February 21: Today on TownHall, Brett Oliver, Family Physician and Chief Medical Information Officer at Baptist Health speaks with Albert Villarin, MD, VP and Chief Medical Informatics Officer at Nuvance Health about health equity and food insecurity. What drew him to the subject of health equity? Did he receive any pushback? How can other organizations get started in their own health equity journey?
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people who have been trained for many years assume that an Asian or African-American female cannot tolerate VBAC as well as a white woman would didn't even apply any kind of calculations.
They just assumed, and that training was false. So now we're going around to bring back the knowledge to say, everyone's equal. Here's, how we calculated correctly for all.
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Welcome to this Weekend Health. My name is Brett Oliver. I'm the CM I for Baptist Health in Kentucky, Indiana. And I'm very excited today to have a friend and colleague Dr. Al Villarin, who is the C M I O for New Vans Health. Al, welcome to the show.
Thank you very much. Pleasure to be here.
Yeah, I'm excited to get into the topic today. We're gonna talk a little bit about health equity , and we were talking before we started taping. Al's been able to do some things very concretely in that space that I'm anxious for him to share. But before we get to that, Al if you could just take a second, just give the folks a brief background and kind of where you come from and how you got into the informatics space over time.
Thank you. It's probably all started as an emergency physician emergency board certified emergency physician from a while back. US military, a retired major, and the reserves back then it was a time of learning technology. How does technology really impact us and patient care?
Can we use computers? Can we use x-ray equipment? Can we digitize images and can we send those images someplace else? So I was assign. One of the scientific groups and we were able to really test it out on the field. And that got me very interested in how we can expand this. This is 19 98, 99, how can we expand this to, our hospital-based practices?
And I became the guy with the computer and the thought about how I wanna innovate utilizing computers and healthcare very early. A lot of people were thinking about the same thing, but we didn't have a, coalescing understanding of where we would go with this. So my interest started there and it just grew from that application into my civilian practice and then became director of medical informatics at the emergency department where I worked at Einstein in Philadelphia.
And the rest is history. Once we started looking at what A C M I O does and create a position and other CMIOs joined the conversation and the whole groundswell around informatics grew out of our interest, clinicians to bring better technology to the bedside.
Crazy that you've been thinking about this stuff since 98, 99.
Wow. so specifically about health equity, what drew you either individually or as your organization's attention to that.
There were three formidable factors involved with this. First, as , a Hispanic male in medicine, how is. Our culture are in other cultures being influenced by technology and the way we practice medicine.
Is it different because a clinician sees you as a race-based patient versus as a patient that has the same pathophysiology and function and clinical care needs as anyone else? Regardless of who you are, how you feel you are, and color of skin. The second one is my son, who is in medical school now in Pennsylvania , and UPenn.
He is of the L G B T Community and learning healthcare differently. Then we learned when we were in medical school. So I'm hearing a lot of those interesting aspects of how they're training, how they're understanding healthcare, how they're expanding health equity around the practice of medicine for an embracement of all clinicians and on all our patients actually.
And the third is reading several papers around how health equity. Is being addressed by changes in the emr. And that fostered an interest by another colleague of mine who is the medical director for health equity to look into clinical measures within the EMR itself, specifically around how we do calculations, what tools we use, et cetera.
Cuz a lot of those tools were designed in the ways of the 1940s, 1950s when health equity wasn't even a thing. It was. Calculation were different because we're applying it to an African-American male. Females who are African-American cannot have V A C procedures because they're higher risk. Well, where does that come from?
And tracing that understanding found, there was no evidence-based medicine whatsoever to elicit that. There's a difference between those practices. So we went into our EMR and found eight areas that we want to remove the tools and replace 'em with non-biased, non-racial tools. The. One of 'em was, pulmonary function studies.
Another one was the E G F R. Another one is the v a calculator. So we've gone around and done this and other doing more research. A lot of different institutes have done this, but we wanna make sure that we give the best care for our patients here and then bring out the experiences we have for, to share with other clinical entities outside.
Well, yeah. So about that project that you did, , why would it matter? To explain maybe to somebody who's watching this, that's more it and not clinical. Why does it matter if the Glomerular filtration rate the kidney function, essentially, let's say for an African-American male, is going to be measured differently , than a Caucasian?
Great question. And, we have to go explain to our African American patients that same explanation because. Prior to the changes in our GFR we were not providing the same care of downstream diagnosis and processes as we would a white male, let's say. So because the calculation was different or was more acceptable to have a different GFR therefore we weren't allowing them the consults later on to kidney evaluation, getting 'em treated earlier like we do with someone else because the numbers were different, we're categorizing them differently, but there was no need to do so.
So now that everyone's categorized together, everyone gets the same equitable. access To those consults for improving their renal function before it goes down to dialysis.
So it would actually, an African American male, for instance, would be allowed to have a lower kidney function filtration rate. And, and still be considered normal, so
Or, or not needing the care that we wanna provide someone else with, with the same number. Exactly.
Well, what other things did you find out in that project that you guys did? You talked about the v a C procedure. You wanna explain that a little bit?
Absolutely. So the, one of the calculators that would previously used was a calculator that brought in.
An index for Asian, African American, non-white women, which unproportional pushed the higher risk into a category that they cannot be offered feedback or they wouldn't be offered feedback, but a in alliance with this. It was also training around that too. So, We've, people who have been trained for many years assume that an Asian or African-American female cannot tolerate VBAC as well as a white woman would and therefore don't, didn't even apply any kind of calculations.
They just assumed, and that training was false. So now we're going around to fix the training and going around, fix the calculator and bring back the knowledge to say, everyone's equal. Here's, how we calculated correctly for all.
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What a great point you, bring up in terms of there's the technical correction of a formula, right?
And that, just recognizing that is a big deal. But the, decades literally of reinforced behavior and operational procedures. That you don't even use the technology cuz you assume something. And that there's more to it than just fixing the IT part, which is, seems like that's always the case regardless of the topic.
We can fix that tea part. But that education that was trained through an attending today, who was a resident back in 1970 is still there and being passed on to the next generation of residents who are trying to break that cycle and make it equal for all patients receive the care that they.
It's crazy to me how particularly the g f r piece is so ingrained. There was no questioning. You just assumed that it was based on evidence , and research and all that. It, it's, it's astounding to me, quite frankly.
Now that brings out the importance , of us, our medical informatic, clinical informaticists, who need to address these issues from an E M R perspective, from a workflow perspective, from a data perspective to be accurate around the evidence and then deliver.
Not just the EMR improvements, but also the educational improvements behind that to support our findings.
Yeah. Very rarely do you and I lead a project or have involvement in a project where there's not, a significant operational slash educational piece. It's why in my organization, the training and support team report up through me because we feel like it's, that important.
Same here. I totally agree and, in educating our clinicians, the uptake, , the adoption has been tremendous. There really has been very little question resistance because they can see it. The evidence shows that I can take care of my patients better if we use the right calculators within an hour processes.
That's a question that I hadn't asked you before. It sounds like there wasn't any, but did you get some pushback? Like, I mean, I, I think it'd be hard if you're like, well, show me the studies and we'll sit down and compare them , but here's the ones we found that, compare different races and kidney function or vaginal birth after cesarean or what have you,
So the institutional large healthcare centers like we are really understand that agile progression to innovative evidence-based practice is the norm. We expect that to happen. We improve quality, improve outcomes. It is the primary care, the non-employed clinical groups that's sometimes. Wanna stay where they are and practice the same way and they feed our network.
So we have to help them understand where we want them to be and help our patients as, as a continuum as a whole.
Yeah. Yeah. So you've just gotta get 'em to read the study as if nothing else. good. Very true. Well, what's along these lines? What's next for you guys? I'm sure you're already planning , other moves.
We are actually aligning food as a medicine as part of our practice. So now in the EMR we can do a quick two or three question assay on, an emission for a patient or a new patient coming in and access their need for, food as part of a medicine cuz you can't be healthy if you're not nourished.
Treating someone for hypertension is only as good as their health that they can deliver by non-medical practices as healthy eating, healthy diets, et cetera. So we have a questionnaire on intake that asks them, you know, , how often during the week do you have a regular meal? Are you going to a food bank for, food?
Are you, looking, always thinking about food as part of your purchasing that makes you uncomfortable cuz you're not sure where it's gonna come next time. And if that's the. We were designing a way to kick over a referral plan that puts that information right in front of the provider to say, Hey, they answered yes to some of these aspects.
Give them a referral to the food bank. Give 'em a referral to nutrition. Give them a referral to the next steps to help break that cycle that they're dependent upon in terms of malnourishment
from a practical. Yeah. No, that's awesome. So from a practical standpoint, is that. Do you have some kind of third party connector, or how does, the average, let's say hospitalist, that's going, okay, well, I've identified it here.
They say they have some food insecurity. I would say the average hospitalist doesn't have time to run down the social worker and get a list of, you know, , how have you guys made that an efficient process or have you yet?
We've just started on that path, , this month. So we're building out those processes in the EMR to send a request to care management or the front desk nurse to follow up with them to say, Hey, we understand you have this issue.
We're happy to help you. Here's some information that you like. Also we're able to connect. Texting within our EMR to the patient directly. So there's a availability of the patient. Give us their phone number. We're able to send 'em a text message. So here's more information about discharge.
This is about medications, but this is about food insecurity and what it means and how we can help you find that. We're also going out to the food banks to give us their processes and we wanna embed that back. So we are gonna retrograde design the connection between clinical and. In the outpatient,
well do most of those third parties, the food banks and things have, the technical ability to do some of that.
That's, that's great to hear, hear. We
give them the ability to connect to us, but just like telephone, et cetera. But knowing that we're gonna send people to their, location. Yeah. So now that they know I'm a patient from New Vans Health, welcome. Let's help you get what you need and we'll give them , a food script to say, here's the nutritional balance we want you to have.
, go to the food bank , and get that food that you need for you and your family or for the patient themselves.
Gosh, yeah, we probably have another. Another podcast talking about that. I'm, so, I'm thankful to hear , the social determinant of health and how you guys are integrating that. Cuz so often we hear that talked about it's the sexy new thing and we gotta take care of social determinants of health.
But then there's the practical, what does that mean? And you guys are putting that into play here. And then the secondary part of that is, we have for so long as a primary care physician, so long ignored food as medicine. Not just being adequately nourished, but using food as a tool for someone to get better.
, and explaining the power that a patient has in their hands, you know, to, eat the, the right things for whatever health or disease state they might have.
You know, Solutions like this come at a large effort by multiple people at the network. So it's not just ourselves, a clinical pharmacist.
We have Dr. Brenda Airs with us as the medical director for health equity, but also we have registration and needs are bringing the correct information into us. We have outreach leadership on the ground that helps us find those areas to give referrals to. So there's a lot connectivity. That has to take that patient from finding about them that their need, what their needs are to getting them the help that they do need, whether it be clinical or, nutritional.
Yeah, great point. Great point. It's a, it's a team for sure. Well, let me, wrap up with asking you the final question. As far as health equity goes, what's one area, let's say you're a CIO or a CMIO at an organization that just really hasn't looked at this issue, , as an organization.
Where should they look first when it comes to health equity, or do you have any suggestions on how to get started?
Frankly, it takes a network to embrace health equity, it starts at the top. With our Dr. Murphy, who is the president, CEO of, Nuvance health and leadership, to say this is an important part of our outreach to patients.
We wanna embrace all patients as equal and care equally for them, regardless of their station in life. the following steps would be creating a division around health equity to allow the focus to be not just operationally but also financially supported. So that's a very important piece.
Because you have a lot of marketing, you have a lot of EMR build, you have a lot of analysts, you have consulting, you have data analytics that has to go behind this. So it's, it's a complete project. It's like almost like building a new emr. But you're, revolving around patient experience and health equity and, inclusion.
That's where we would start. Have the operational leadership, embrace it and move forward with it as part of an everyday understanding, because it starts from the top and then it has to move outward and downward educational at every level. So at rounds for the, residents at huddles, safety huddles for the nursing staff everyday conversation it comes up.
How are we doing with health equity? And measure it. Have a transparent dashboard that says, here's how we're doing across our network. Here's where we're lagging. Let's put a little more emphasis and focus on that. But if you don't measure it, you don't know how you're doing in health equity. But I will also bring in the, end user as well.
We have an LGBT Patient PFAC that works with us to help us understand what their needs are in the community and how to best elicit their interactions with those patients and bring them into our fold so we can care for them, not just from an Advertising or marketing campaign, but also from our electronic campaign, meaning our informatics campaign.
We have ability to send a link so they can register as a new patient. How are we addressing health equities around those links? Are we being respectful of LGBT community or African-American community or Asian community? Are we respectful as we present that data to them in that link that we're embracing all patients?
equally And that's a very important piece. The image out front to the patient is an important part of success for any health equity implementation
Sounds like a, culture shift. And those, take lots of people and lots of efforts. So I, I applaud the efforts that you guys have done there at New Vance.
It's it's wonderful to hear about and it's motivating, hopefully for others to, to take the bull by the horns and, work on this. So, Al I really want to thank you for spending some time with us. I know you're busy and I think hopefully folks can learn from this and we can see more of this spread across our country.
So thanks so much for being here.
Thank you very much for the time. I appreciate it. Have a good day. You.
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