telehealth program.

00;14;54;18 - 00;15;05;01
Crystal Wilson
At the hospital in the recovery room, I met with this woman. I can't remember her name and she gave me like a monitor for my blood pressure and a

00;15;05;01 - 00;15;05;18
Crystal Wilson
scale and

00;15;05;18 - 00;15;32;01
Crystal Wilson
she asked me if I wanted to be involved with some of the programs. And I'm like, You know what? It's not going to hurt. You know, it can do nothing but help me. There were a bunch of programs available for me. I call it counseling. That for me was a really good coping mechanism. So I heard from different moms, you know, building relationships.

00;15;32;03 - 00;15;37;11
Crystal Wilson
So I think it was a really, really good program. The support group was

00;15;37;14 - 00;15;38;19
Crystal Wilson
a huge thing.

00;15;38;21 - 00;15;48;16
Crystal Wilson
The counseling, the meeting of the moms and all of that. Try to reduce stress anxiety, which also affects your blood pressure.

00;15;48;18 - 00;16;00;15
Julia Resnick
The health care workers at Winnie Palmer couldn't accomplish this alone. They partnered with a local organization run by our guest, Peggy Burgess. Peggy shared the origin story of her organization.

00;16;00;18 - 00;16;30;01
Peggy Burgess
It is a interesting story. I started Center for Change in 2003. I started it because my sister, who was only 48 years old at the time, died of colon cancer. And what amazed me about her reaction to having stage four cancer that early is she had no resources. So I wrote a program and it was called the Renee's Dream Program.

00;16;30;03 - 00;16;51;26
Peggy Burgess
And what it was about was educating people who had less resources than she had to find out where they can go for treatment, who they could talk to, what they can do to improve their health, and trying to give her just a sense of security or control.

00;16;51;28 - 00;17;05;10
Julia Resnick
Out of this original program grew The Center for Change, an organization that leverages community health workers and offers health coaching and self-management courses and chronic disease, amongst other opportunities to improve health.

00;17;05;13 - 00;17;34;21
Peggy Burgess
What we were actually doing was - and I'm so glad Orlando Health had the program designed where they had the bus available. They had the clinicians available and they were part of the program was requiring them to make sure that they go it. And for our end, it was no more than providing that extra push, that extra check in with them to see, are you doing okay?

00;17;34;24 - 00;18;07;26
Peggy Burgess
Are you following through? Why haven't you gone to check on this or that really doesn't sound normal to me. I would suggest that you check on this. You'll be surprised at the number of young mothers who are unaware of signs and symptoms and would say, Well, I have an appointment in three weeks. No. If you have swelling to this extent and is moving up your legs, something is wrong

00;18;07;27 - 00;18;36;01
Peggy Burgess
now. You need to have that checked. Sometimes just that motherly push is enough to say, okay, okay, I'll go. And they know that we're going to call back because we are their accountability partner in a way, because it is our responsibility to make sure that not only are we educating, but we're there for support and we're also there to listen.

00;18;36;04 - 00;19;20;11
Peggy Burgess
One of the biggest things that the community health workers  - and we train them to do - is please listen to what your client or your patient is saying to you. Listen, because they will give you all the clues that you need to help them. I love the program that we're working with with Orlando Health now, But if it was my goal, my goal would be for it to continue to grow so that not just a few of the mothers that are high risk, but all mothers that are high risk would have access to this.

00;19;20;14 - 00;19;31;20
Julia Resnick
The Center for Change wasn't the only community partner involved in this program. Dr. Boardman spoke to the other groups that have been instrumental in providing holistic wraparound services for new moms.

00;19;31;22 - 00;19;54;02
Lori Boardman, M.D.
I'm going to call out a couple that really have done a fabulous job, and one of those is Second Harvest Food Bank. So Second Harvest has been a partner with us through two of the grants that we've gotten from the Florida Department of Health. They've been able to identify those patients. They have a very streamlined process and they were able in the one grant, we enrolled about 1200 women about six months.

00;19;54;02 - 00;20;25;09
Lori Boardman, M.D.
They had touched 500 patients and their families with food boxes. They were 90 days of food boxes being delivered every other week. For families that really needed it continued. And then another group that we worked with, we've worked with a number of folks was Christine Certain who a perinatal licensed mental health counselor. She's been doing group counseling for patients who screened positive for the depression or anxiety, which is a very common side effect of pregnancy.

00;20;25;09 - 00;20;30;13
Lori Boardman, M.D.
And in the postpartum period, it manifests itself. But you can see it throughout pregnancy.

00;20;30;16 - 00;20;49;19
Julia Resnick
Addressing the medical, social and emotional needs of new moms helps create an environment where they and their babies can thrive. And the perinatal hypertension telehealth program has been incredibly successful in moving the needle on pregnancy and postpartum outcomes. Dr. Boardman shared the impact that it has had on their patient population.

00;20;49;21 - 00;21;14;01
Lori Boardman, M.D.
So when you look at participation from patients that have known hypertensive disorders, we recommend coming in for a visit in about 7 to 10 days. White women and Hispanic women, about 80% of those patients will go to them. About 25% of black patients will go to those visits. With the virtual visit platform, everybody participated in excess of 70 to 75%.

00;21;14;03 - 00;21;35;27
Lori Boardman, M.D.
So we didn't see those disparities anymore. And if a patient completed at least one of those two visits, the readmission rate was about half of what it was for patients who didn't do that. It's now become embedded in Winnie Palmer. It's part of what we do. It's not a pilot, it's not a study. It's really how we treat our patients.

00;21;36;00 - 00;21;39;13
Lori Boardman, M.D.
That's gone exceedingly well.

00;21;39;16 - 00;21;56;23
Julia Resnick
Everyone's needs are different. To get the best outcomes and reduce risk, hospitals need to design care with and around patients and create systems that make it easier for new moms to care for themselves and their babies. We'll wrap up with some closing thoughts from doctors Nwabuobi and Boardman.

00;21;56;25 - 00;22;32;17
Chinedu Nwabuobi, M.D.
Like I said earlier, pregnancy being kind of a stressor can mask this. So just be on top of your care, be very involved, be an advocate for yourself, speak up, ask questions. Those symptoms that you've read online, you've seen on Tick-Tock that you consider are normal should not be normal until it has been completely addressed by your OB provider. To make sure we care for women more before they become pregnant so that when they become pregnant, there's already that understanding of what the risk is, hopefully we've mitigated it, and how we can make for the best pregnancy outcomes of it.

00;22;32;19 - 00;22;55;10
Lori Boardman, M.D.
I know from thinking about even creating programs and all this kind of stuff, having the end user be involved in the conversation, and I think listening to our patients learn from our patients and then when you start to implement your whatever you're deciding they're going to do, make sure that it aligns with what they want to do because otherwise we're never going to be successful.

00;22;55;12 - 00;23;02;04
Lori Boardman
And I think they know better than we know what's going to work, for them and often for their communities.

00;23;02;07 - 00;23;27;26
Julia Resnick
Heart Month can be a catalyst for health care organizations to reimagine what it takes to create the conditions for a heart healthy pregnancy. And that will require going beyond the hospital walls to engage patients and collaborate with stakeholders who all share the same goal, healthy moms and healthy babies. By designing pregnancy care around patient needs, recognizing who is at risk of complications and reducing barriers to support,

00;23;27;28 - 00;23;56;06
Julia Resnick
hospitals can make progress towards reducing maternal morbidity and mortality. A big thank you to all of our speakers: Lori Boardman, Chinedu, Nwabuobi, Peggy Burgess and Crystal Wilson. I appreciate everything you do to support the health of your patients and community members. For more resources on improving maternal health visit www.aha.org/betterhealthformothersandbabies

00;23;56;09 - 00;24;08;17
Julia Resnick
Thank you for tuning in to this episode of Beyond Birth and Advancing Health Podcast. If you missed any of our previous podcasts, you can find them wherever you listen to your podcasts and please subscribe to the Advancing Health Channel. We'll see you next time.

00;00;00;20 - 00;00;25;29
Tom Haederle
While the impending arrival of a new baby is an occasion for joy, pregnancy is also a major stressor on a pregnant person's body. Cardiovascular conditions are one of the most prevalent complications of pregnancy and one of the leading causes of maternal mortality.

00;00;26;02 - 00;00;51;21
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. In this podcast, the AHA’s Julia Resnick, director of Strategic Initiatives, explores how Orlando Health is reaching outside its walls to create the conditions for a heart healthy pregnancy and postpartum for new parents.

00;00;51;23 - 00;01;15;18
Chinedu Nwabuobi, M.D.
My family and I moved from Nigeria when I was 16. And I always tell people this, which is, you know, growing up, unlike in the United States where I tend to see a lot of joy surrounding pregnancy, surrounding births. I grew up in a place where when a woman was pregnant, there was joy associated with it. But when it got closer to the time for delivery, there was a lot of fear.

00;01;15;20 - 00;01;40;10
Chinedu Nwabuobi, M.D.
There was a lot of uncertainty. There was a lot of prayer groups being brought together to pray that a woman makes it out alive. I lost my lovely aunt while she was having her seventh child from postpartum hemorrhage, which was very devastating. A lot of people in the U.S., when they think of pregnancy, they obviously, you know, most times think about how I'm going to go have the baby, come back home.

00;01;40;13 - 00;01;48;03
Chinedu Nwabuobi, M.D.
But the truth is that, unfortunately, anybody can lose their life in the pregnancy.

00;01;48;05 - 00;02;11;26
Julia Resnick
That was Dr. Chinedu Nwabuobi, grounding us in the medical risks inherently involved in pregnancy. He is a maternal fetal medicine physician at Orlando Health Women's Institute Center for Maternal Fetal Medicine. I'm Julia Resnick, director of Strategic Initiatives at the American Hospital Association. And this is Beyond Birth in advancing Health Podcast. Today, we'll be focusing on matters of the heart.

00;02;11;29 - 00;02;40;24
Julia Resnick
Not only is February Valentine's Day, it is also Heart Health Month, a month dedicated to raising awareness of heart, health and cardiovascular conditions. Today, we will be exploring cardiovascular health during and after pregnancy and what hospitals can do to help create the conditions for a heart healthy pregnancy. So why heart health? Pregnancy is a major stressor on the body, and particularly on the heart  - complicating up to four in 100 pregnancies.

00;02;41;01 - 00;03;04;14
Julia Resnick
Cardiovascular issues continue to be one of the most common causes of maternal morbidity and mortality. One-in-three pregnancy related deaths in the U.S. are due to cardiovascular problems, and people who are black, American, Indian or Alaska Native are at higher risk of heart conditions during pregnancy and have a much higher risk of dying during pregnancy or soon after.

00;03;04;17 - 00;03;26;22
Julia Resnick
Hospitals know that creating the conditions for a heart, healthy pregnancy and postpartum period is key to improving outcomes. In this podcast, we'll be exploring how Orlando Health is reaching outside its walls to meet the needs of moms who are at risk of experiencing cardiovascular issues. You'll hear more from Dr. Nwabuobi, as well as Dr. Lori Boardman, chief quality officer at Orlando Health

00;03;26;22 - 00;03;46;09
Julia Resnick
Winnie Palmer Hospital for Women and Babies. Peggy Burgess, founder and CEO of the Center for Change and Crystal Wilson, a new mom who participated in Orlando Health's telehealth hypertension program after giving birth. We'll start with Dr. Boardman’s overview of Winnie Palmer Hospital and the population they serve.

00;03;46;11 - 00;04;11;14
Lori Boardman, M.D.
Winnie Palmer is really sort of almost iconic nationwide, and it has been that way because of generally the large volume of patients that we take care of here. So in the last fiscal year of full data that we have, we delivered 14,550 patients under one roof. We take care of 142 neonatal beds and their occupancy runs around 80 to 90%.

00;04;11;15 - 00;04;35;28
Lori Boardman, M.D.
So not only do we have a large patient population of persons who are delivering, but we have a lot of sick babies as well. So we have a lot of babies born early and a lot of babies with complex needs. So Winnie Palmer Hospital is a standalone women's hospital, it's an 11 story building. It houses a Labor floor of about 28 delivery rooms and houses, three floors for postpartum care.

00;04;36;00 - 00;04;53;18
Lori Boardman, M.D.
We have a floor dedicated to the NICU which again is large, and you get lost wandering around it because of the number of beds and pods involved. We have a triage area for taking care of those patients coming in with emergency needs and all the volumes in these sites are quite high.

00;04;53;21 - 00;05;04;20
Julia Resnick
Dr. Nwabuobi who you heard from at the beginning, specializes in perinatal cardiovascular health. I spoke with him about the prevalence of heart conditions during and after pregnancy.

00;05;04;23 - 00;05;41;02
Chinedu Nwabuobi, M.D.
About several hundred women die each year in the United States because of pregnancy related complications, right. Like no death is too little. So several hundred, that's that's too many already. And that's I can imagine with some of the numbers I'm seeing nowadays, probably higher now. The most recent report we have in the United States, as far as pregnancy associated mortality rates, and this is covering from 2007 to 2016, is pointing out that data is actually about 16.7 deaths per 100,000 live births.

00;05;41;04 - 00;06;09;13
Chinedu Nwabuobi, M.D.
And the top cause of that turns out to be cardiovascular disease, about 26.5%. So on a national scale, that is already quite an alarming number. The volume continues to increase. But when you look, we are talking about chronic hypertension, which is a cardiovascular complication. You're looking at about 8.6% in our African-American patients. You look at about 4.7% Hispanic patients and is Hispanic of any race.

00;06;09;19 - 00;06;42;12
Chinedu Nwabuobi, M.D.
And you're looking at about 6.2% in all non-Hispanic white. And then when you bring in something like actual preexisting cardiac disease, about 5.1% in our African-American patients, let me just say black patients as a as a whole, non-Hispanic blacks by about 3.9% in our non-Hispanic white and about 3.1% in our Hispanic patients of any race. So, again, these are numbers that continue to rise over time, but it's both a local and a national problem that needs all hands on deck.

00;06;42;15 - 00;06;52;27
Julia Resnick, M.D.
And you kind of touched on this, but are there certain populations that are particularly at risk for both maternal mortality and maternal morbidity due to cardiovascular issues?

00;06;52;29 - 00;07;24;07
Chinedu Nwabuobi, M.D.
I'm glad some of these things are starting to get national attention as far as like the media is concerned. But this is something that continues to marvel a lot of us, which is the fact that even among the black race, when you correct for education, where you correct for socioeconomic status, that a patient who is of a black race continues to have up to fourfold the amount of risk of maternal mortality, including cardiovascular causes of death when compared to the other races.

00;07;24;13 - 00;07;48;29
Chinedu Nwabuobi, M.D.
So that's definitely a fact. Something else that we continue to see to be a population that is at risk for some of these complications are women who are aged 35 and above. You know, I tell a lot of my patients, I joke with them when I say, you know, well, age is just a number. But in this case, it's not just the number because, as you know, your age goes beyond just having knee pain or aches, getting out of the bed

00;07;48;29 - 00;08;10;20
Chinedu Nwabuobi, M.D.
now. It really actually counts your chances of making it out of your pregnancy healthy, and the baby, you know, healthy as well. So age is a factor that we need to pay close attention to. And then there's also the factor of patients who do not have prenatal care and I think the angle of looking at this is probably thinking about access to care.

00;08;10;22 - 00;08;35;01
Chinedu Nwabuobi, M.D.
Most people do not just ignore care completely. There are several factors that limit them deciding that they will get up, go see a physician, go see a midwife, go see whoever that provides their prenatal care to get care beyond the fact that they are noncompliant. Right. Some people have issues with transportation. Some people do not even have a place to live.

00;08;35;03 - 00;09;06;25
Chinedu Nwabuobi, M.D.
Some people are probably a juggling two or three jobs to make ends meet and not able to make that appointment. Sometimes we do not have the best clinic hours to actually accommodate all of these patients with some of the things going on in their lives. It's very multifactor, but again, it comes down to that lack of access. So these three populations with the black race, the age and limited access to care can definitely exacerbate the issue of cardiovascular complications and pregnancy.

00;09;06;27 - 00;09;20;09
Julia Resnick
It is clear that some people are more at risk of experiencing cardiovascular issues during pregnancy than others. To target their efforts and address those inequitable birth outcomes, Dr. Boardman and her team dug into the data.

00;09;20;11 - 00;09;51;28
Lori Boardman, M.D.
There's a lot of disparities and we can talk about a number of them that we see in our data. This just mimics nationwide data, and we know that black women in particular are disproportionately affected by severe maternal morbidity and mortality. And we know that they, no matter what their background is, no matter how much education they've gotten, no matter how much money they make or where they live, they all have a similar pattern of unfortunately, being more likely to have a severe maternal morbidity event in their lives.

00;09;52;00 - 00;10;15;29
Lori Boardman, M.D.
And you see it on television. Serena Williams can't get it done. Nobody can. So what we did and what I've done for the last decade is, is create some dashboards that really allow us to look at different things. So we have a whole set of dashboards around severe maternal morbidity. One is just outlining and knowing what those severe maternal morbidity events are.

00;10;16;02 - 00;10;41;24
Lori Boardman, M.D.
So our most common forms of severe maternal morbidity tend to be sepsis, which is a severe infection, tend to be renal failure, and then also tend to be more of those hemorrhage events. So we do follow those. And the biggest one probably is now hypertension or hypertension related causes. So we look for those rates and we are able to calculate that.

00;10;41;24 - 00;10;59;26
Lori Boardman, M.D.
But we also want to have a way to identify those patients who are at greater risk for having a severe maternal morbidity event. And one of those is to use something called the comorbidity index. So we've been able to collect that information at the time of delivery so we have a good idea what our patients are struggling with.

00;10;59;29 - 00;11;21;07
Lori Boardman, M.D.
For example, if we look at the black population, that population comes in with a preexisting history of anemia and almost half of those patients. We know there's opportunity there to follow them more closely. We know that when we looked at our patients coming back after they've been here for delivery to be readmitted to the hospital, the most common cause was hypertensive disorders.

00;11;21;10 - 00;11;46;20
Lori Boardman, M.D.
So using that as a way to move forward, we also knew we were in the middle of a pandemic and a lot of people weren't coming into the hospitals or going to practices. So we use the telehealth platform to have a program that we established while those patients were in the hospital, they delivered. If they had any kind of hypertension problem or they had even had a history of chronic hypertension before they came in, we wanted to follow them

00;11;46;20 - 00;12;07;12
Lori Boardman, M.D.
when they went home. It did really well. And then a lot of providers were, well, skeptical of the program. But then when they saw the results, everybody jumped on board. So at this point, we have everybody involved with our postpartum hypertension program. That means that when those patients go home, we want them to be teed up as much as we can to go home in a healthy way.

00;12;07;12 - 00;12;28;12
Lori Boardman, M.D.
So the institution started doing something called "meds to beds" so that you would go home with your prescription in hand. If you had to be on something for your blood pressure, you were given it so that you didn't have to go to a pharmacy and try to get it delivered to you or have to go through anything. So most patients were able to go home with a prescription.

00;12;28;14 - 00;12;48;24
Lori Boardman, M.D.
We recruited them before they left the hospital. Our retention rate from recruitment was over 90%. So every month we had about 300 patients and we would have close to almost all of them would be in the program. Initially, we wanted to do day two after you got home and then a day five visit, because most of our readmissions were in that first week.

00;12;48;26 - 00;13;10;11
Lori Boardman, M.D.
But we found out very quickly that we needed to do one the day after you went home. So we caught more people doing that. We were able to engage with them in the platform like we're using. So I'm looking at you and we're having a conversation. We use the platform to not only ask them about their blood pressure, but also to ask some other related questions.

00;13;10;13 - 00;13;40;27
Lori Boardman, M.D.
We screened all the women for depression and anxiety. We screened everybody for social determinants of health and social drivers of health and we also talked a lot about breastfeeding because we know that black women are much less likely to breastfeed, so to provide them the support to do that before the patient went home. Everybody went home with a cough and a monitor and then they were given education about how to know when there's a sign or symptom that you're having that needs to be addressed.

00;13;41;05 - 00;14;00;16
Lori Boardman, M.D.
Who to call. If the blood pressure was sort of in the middle range, you would call the provider. If it wasn't, they would come to the hospital. And for most patients, and particularly for those patients that struggle probably with social support and transportation, they couldn't believe that they could do all of this in their kitchen or their bedroom or wherever they wanted to be.

00;14;00;18 - 00;14;23;02
Lori Boardman, M.D.
And it just took off that load of having to worry about who's going to drive you. We could even do some of those social determinants, social drivers of health like hunger and food, getting them delivered directly from one of our community partners and they can drive that stuff to their home so they can have fresh vegetables and other perishable and nonperishable items.

00;14;23;04 - 00;14;32;13
Lori Boardman, M.D.
So when I would even be recruiting them, people would cry. They just couldn't believe that this kind of program would exist.

00;14;32;16 - 00;14;35;03
SFX
Baby cooing

00;14;35;05 - 00;14;54;16
Julia Resnick
Crystal Wilson delivered her third child at Winnie Palmer last year. During the course of her pregnancy, she learned that she had previously undiagnosed cardiovascular issues. After giving birth, her provider knew her heart was at risk for future complications. Enter the perinatal hypertension telehealth program.

00;14;54;18 - 00;15;05;01
Crystal Wilson
At the hospital in the recovery room, I met with this woman. I can't remember her name and she gave me like a monitor for my blood pressure and a

00;15;05;01 - 00;15;05;18
Crystal Wilson
scale and

00;15;05;18 - 00;15;32;01
Crystal Wilson
she asked me if I wanted to be involved with some of the programs. And I'm like, You know what? It's not going to hurt. You know, it can do nothing but help me. There were a bunch of programs available for me. I call it counseling. That for me was a really good coping mechanism. So I heard from different moms, you know, building relationships.

00;15;32;03 - 00;15;37;11
Crystal Wilson
So I think it was a really, really good program. The support group was

00;15;37;14 - 00;15;38;19
Crystal Wilson
a huge thing.

00;15;38;21 - 00;15;48;16
Crystal Wilson
The counseling, the meeting of the moms and all of that. Try to reduce stress anxiety, which also affects your blood pressure.

00;15;48;18 - 00;16;00;15
Julia Resnick
The health care workers at Winnie Palmer couldn't accomplish this alone. They partnered with a local organization run by our guest, Peggy Burgess. Peggy shared the origin story of her organization.

00;16;00;18 - 00;16;30;01
Peggy Burgess
It is a interesting story. I started Center for Change in 2003. I started it because my sister, who was only 48 years old at the time, died of colon cancer. And what amazed me about her reaction to having stage four cancer that early is she had no resources. So I wrote a program and it was called the Renee's Dream Program.

00;16;30;03 - 00;16;51;26
Peggy Burgess
And what it was about was educating people who had less resources than she had to find out where they can go for treatment, who they could talk to, what they can do to improve their health, and trying to give her just a sense of security or control.

00;16;51;28 - 00;17;05;10
Julia Resnick
Out of this original program grew The Center for Change, an organization that leverages community health workers and offers health coaching and self-management courses and chronic disease, amongst other opportunities to improve health.

00;17;05;13 - 00;17;34;21
Peggy Burgess
What we were actually doing was - and I'm so glad Orlando Health had the program designed where they had the bus available. They had the clinicians available and they were part of the program was requiring them to make sure that they go it. And for our end, it was no more than providing that extra push, that extra check in with them to see, are you doing okay?

00;17;34;24 - 00;18;07;26
Peggy Burgess
Are you following through? Why haven't you gone to check on this or that really doesn't sound normal to me. I would suggest that you check on this. You'll be surprised at the number of young mothers who are unaware of signs and symptoms and would say, Well, I have an appointment in three weeks. No. If you have swelling to this extent and is moving up your legs, something is wrong

00;18;07;27 - 00;18;36;01
Peggy Burgess
now. You need to have that checked. Sometimes just that motherly push is enough to say, okay, okay, I'll go. And they know that we're going to call back because we are their accountability partner in a way, because it is our responsibility to make sure that not only are we educating, but we're there for support and we're also there to listen.

00;18;36;04 - 00;19;20;11
Peggy Burgess
One of the biggest things that the community health workers  - and we train them to do - is please listen to what your client or your patient is saying to you. Listen, because they will give you all the clues that you need to help them. I love the program that we're working with with Orlando Health now, But if it was my goal, my goal would be for it to continue to grow so that not just a few of the mothers that are high risk, but all mothers that are high risk would have access to this.

00;19;20;14 - 00;19;31;20
Julia Resnick
The Center for Change wasn't the only community partner involved in this program. Dr. Boardman spoke to the other groups that have been instrumental in providing holistic wraparound services for new moms.

00;19;31;22 - 00;19;54;02
Lori Boardman, M.D.
I'm going to call out a couple that really have done a fabulous job, and one of those is Second Harvest Food Bank. So Second Harvest has been a partner with us through two of the grants that we've gotten from the Florida Department of Health. They've been able to identify those patients. They have a very streamlined process and they were able in the one grant, we enrolled about 1200 women about six months.

00;19;54;02 - 00;20;25;09
Lori Boardman, M.D.
They had touched 500 patients and their families with food boxes. They were 90 days of food boxes being delivered every other week. For families that really needed it continued. And then another group that we worked with, we've worked with a number of folks was Christine Certain who a perinatal licensed mental health counselor. She's been doing group counseling for patients who screened positive for the depression or anxiety, which is a very common side effect of pregnancy.

00;20;25;09 - 00;20;30;13
Lori Boardman, M.D.
And in the postpartum period, it manifests itself. But you can see it throughout pregnancy.

00;20;30;16 - 00;20;49;19
Julia Resnick
Addressing the medical, social and emotional needs of new moms helps create an environment where they and their babies can thrive. And the perinatal hypertension telehealth program has been incredibly successful in moving the needle on pregnancy and postpartum outcomes. Dr. Boardman shared the impact that it has had on their patient population.

00;20;49;21 - 00;21;14;01
Lori Boardman, M.D.
So when you look at participation from patients that have known hypertensive disorders, we recommend coming in for a visit in about 7 to 10 days. White women and Hispanic women, about 80% of those patients will go to them. About 25% of black patients will go to those visits. With the virtual visit platform, everybody participated in excess of 70 to 75%.

00;21;14;03 - 00;21;35;27
Lori Boardman, M.D.
So we didn't see those disparities anymore. And if a patient completed at least one of those two visits, the readmission rate was about half of what it was for patients who didn't do that. It's now become embedded in Winnie Palmer. It's part of what we do. It's not a pilot, it's not a study. It's really how we treat our patients.

00;21;36;00 - 00;21;39;13
Lori Boardman, M.D.
That's gone exceedingly well.

00;21;39;16 - 00;21;56;23
Julia Resnick
Everyone's needs are different. To get the best outcomes and reduce risk, hospitals need to design care with and around patients and create systems that make it easier for new moms to care for themselves and their babies. We'll wrap up with some closing thoughts from doctors Nwabuobi and Boardman.

00;21;56;25 - 00;22;32;17
Chinedu Nwabuobi, M.D.
Like I said earlier, pregnancy being kind of a stressor can mask this. So just be on top of your care, be very involved, be an advocate for yourself, speak up, ask questions. Those symptoms that you've read online, you've seen on Tick-Tock that you consider are normal should not be normal until it has been completely addressed by your OB provider. To make sure we care for women more before they become pregnant so that when they become pregnant, there's already that understanding of what the risk is, hopefully we've mitigated it, and how we can make for the best pregnancy outcomes of it.

00;22;32;19 - 00;22;55;10
Lori Boardman, M.D.
I know from thinking about even creating programs and all this kind of stuff, having the end user be involved in the conversation, and I think listening to our patients learn from our patients and then when you start to implement your whatever you're deciding they're going to do, make sure that it aligns with what they want to do because otherwise we're never going to be successful.

00;22;55;12 - 00;23;02;04
Lori Boardman
And I think they know better than we know what's going to work, for them and often for their communities.

00;23;02;07 - 00;23;27;26
Julia Resnick
Heart Month can be a catalyst for health care organizations to reimagine what it takes to create the conditions for a heart healthy pregnancy. And that will require going beyond the hospital walls to engage patients and collaborate with stakeholders who all share the same goal, healthy moms and healthy babies. By designing pregnancy care around patient needs, recognizing who is at risk of complications and reducing barriers to support,

00;23;27;28 - 00;23;56;06
Julia Resnick
hospitals can make progress towards reducing maternal morbidity and mortality. A big thank you to all of our speakers: Lori Boardman, Chinedu, Nwabuobi, Peggy Burgess and Crystal Wilson. I appreciate everything you do to support the health of your patients and community members. For more resources on improving maternal health visit www.aha.org/betterhealthformothersandbabies

00;23;56;09 - 00;24;08;17
Julia Resnick
Thank you for tuning in to this episode of Beyond Birth and Advancing Health Podcast. If you missed any of our previous podcasts, you can find them wherever you listen to your podcasts and please subscribe to the Advancing Health Channel. We'll see you next time.

Hospitals and health systems are rightly called cornerstones of their communities, and none take that mission more seriously than Advocate Health. The health system works with local partners to address a variety of community needs, providing nearly $6 billion in community benefits in 2023. In this conversation, Kinneil Coltman, chief community and social impact officer at Advocate Health, discusses Advocate’s wide-ranging programs and initiatives, including food insecurity, affordable housing and meaningful employment.


 

View Transcript
 

00;00;00;22 - 00;00;22;10
Tom Haederle
Hospitals and health systems are rightly called cornerstones of their communities. And as nearly 6 million patients spread across six states can attest, few care providers take that mission more seriously than Advocate Health. Headquartered in Charlotte, North Carolina, Advocate is the third largest nonprofit health system in the nation and takes pride in serving a large number of under-resourced patients.

00;00;22;12 - 00;00;40;14
Tom Haederle
Name a want or a need or a gap in community services, and chances are Advocate Health is already working with local partners to address it.

00;00;40;16 - 00;01;05;10
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. According to Dr. Kinneil Coltman, chief community and social impact officer, Advocate Health provided nearly $6 billion in community benefits in 2022. The funds supported a wide variety of programs and initiatives as leaders spent a lot of time thinking about where do we focus?

00;01;05;12 - 00;01;21;24
Tom Haederle
In this podcast hosted by Aaron Wesolowski vice president of Policy, Research, Analytics and Strategy with AHA, Coltman says certain priorities leapt to the top. They included addressing food insecurity, affordable housing and a meaningful employment.

00;01;21;26 - 00;01;31;13
Aaron Wesolowski
Dr. Coltman thanks so much for joining us. We're so excited to be talking today. Can you start by telling us a little bit about Advocate health and the patients and communities that you serve?

00;01;31;16 - 00;01;59;25
Kinneil Coltman
Advocate Health is the third largest nonprofit health system in the nation. We serve a diverse array of patients, nearly 6 million unique patients across six states: Alabama, Georgia, Illinois, North Carolina, South Carolina and Wisconsin. Many of our hospitals serve as the primary safety nets in their communities, so we serve a large number of under-resourced patients.

00;02;00;04 - 00;02;19;24
Kinneil Coltman
We're the number one Medicaid provider, for example, in Illinois and North Carolina by volume. But throughout our footprint, we also care for patients in about 68 rural counties, and that's about 3 million residents. So we're really proud of the work that we do around solving for underserved communities needs.

00;02;19;26 - 00;02;25;28
Aaron Wesolowski
Great. How does advocate think about community benefit across the system and across all those hospitals?

00;02;26;00 - 00;02;57;23
Kinneil Coltman
When I think about community benefit, I think about what are we doing that is truly benefiting society? We've noticed that sometimes those conversations may focus on one aspect of our community benefit, but we really look at it holistically. The pandemic really shined a light on the absolute necessity for us to focus on working even further upstream than maybe we would have in the past to really focus on disrupting those root causes of health inequities in our communities.

00;02;57;24 - 00;03;21;10
Kinneil Coltman
For us, we spent a lot of time thinking about where do we focus? so that we're going to have the deepest and most meaningful impact. And for us, we've kind of drawn a line in the sand around food insecurity, affordable housing and employment. When I say that, I mean meaningful employment, good wages, the provision of health insurance, career and economic mobility.

00;03;21;17 - 00;03;46;16
Kinneil Coltman
So that's where we focus our energies, both in terms of the programs we develop internally, but also in how we invest in the community. But all in and in 2022, we we had nearly 6 billion in community benefit, and that includes free care for low income patients, but also the cost of educating the next generation of health care workers and research.

00;03;46;16 - 00;04;15;07
Kinneil Coltman
We have a huge research enterprise that extends across our footprint, but also investing in those safety net organizations that we know are really serving those that need it most in our community. We've invested in things like a medical clinic in an HBCU in Charlotte for really novel solutions like virtual care in community centers. And we have countless food pharmacies across our footprint.

00;04;15;07 - 00;04;21;10
Kinneil Coltman
So it manifests in a variety of ways, but all in service to disrupting those root causes of health inequities.

00;04;21;12 - 00;04;38;15
Aaron Wesolowski
That's really impressive and really exciting to hear, and I want to hear more about it. Before we go deeper into Advocate Health and all the good that that you all are doing, I'm curious to hear a little bit more about you and your career. How did you get into health care and how did you find yourself in the role that you're in now?

00;04;38;17 - 00;05;07;17
Kinneil Coltman
Yeah, so I actually grew up in a rural area myself. I grew up in the mountains of western North Carolina. I had some really profound experiences in high school and in undergrad that led me down this path of wanting to work on kind of institutionalized systems of inequality. And so that's what I've devoted my career to, is really helping to architect health equity strategies in large complex health systems.

00;05;07;17 - 00;05;26;22
Kinneil Coltman
And for me, it's very personal. I still have a lot of family members that live in very rural areas that have a lot of challenges around transportation and other social drivers of health. So I, I think a lot about the folks that I grew up with when I think about the energies that I bring to my work every day.

00;05;26;24 - 00;05;39;19
Aaron Wesolowski
Well, thank you for sharing that. What trends have your hospital seen in recent years in terms of patient and community needs? And how has that changed Advocate's focus on providing care beyond the four walls of the hospital.

00;05;39;22 - 00;06;10;03
Kinneil Coltman
You know, I think it all boils down to meeting people where they are and getting to them before they need us, right? That's the goal. And so a lot of our conversations with our leadership are around modernizing access. We know the access to care is is a dramatic issue that impacts health across the country. So we've tried to think about really creative ways to reduce that friction to access care and to make it easier for folks, no matter where they live, to be able to access care.

00;06;10;06 - 00;06;37;18
Kinneil Coltman
So thinking about things like our virtual strategy. If there are gifts around COVID, that is absolutely been one. It's helped us to kind of broaden our aperture around thinking about where and how we can use virtual care in the future. So we, for example, have made huge investments and had other investments from partners in school-based primary care and behavioral health in schools.

00;06;37;21 - 00;07;07;00
Kinneil Coltman
We are in 213 schools and that number grows every time I share that in 11 counties. And, you know, had just in the last year 26,000 patient visits with those. And we've been able to show that we can have a 32% reduction in E.R. visits once we create those kinds of interventions. We've also embedded virtual clinics in low income, affordable housing communities, in immigrant service centers.

00;07;07;03 - 00;07;40;13
Kinneil Coltman
We're thinking about all kinds of places where we can deploy these interventions in new and different ways. We also see it a lot of promise around the management of chronic disease. We've stood up virtual chronic care management programs for patients that have those tough chronic diseases to manage, like diabetes, for example. So enrolling patients in those programs, knowing that they don't have to access transportation and deal with some of the other friction of accessing care that they can access, that support virtually is a big deal.

00;07;40;16 - 00;08;06;11
Kinneil Coltman
And then the last one that I'll mention is our signature hospital home program, which we stood up virtually overnight during COVID. But since then we've been able to care for hundreds of patients at a time from the comfort of their home. And if you think about it, no matter how good of a job we think we do around care, our hospitals, people would always rather be in their homes than in a hospital.

00;08;06;11 - 00;08;25;28
Kinneil Coltman
And so we've been able to deliver hospital level care inside the comfort of someone's home. So we're still working on those solutions, but we are giving it all we've got because we know that our patients and communities are depending on us to kind of pass those traditional access points that we've relied on historically in health care.

00;08;25;29 - 00;08;34;20
Aaron Wesolowski
That's great. And I imagine that a lot of those local partnerships help you anticipate new needs that might be coming down the road at you as well.

00;08;34;22 - 00;09;03;01
Kinneil Coltman
Yeah, absolutely. So we've seen, for example, we obviously have a large footprint in Chicago, and Chicago has had, you know, a surge in immigrants and in recent months. And so trying to figure out how can we be part of the solution of delivering care in unique and different ways. But we're seeing that opportunity across our footprint to listen more deeply to our communities and say, where do you want to get care?

00;09;03;02 - 00;09;17;05
Kinneil Coltman
How do you want to get care? When do you want to get care? And then we have a wonderful strategy team that's guiding us to think about innovative solutions in terms of how we deliver that care differently than we have in the past.

00;09;17;07 - 00;09;31;10
Aaron Wesolowski
Stepping back, can you tell us why Advocate is committed to providing these services that that clearly extend beyond traditional medical care? Why is it important to impact health and well-being before someone even becomes a patient in a facility?

00;09;31;13 - 00;09;59;05
Kinneil Coltman
I think the answer to that question is, you know, a five-minute conversation with any emergency medicine provider that I've ever worked with, and I'm sure you have as well heard these stories that you think about in our emergency rooms. You may have someone who's unhoused and they may come two and three times a week sometimes. But as soon as that person secures housing, then we see their use of emergency rooms change for the better.

00;09;59;05 - 00;10;34;16
Kinneil Coltman
Right? And so you have all these stories that our providers collect and tell us about. And I think that creates a sense of urgency for us to be able to work further upstream, try to prevent that unhoused situation in the first place, try to get at those root causes that led to that incident of homelessness. So those are the things that we're thinking about all the time, that we've got to constantly work upstream because, you know, we have level one trauma trauma center  hospitals in so many communities that are in need.

00;10;34;19 - 00;10;53;27
Kinneil Coltman
We are the safety net. When all of the other safety nets break down, we see - we're at the very end of the line. So we see when all the other social systems fail, we're there to catch patients and community members when they need us so that that creates a burning platform, I think, to work upstream and be part of the solution.

00;10;54;00 - 00;11;16;09
Aaron Wesolowski
Building on that topic of of access, you know, ensuring that that all community members have access to care also means working to make care more affordable and make sure that patients have options around financial assistance. Can you talk about your work to improve financial assistance and the process around accessing it? And why is it important for families and patients?

00;11;16;12 - 00;11;40;01
Kinneil Coltman
So I mean, we talk about that all the time. In fact, when Atrium Health and Advocate Aurora Health came together just over a year ago, that was one of our big commitments was around affordability. And we already, in both legacy systems, had a lot of strengths, but we tried to, you know, curate the best of what each legacy system had in terms of building.

00;11;40;04 - 00;12;05;06
Kinneil Coltman
What I would argue is one of the most comprehensive and patient centered financial assistance programs in the country, because you hear a lot of discussions about federal poverty levels. And then, of course, we've committed to a very generous level of 300% federal poverty level gets full financial assistance, full charity care, and then up to 400% very, very deep discounted care.

00;12;05;08 - 00;12;28;22
Kinneil Coltman
You know, the devil's in the details on some of this stuff, that it's how we administer our program that I think is really meaningful for patients. So when you think about our patients who are under resourced and what may be going on in their lives, maybe working two and three jobs, we've really thought critically about how can we reduce the friction involved in qualifying for our financial assistance programs.

00;12;28;22 - 00;12;53;02
Kinneil Coltman
And so we have invested in a pre-qualification service that's really effortless, seamless to our patients. So I'm really proud of the way that we're working to reduce friction for patients and being able to access our policies. We also provide financial assistance for care that we know patients need. So it's not just for emergency care, but it's also for other essential care, primary care, behavioral health care.

00;12;53;02 - 00;13;14;17
Kinneil Coltman
So those are the things that we focused on. There's a lot of other players in the industry providers, insurers, drugmakers, pharmacy benefit managers. I can go on and on...that together, we need to solve for the affordability challenges in health care. We're committed to being part of that coalition that solves for this together.

00;13;14;20 - 00;13;26;04
Aaron Wesolowski
Absolutely. And that's that's great to hear. Last, what are you most hopeful about in health care? And are there things that you're really excited about in terms of innovations or patient programs that Advocate Health has planned?

00;13;26;06 - 00;14;12;26
Kinneil Coltman
There's so many big challenges ahead of us as an American health care system, right? But I'm also encouraged about what we can accomplish when we really focus. COVID taught us how much we can accomplish if we really focus on something. So for our part, over the last year, we've been standing at the Advocate National Center for Health Equity, and that's a really bold and ambitious strategy because it involves a national operating model that then will manifest interventions in all of our major service areas in different ways based on what the community tells us it needs, but also based on what we know from a public health data standpoint, is also necessary to improve health.

00;14;12;26 - 00;14;53;04
Kinneil Coltman
And so we are working on a very robust health equity analytics platform that will help us think differently about how we bring data to providers to intervene, but making sure that we have good clean data across our 6 million patients, but then also developing a framework of health equity interventions in our clinical environment. Soup to nuts. Every service line is then, you know, we have board approved health equity goals that we're cascading throughout the enterprise, but we're also looking at architecting national partnerships around those social drivers of health.

00;14;53;06 - 00;15;19;18
Kinneil Coltman
But with all of our interventions, we have committed to studying them academically, right. In an academically rigorous way so that we can develop proof points, that we can educate other health systems that want to do this work, but also policymakers, elected officials on what are the solutions of the future around health equity, because we've got to have partnerships and a coalition to solve for these entrenched inequities together.

00;15;19;25 - 00;15;32;21
Kinneil Coltman
So I'm excited about that. You know, we're still in building mode, but I'm encouraged that we have a very ambitious board behind us that's very motivated around our health equity goals and ambitions.

00;15;32;23 - 00;15;44;29
Aaron Wesolowski
Great. Well, thank you for sharing that. It's really heartening to hear all that you all are doing and the scale of the benefits that you're offering the communities you serve. And so thank you for sharing it. Thank you for being with us today.

00;15;45;02 - 00;15;47;04
Kinneil Coltman
Yeah, my pleasure. Thanks very much.

Hackers and cybercriminals are targeting hospitals and health systems at alarming rates, disrupting operations and threatening direct patient care. In this conversation, Bryan Smith, recently retired section chief of the Cyber Criminal Operations Section with the FBI, discusses how the Bureau tackles the huge challenge of protecting the nation's caregivers from these attacks, and how partnerships are crucial in prevailing against cybercriminals.


 

View Transcript
 

00:00:00:29 - 00:00:28:12
Tom Haederle
If the steady rise in hospital ransomware attacks has taught us anything, it's that cybercriminals never take a day off. Life saving technology, CT scanners, MRIs and heart monitors can all be - and are - targets for cybercriminals every minute of every day, disrupting hospital operations and threatening patient care until a ransom is paid. That means that the good guys, the defenders against these threat to life crimes, can never take a day off either.

00:00:28:15 - 00:00:42:09
Tom Haederle
Well, they don't. And their constant vigilance is making a difference.

00:00:42:11 - 00:01:08:25
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I’m Tom Haederle with AHA Communications. Hackers are targeting hospitals and health care companies at alarming rates. It’s a continual cat-and-mouse game. When a cybercrime ring is arrested or shut down, new ones quickly pop up in their place. In many ways, the FBI is the tip of the federal spear pushing back against cyber criminals and their ceaseless assaults on the health care sector.

00:01:08:28 - 00:01:33:16
Tom Haederle
In this podcast, hosted by John Riggi, the AHA’s National Advisor for Cybersecurity and Risk, we hear from Bryan Smith, recently retired section chief of the FBI's Cybercriminal Operations section, on how the Bureau tackles the huge challenge of protecting our caregivers from ransomware attacks and how critical it is to partner with a private sector to prevail in the long game against cyber criminals.

00:01:33:18 - 00:02:03:17
John Riggi
Thank you, Tom, and thanks for everybody tuning in today. We've got another great special episode on cybersecurity issues. I'm really pleased and privileged to be joined today by my good friend and former colleague Bryan Smith. Bryan is the section chief of the criminal section of the FBI's Cyber Division, and he's been in the FBI since 2002. So just over 20 years, tremendous change in cyber and all types of investigations in the FBI since that time.

00:02:03:24 - 00:02:07:10
John Riggi
Bryan, welcome If you could, tell us a little bit about your background.

00:02:07:17 - 00:02:36:03
Bryan Smith
Great. Thanks, John. I really appreciate being here. And it's always good to have a conversation with you and looking forward to this talk today. Like you said, I've been in the Bureau for over 21 years. Prior to the Bureau, I did consulting work for Deloitte and Accenture, and then within the Bureau, I spent most of my time working white collar financial crime dealing with cryptocurrency and then probably for the last ten years, getting back to what I did before the Bureau, which was cyber.

00:02:36:06 - 00:02:52:11
Bryan Smith
Cyber is what white collar was 25, 30 years ago, and that cyber is just the new method by which folks are doing the same things that they've done since antiquity. They're stealing secrets, they're stealing money, they're trying to gain a competitive advantage. And so it's a really interesting space to work.

00:02:52:14 - 00:03:25:27
John Riggi
In as we realize the bad guys are evolving, just as technology is evolving, It's another way to steal money, much more effective and efficient way to steal money, steal secrets and commit crimes against the United States and our good citizens. But of course, the thing that we're most concerned about are these high impact ransomware attacks, which shut down medical technology in hospitals and health systems and really result in the very serious disruption and delay to health care delivery, ultimately risking patient safety.

00:03:25:29 - 00:03:53:13
John Riggi
Now, on the plus side, I can't have it all doom and gloom. On the plus side is that we as a field, as a hospital field, as a health care field, have come together just as we did during the pandemic, to exchange threat information and best practices and work with the government and very closely with the FBI in particular for the common defense, in the common good of the health care field and the nation, and most importantly, the nation.

00:03:53:15 - 00:04:05:06
John Riggi
Bryan, given your role as national leader for all FBI cyber criminal investigations, what do you see as the most significant cyber threat that is impacting health care today?

00:04:05:09 - 00:04:29:08
Bryan Smith
You know what I'd say is probably the biggest cyber threat that we're facing right now are I think the health care is facing right now is probably ransomware because it's immediate and it impacts hospitals or medical facilities ability to operate on any given day, which obviously has significant impacts on revenue, certainly has a significant impact on expenses as to we've got to still operate.

00:04:29:08 - 00:05:12:01
Bryan Smith
We can't bring money in because we don't have services that we can perform here. But as we've seen in a number of instances, it has a real life impact on individuals. And that the care that these individuals are needing, they are not able to get because of the ransomware attack. And so we've had some instances where, you know, you know better than I and people in this industry know better than I that the precision by which we get our medical care and the medications that we get are so precise in certain instances, be it chemotherapy or other specific ailments that we have, that if we don't have those records in front of us, we can harm

00:05:12:01 - 00:05:33:25
Bryan Smith
the patient. And so when an entity gets hit with ransomware and they're in a position where they cannot in good conscience deliver the care that the person needs because they can't tell what that amount and the dosage should be, that has a real life impact and can impact lives. And so it's critically important that we are all focused on that ransomware threat.

00:05:33:27 - 00:05:50:11
Bryan Smith
Yeah. And then on the economic side, there's the aspect of thinking about the long term intellectual property that's being stolen by foreign adversaries from our medical institutions that they're leveraging to create their own in direct competition with us.

00:05:50:13 - 00:06:32:23
John Riggi
Thanks for all that, Bryan. When a ransomware attack strikes a hospital and the encryption disables every piece of medical technology, shuts down our internal networks in our Internet connections, we have seen, unfortunately, time and again, a serious disruption in delay of health care delivery. So what does that mean? That means when there is a stroke patient enroute to the nearest available emergency department and that hospital is under a ransomware attack, they're going to have to divert that ambulance because they won't have the necessary CT scanners perhaps available to diagnose that stroke case.

00:06:32:25 - 00:07:06:03
John Riggi
Really very serious consequences. That's why we say and I know the FBI director Ray has publicly proclaimed that we believe and the FBI believes that ransomware attacks against hospitals are truly threat to life crimes. Given your role, national view, what do you believe are the most common vulnerabilities and methods being used by our cybercriminal adversaries to take advantage, to penetrate our networks, to steal our data and execute these highly disruptive ransomware attacks against U.S. health care?

00:07:06:06 - 00:07:29:23
Bryan Smith
Yeah. So by and large, the things that we see is the things that we've been seeing for the last 15 years, which is spear phishing or phishing emails, by which then they're able to gain access to somebody's system. Then they move laterally, escalate privileges, gain additional insight into the system, and then figure out what it is that they want to do while they're in there and what they can take advantage of.

00:07:29:25 - 00:08:11:03
Bryan Smith
We have seen some zero day exploits over this past year, and that gets into some of those scenarios where there actually were patches and some vulnerabilities that were identified that could have been mitigated had people been updating their systems. And so there's a huge learning curve on the user engagement and users owning the problem here. But there's also some really simple things, some fundamentals that can be done by organizations and by individuals to make sure that they're doing the rudimentary, fundamental activities that keep each of us safe on our own systems.

00:08:11:05 - 00:08:36:03
John Riggi
So as I always say, the bad guys simply hack before we patch. And in health care, sometimes it takes a while because we can't just patch a medical device quickly without testing it and understanding what the ramifications for patient safety are. Now, I'm going to get on my my soapbox a little bit here and say, look, yes, we've got to do a better job of patching, but the technology providers have to give us more secure technology.

00:08:36:06 - 00:09:01:26
John Riggi
And I know the White House has promoted the concept of secure by design and secure by default. So kind of shift that responsibility back to the technology developers versus the end user. Shared responsibility: You know, my belief is we've got to get the technology providers to give us better secured technology. Now, with that, we certainly understand that no organization, including the federal government, is 100% immune from cyber attacks.

00:09:01:28 - 00:09:13:04
John Riggi
Bryan, what do you believe are the top three, 3 to 5 best practices to help mitigate the risk of a successful cyber attack against health care or any organization?

00:09:13:06 - 00:09:48:16
Bryan Smith
Well, I guess the first one is doing the fundamentals. I love baseball and I love baseball is that if you do the fundamentals right, you do the little things right, then big things will happen for you. And you do that over time. And I think that's appropriate within the cybersecurity arena. Is that if you're patching, if you're running antivirus, if you have engaged personnel who are looking at this stuff, not on a quarterly basis, but this is every day activity and you do that well, you're going to catch a lot of the activity and or you're just going to make it harder for the adversary to get in there.

00:09:48:16 - 00:10:10:11
Bryan Smith
And they may decide that they're going to give up and move on. The other thing is that we want people to think functionally. And when I say functionally, I go back to my earlier comments about what cyber being used for, and it's everything that people have been doing since antiquity. We want people to think of if someone gets into my network, what is it they can do here?

00:10:10:14 - 00:10:35:18
Bryan Smith
What can they take advantage of? How would they monetize it? Because that's what you're talking about here. At least with the cybercriminal actors, they are financially motivated and so if you can figure out how they make money based off the information that they have within your department, your division, your group unit or your work unit, and protect against that, you make it a lot harder for them to then monetize that type of information.

00:10:35:21 - 00:10:56:23
Bryan Smith
And that goes along with treating this like a business problem. I think far too often we've treated as an IT situation, so the business lines need to take some ownership of, Hey, I'm part of this, I need to be doing due diligence and making sure that what I'm doing on my network and what am I'm doing with our systems is not going to put the organization at risk.

00:10:56:26 - 00:11:15:25
Bryan Smith
And until we do that, it's going to be an arms war for the IT folks. So we've got to get that pulled together. And then the last thing I think is be prepared. Recognize that no matter what you do, you are likely going to be a victim of some sort of cyber attack. And are you prepared for what that means?

00:11:15:27 - 00:11:33:21
Bryan Smith
And that means do you have the partnerships laid out ahead of time so that you know who to call, what that's going to look like? Do you have a plan when there's an incident and let's say it's ransomware of do you have a policy of whether you pay or don't pay? Who's going to be helping you with the negotiations on it?

00:11:33:23 - 00:11:45:27
Bryan Smith
You want the game to slow down when you're in this event, which means that you're prepared for and you've already thought through what that's going to look like. And now it's just a matter of executing it and you're not having to think on the fly.

00:11:45:29 - 00:12:24:15
John Riggi
So gaming it, train like you fight, right, as we would say. So that will help reduce the stress level and make those decisions much easier. So, Bryan, as we've been chatting, I've been thinking, as I heard you talk about defensive measures, the basics, but we know that defensive measures can only go so far in reducing the risk of a cyber attack. And I believe, you know, based upon my experience in FBI cyber and counterterrorism, that's extremely difficult for the FBI to conduct law enforcement operations overseas, including arresting bad guys that are being sheltered by hostile nation states like Russia, China, North Korea and Iran.

00:12:24:18 - 00:12:47:05
John Riggi
So just like in terrorism matters, we may not be able to arrest our way out of the cyber threat. But I also believe there must be a whole of government approach to this, and that would include leveraging all the capabilities of the U.S. government to conduct offensive cyber operations to disrupt and dismantle these foreign bad guys before they attack us over here.

00:12:47:12 - 00:12:58:25
John Riggi
So, Bryan, can you tell us about how the FBI is going on the offense against these foreign cybercriminal organizations? And I know you've had some successes recently, so can you tell us about that?

00:12:58:27 - 00:13:19:12
Bryan Smith
We've broken that down in a couple of different areas, and then we target all of those areas, not just one of them, not just the finances, not just the infrastructure, not just the malware and the the marketplaces and forums by which they communicate, but all of them, and that it really becomes a targeting of the ecosystem. I would call this an ecosystem problem.

00:13:19:12 - 00:13:43:01
Bryan Smith
It's not a ransomware problem. Ransomware is a symptom of a larger disease. And what we're trying to do is eradicate the disease. In the process we may take care of the symptom, but we've got to go after that ecosystem. As we've moved forward with our strategy, we've also recognized that this is not going to be some sort of one knockout blow that's going to stop them from engaging this activity.

00:13:43:04 - 00:14:15:16
Bryan Smith
Just like any business, businesses don't go bankrupt overnight. They go bankrupt over time because they make bad decisions, they make bad investments, their expenses get too high over time. And eventually it gets to the point where they can no longer be a going concern. And that's what we're trying to do with the cyber adversary, is increase the expenses for them to engage in this conduct and expenses can be the risks of you might be going to jail, expenses can be it costs more because we're tearing down your infrastructure.

00:14:15:18 - 00:14:40:12
Bryan Smith
It costs more for you to get into the network. So that goes back to the defense side of this and that if you're prepped and you make it harder for them, that's raising the business costs on their end. And now what you're seeing across the board is that when we take actions, it's not just the FBI, it's the FBI with a multinational partnership with a number of different entities to include sometimes civil and regulatory entities.

00:14:40:13 - 00:14:54:18
Bryan Smith
Again, with the objective of there's not going be a knockout punch, but we can deliver body blow after body blow over time that will get us into a position where I think we can clean up the ecosystem in a much more comprehensive way.

00:14:54:20 - 00:15:24:10
John Riggi
Truly appreciate your comments, Brian. And I was thinking back again to my counterterrorism days, and it's the same problem. We knew there would not be one knockout blow, but you know, this continuous effort of what I call the enterprise theory of investigation: Go after the leadership, the communications, the finances, operational activity, the entire infrastructure that they might be using to ultimately increase risk and consequences for the bad guys as the deterrent and hopefully disrupt them.

00:15:24:12 - 00:15:51:26
John Riggi
So Bryan, victims of ransomware attacks or other cyber attacks often reluctant to work with the federal government, often upon advice of outside counsel, because they're concerned that the information provided to the FBI to further the investigation may ultimately be used against the victim in some future regulatory or civil liability matter. Brian, can you tell us how the FBI works with cyber victims to maintain confidentiality?

00:15:51:28 - 00:15:56:23
John Riggi
And also, does the FBI share information with regulatory authorities?

00:15:56:25 - 00:16:22:25
Bryan Smith
Yeah. So one of the issues that we have across the board is a reluctance by victims to report. And so we really need to change that reporting mechanism. Now, we don't say what companies got hit with it, but over time we develop that. We can't do that if people don't report to us. And so it's critically important for now and in the future that if you want to prevent these things to tell us what's going on, it begs the question of why not?

00:16:22:25 - 00:16:41:12
Bryan Smith
And I think some of it is that people don't know what to expect. What I'll tell you, we will not be showing up in the blue ray jackets with the yellow letters on the back. We're not going to make a scene at your office building. You call us. We will handle this in a very discreet fashion. If it's important for us to be out there, then we will do that in a discreet way.

00:16:41:15 - 00:17:01:29
Bryan Smith
We are not looking to revictimize folks. The other part is that there's got to be a value proposition for the victim of, Well, what do I get out of this? Well, one, you can help protect the ecosystem and which I talked about before as far as the intelligence that we can share. Just like us, criminals make mistakes. So we make mistakes and we let them into their network.

00:17:02:02 - 00:17:25:15
Bryan Smith
They will make mistakes. And the more victim data that we have that we can then identify instances where, you know, their VPN dropped or they reused a wallet ID or something that we can then latch on to make connections and then we can actually identify. And then once we identify, then we have a much better shot at doing something about the actor.

00:17:25:17 - 00:17:47:08
John Riggi
Thanks, Bryan. So obviously there's not only a benefit potentially for the victim to contact the FBI. You may be able to assist and guide them through the incident. Just as you said, you've got the experts, but also it's good for the nation. It's good for the nation and the rest of the sector. A victim cooperate and can help prevent future attacks against other hospitals or other entities.

00:17:47:11 - 00:17:56:19
John Riggi
Bryan, I just want to clarify in terms of sharing information with the regulatory authority, is investigative information shared with regulators for their purposes?

00:17:56:21 - 00:18:11:05
Bryan Smith
We are not regulators. And so when you give information to us, it is going to be held by the FBI. And we take the sensitivity of that information. We understand it. We're going to use it in the investigative capacity, but it's not going to be used for any sort of civil regulatory action against you.

00:18:11:07 - 00:18:42:19
John Riggi
And also, I'd like to point our listeners to a very helpful statute. It's called the Cybersecurity Sharing Act of 2015. I'm not a lawyer, but it does provide lots of robust regulatory and civil liability protections in that statute for victims and private entities to share information with the federal government. So have your outside counsels take a look at that statue, and I think you'll find that there are protections for sharing information with the federal government, cyber threat information sharing.

00:18:42:21 - 00:19:03:13
John Riggi
Right. So speaking about contacting the FBI, at what point during a cyber attack should a victim, hospital or health system actually reach out to the FBI? And what's the best way to contact the FBI? And let's say in an urgent ransomware situation, we've got we've got ambulances on diversion with stroke and heart attack patients who do we call in that situation?

00:19:03:16 - 00:19:36:13
Bryan Smith
So my advice is be prepared. And being prepared is to have the local FBI contact the supervisory special agent in your area that you can call and say this is what's going on here, that that's not the first time that you've had a conversation with them, that there's a relationship there. And so they can then help and walk you through. You know, let's say you haven't done that the earlier you call the local FBI office in the incident, the better because we're going to provide you with the help that we can. We will provide that to you and try and help out on it.

00:19:36:17 - 00:19:53:14
Bryan Smith
That includes whether or not we are aware of decryption capabilities. Sometimes those are ones that we have. There may be also ones that we know that maybe a private sector entity has. And so we will share that type of information with you to help you kind of deal with that incident as it's happening in the moment.

00:19:53:16 - 00:20:04:12
John Riggi
What can a victim organization realistically expect if they contact the FBI for assistance during a cyber attack? Does the FBI always have the magic decryption key?

00:20:04:15 - 00:20:30:14
Bryan Smith
Unfortunately, we don't. I wish we had it every single instance. But if we did and this wouldn't be such a lucrative business for the adversary to be in. So if we have it will provide it to you. But what you can't expect is that we're going to have any indicators of compromise about the group. Unless it's a new group, we will share what we know about how that group operates, our experience with them in the negotiations, what you can expect on the back side of it.

00:20:30:17 - 00:20:44:13
Bryan Smith
And so that just that kind of insight of this is what and how they do this. Is really helpful for you understand what you can expect and then you can make decisions based off information, not based off what you think might be happening.

00:20:44:15 - 00:20:56:28
John Riggi
So could you could describe to us a little further on what your role is at the FBI and how you work with CISA, HHS and the intelligence community, even state and local agencies on cyber issues?

00:20:57:00 - 00:21:17:14
Bryan Smith
Yeah, I think if I could sum this up in kind of one phrase is that we're all in this together. And that is government, that's private sector, that's international partners. I'm really proud to work at the FBI. We have some incredible people here. But as good as we are, we can't do this alone. And so we need partnerships.

00:21:17:14 - 00:21:49:00
Bryan Smith
And that's why we have engaged with HHS and CISA and the IC community and Secret Service and foreign partners. If you look at any of the operations that we've had, there's a good 12 to 14 different flags on there, and that doesn't even count then the fact that there may be three or four different agencies within each of those countries that are working on these things together, so that we can have the maximum impact in a bunch of different areas against the adversary.

00:21:49:03 - 00:22:03:13
John Riggi
It's just great to hear that. Again, that same philosophy, one team, one fight force multiplier is being leveraged in this fight against these cyber adversaries as well. So, Brian, as we close out here, any final thoughts for our listeners?

00:22:03:16 - 00:22:27:18
Bryan Smith
Yeah, just a couple of things. There's not going to be, as we've talked about before, one knockout punch on this. But if we can deliver body blow after body blow, then that will have an impact. One of the lessons that we've learned is that we're all in this together. And so one of the best practices that I've seen across a variety of industries is partnerships between related entities.

00:22:27:18 - 00:22:42:07
Bryan Smith
And whether this is in the financial services or in other industries, is that when we share information and we collaborate with each other, we are making it harder for the adversary to attack any of us.

00:22:42:09 - 00:23:00:09
John Riggi
Thank you very much, Bryan. Thanks for all your thoughts and for being here with us today. Thank you and your team for what you're doing to help defend the nation against cyber threats. And thanks to all the men and women in the FBI for what you all do every day to defend the nation against cyber and physical threats.

00:23:00:11 - 00:23:13:10
John Riggi
And special thanks to all our frontline health care heroes for what you do every day to care for our patients and serve our communities. This has been John Riggi, your national advisor for Cybersecurity and Risk. Stay safe, everyone.

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