About Peter Margolis

I'm a pediatrician and epidemiologist. I work on improving health by changing systems of care delivery. I am Director of Research at the James Anderson Center for Health Systems Excellence at Cincinnati Children's Hospital Medical Center. I am also Scientific Director of the ImproveCareNow Network and co-developer of the Collaborative Chronic Care Network project.

Collective Wisdom to Improve Health and Health Care

Posted on 28 August 2012 by Peter Margolis

ImproveCareNow and the Collaborative Chronic Care Network (C3N) project

We all know the current system of chronic illness care isn’t working. It’s not working for kids with diseases like Crohn’s disease and ulcerative colitis; like Bianca (not her real name) that experience a lot of pain. But pain is the least of Bianca’s worries. Without optimal treatment, she’ll likely have stunted growth, possible arthritis, and a significant risk of surgery. And many normal childhood events like sleepovers or birthday parties….. a real stress.

The system is also not working for Dr. Sandy Roan (also not her real name), Bianca’s doctor. Dr. Roan has a variety of treatment options, but the “best evidence,” the evidence that results from randomized trials, can’t provide information on what will work best for a particular individual.

It’s also not working for Bianca’s mom, Anna, because the care delivery model doesn’t make it easy for her participate in Bianca’s care. She is wondering about trying diet modifications to see how best to control Bianca’s symptoms. She keeps an eye on what’s going on but feels the doctor’s role is to come up with solutions. She doesn’t really see the collaborative possibilities.

Finally, it’s not working for Dr. Vincent Kapoor (not a real name). He’s a researcher interested in improving IBD care but he’s faced with small unrepresentative data sets, and a lack of easy and productive ways to share data and increase the impact and reach of his research.

The Institute of Medicine’s “learning healthcare systems” model provides an exciting vision in which patients, clinicians and researchers work together to choose care based on best evidence; together they drive discovery as natural outgrowth of patient care; and ensure innovation, quality, safety and value, all in real-time. But so far, neither patients, nor doctors, nor researchers have easy access to such system.

Collective wisdom

What if we could harness the collective intelligence of patients, clinicians and researchers to create such a system? Think of Wikipedia, or, in science, how open, rapid sharing of data in advance of publication in the human genome project accelerated the sequencing years ahead of schedule. These are examples of how the production of knowledge, information, and know-how can be distributed over large groups of people. Yochai Benkler, of Harvard, calls this form of production network-based or “social” production.

http://www.ted.com/talks/yochai_benkler_on_the_new_open_source_economics.html

Network based production is suited to complex systems like health care, precisely because the necessary knowledge, skills and tools are often beyond the capacity of one place, one person, or one organization; because the stakeholders in the process, patients, clinicians and researchers, are motivated and have skills that can be devoted to the task; and finally because the scientific questions about how to accomplish improvements in health and health care, require a multidisciplinary complex systems science perspective.

With combined support from the NIH transformative research program, a US Agency for Health Care Research and Quality Enhanced Registries grant and 38 ImproveCareNow Network care centers; a team of patients, families, clinicians and researchers are working together to create what we call a collaborative chronic care network or C3N. A C3N is a network-based production system for health and health care.

Does this sound like an outlandish idea? It’s not; it’s actually already taking place. In the ImproveCareNow Network pediatric gastroenterologists are working together to share their collective wisdom and know-how to continuously improve the care and outcomes of children and adolescents with Crohn’s disease and ulcerative colitis. The percent of patients in remission has risen and been sustained without the introduction of new medications.

How did ImproveCareNow do it? SHARING – sharing data, sharing knowledge, sharing know-how, and sharing work. Every ImproveCareNow center pools their data, compares outcomes, standardizes care and learns from one another about how to get better results. An article in this month’s New Yorker, by Atul Gawande describes how standardizing and making care more reliable can make medicine more effective and lower cost. http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande

The C3N project is collaborating with the ImproveCareNow Network to take our work to the next level; redesigning an existing clinician-centric network into one that involves everyone – patients, families, clinicians and researchers.

How do you create a network based production system for health and health care? In my next post, I’ll write about the three ways in which patients, families, clinicians and researchers are co-designing this new system.

In the meantime, you can learn more about the ImproveCareNow Network at https://improvecarenow.org; the C3N Project at https://c3nproject.org, and listen to the talk delivered at the Patient-Centered Outcomes Research Institute, which forms the basis for this post: http://youtu.be/FxYbSEXWzhU

Health IT at the White House

Posted on 26 June 2012 by Peter Margolis

On June 19^th, I was honored to represent the ImproveCareNow network and other learning networks at a White House meeting on how Health Information Technology (health IT or HIT) can improve health outcomes.

Present were about 75 leaders from institutions and practices that have advanced the use of health IT to improve care and outcomes. In his opening remarks, Farzad Mostashari, MD, Director of the Office of the National Coordinator for Health (ONC) IT made a number of important points:

The number of offices using electronic medical records (EMRs) has doubled and about half (2,400) hospitals in the US now have EMRs
Increasing the use of health IT faces many challenges: workforce training, data sharing, privacy and security. The opportunity is to move beyond simply implementing new technology to using health IT to improve care and outcomes. ONC is particularly interested in how to turn data collection through electronic health records into a quality improvement program and so invited groups like ours.
What’s unique about HIT is how fast it can adapt and change in response to needs and feedback
And it’s important to harness the knowledge within the field. For me, this was the most important message of the day and one that’s right in line with what we’re doing in the ImproveCareNow Network and C3N Project. It’s our responsibility to share the knowledge of all – patients, clinicians, and researchers to make health care better. If patients and clinicians don’t speak up and share what they know, patients will suffer by not getting the best care

During the conference participants shared numerous examples of how HIT and the Affordable Care Act are working to make care better, more efficient and cheaper

HIT helps to engage patients in collaboration in addressing their problems. “You use it in collaboration with patients to guide their care.” Mike Zeroukian, MD
Charles Kennedy, MD Aetna. “We will increasingly see health insurers pay for health information exchange and better use of data.”

Participants also noted the many limitations of current technologies including:

Ways for patients to share information among providers
The need for greater public awareness about individual vendors’ willingness and action in making data sharing possible across systems
The need for public usability ratings for EMRs (like Consumer Reports) to spawn greater competition in meeting the needs of practicing clinicians
The need for EMR vendors need to learn about how to support QI

Overall, it was clear that administration officials were listening and that much excellent work is taking place in the field. It’s a pleasure to be able to represent the work of ImproveCareNow and the C3N Project, which is one of several data and knowledge sharing networks for kids with chronic illness. Networks such as ours will be the way of the HIT future.

Learning about changing health care systems – My story

Posted on 30 May 2012 by Peter Margolis

As a young person growing up in Washington, DC in the late 60s and early 70s, I was immersed in the importance of changing the system. My father was a lawyer and my mother a social worker. My family placed a strong emphasis on taking responsibility for making things better. Several years later, when I decided to go to medical school in New York City to train at Bellevue Hospital, I wanted to experience medicine in one of the country’s biggest urban public hospitals. During medical school, I also decided to join the National Health Service Corps as a way to provide service.

Fresh out of residency, I was eager to put into practice all that I had learned. However, I wasn’t able to start my work in Corps in Rochester, New York immediately. I found a position with the Elmwood Pediatric Group while I waited for my service to begin. After I began my service, I continued to spend parts of days and weekends at the Elmwood Group.

There was a striking difference in the environment of the private practice and the neighborhood clinic. At the clinic, appointments were scheduled twice a day in blocks, once in the morning and once in the afternoon. Mothers and children waited for hours in a cramped waiting room devoid of pictures or toys. At the Elmwood Group, we saw many more patients, equally complicated cases, in a schedule that ran on time. At Elmwood, I would see poor kids with asthma whose disease I could manage much more effectively than I could at the health center because it was easier to develop an effective relationship with patients in a system that ran efficiently and that communicated a sense of caring. In short, I was struck by my inability to produce the same outcomes (even though I was the same person) working in two different systems. It was simply unavoidable that my effectiveness as a clinician depended on the system in which I was working.

I also discovered that by focusing on what patients need and want, I could change the system. After I was named director of pediatrics at the clinic, I took what I learned about efficient office operations at the private practice, did some reading about queuing theory and succeeded in implementing a scheduling system that improved the experience for patients and increased the number of children for whom we cared by about 50%, with no increase in staff, while reducing the number of no-shows. From this experience, I also learned that changing the system affected not only the patients but also the doctors caring for them. It was so much more satisfying for all the physicians to see patients in a system that ran efficiently, communicating to our patients that we respected their time.

My appreciation for the importance of the healthcare delivery system deepened when Corps transferred me to a storefront clinic the south central neighborhood of Los Angeles. By the time I left Rochester, I had realized that I needed to have more skills than I had learned in medical school if I was going to change the system. I wasn’t hesitant to share my “big ideas” for better healthcare delivery with my partners of the Elmwood Group. One evening after work, one of them put his arm on my shoulder and said, “don’t become one of those researchers who just studies why those of us in practice don’t use evidence or don’t provide the best care for our patients. You better figure out how to be useful.”

This was a defining moment. Over the past 20 years, I have studied and learned about how to use and apply improvement science and systems engineering to enable doctors, nurses and, now patients work together to make health care the best it can be, applying the knowledge we have today, and discovering and creating innovations that will make care better tomorrow. That’s why I’m proud to be part of the ImproveCareNow Network.