1. What do you like best about your role at ICSI?
I really appreciate the chance to work on difficult health care problems facing our state. I believe the partnership of care delivery and health plans is vital to transforming our system to provide the care that our patients deserve. Our work brings together health system leaders, practicing clinicians, patients and other stakeholders and provides the time and space to understand what is and isn’t working from all points of view, and consider actions to begin to close the gaps.
I also get to work with a great team at ICSI. We have a staff of highly capable people, all driven to accomplish our mission of supporting the health system as it moves toward better care, smarter spending, healthier people and professional satisfaction for health care workers.
2. You are the Chief Medical Officer for ICSI. Do you feel your background puts ICSI in a position to better understand and meet the needs of children/teens and their families?
This is an interesting question, which I’m going to answer in two ways.
First, the topics and issues that have been the focus of ICSI activities over the last 24 years were determined by our members and sponsors. They chose topics based on their needs to improve the care and services they provide. Children and adolescents have been considered in our past guideline work; in fact, ICSI work groups created the first evidence-based guidance for ADHD and Childhood Obesity. Recently, the challenges faced by care systems and payers due to the aging population’s increasing incidence of chronic disease has been a major focus of attention, resulting in much of ICSI’s work directed to the adult population.
However, the current focus on population health and better understanding of the impact of social determinants on health, along with research on the impact of childhood events on adult health, is once again bringing attention to the needs of children and adolescents and how the health system can improve overall health. While I am not in the position to choose what work ICSI will undertake, being a pediatrician does enable me to interpret the issues impacting kids in ways that help us maintain a focus on this population as well as adults.
The second way I would answer this question has to do with the point of view I bring to problems facing the health care system, which I believe arise from many years of practicing in pediatrics.
First, I tend to look at systems as being in a constant state of change. Babies become toddlers, who become teens and then adults, and one of my roles as a pediatrician is to support this change. This developmental view is what I expect, and it allows me to be more comfortable with the constant change we are experiencing in health care today.
Second, pediatricians constantly watch behavior. Knowing the age of a child is important, but not enough to completely understand the child. Young children are not able to tell you what they are experiencing. Children may let their parents speak for them. Teens may choose not to speak at all. Watching behavior becomes as important to diagnostic clues as the spoken history. Understanding that behavior can provide clues to understanding human systems, and being experienced in using this to formulate solutions, serves me well when working with care systems to effect change.
Third, as a pediatrician, I deeply understand the importance of relationships. Watching a mother and baby, a father and toddler, parents and teens, provides me with information that is as important as the physical exam. Helping families build nurturing relationships that support the growth of children is a key role in pediatrics. And understanding the larger context in which the family lives is key to providing the support they need to thrive. This relational point of view has heavily influenced my leadership style and how I interact with others to bring about the improvements we need in health care.
So while being a pediatrician is important in keeping children’s issues on the table, what I have learned from practicing pediatrics may be equally important in my role.
3. What is one initiative you’re currently involved with that is having a significant impact on patient care?
Several months ago, a group of health system CEOs gathered to discuss challenging, complex and long-standing problems, which they thought might be better tackled collaboratively. One topic identified is the opioid crisis, focusing on actions that the health system can take to decrease overdose deaths from prescription opioids. ICSI has a long history of acting as a neutral convener, and is taking that role here as well. There are several working groups of various experts from these organizations, each with a focus on part of the problem: 1) Recommending common prescribing practices for acute pain, 2) Identifying and developing plans for patients at high risk of opioid overdose, 3) Increasing the availability of safe disposal options, and 4) Improving access to chronic pain treatment. It is noteworthy that Children’s Minnesota is part of this collaborative, including Bob Bonar’s participation in the CEO group that is directing this effort.
The second topic is access to mental health services, which is of course a complex issue that impacts all age groups. An initial focus area is the impact that behavioral health crises have on the emergency departments and the challenge of finding inpatient beds when needed. While there is an overall shortage of inpatient beds, it is a particular issue for children and adolescents. There is much work to be done to find solutions and to take action, and children’s needs are a priority item.
4. Many pediatricians feel overwhelmed by regulations, paperwork and patient loads. How and why can they fit QI into their busy schedules?
There is a heavy burden on pediatricians these days, as you note, including the challenges presented by EHRs. Burnout is a real for our profession, as it is in other primary care settings, which can make it seem too burdensome to take on improvement projects. To address this, I’d suggest that improvement be viewed as a “team sport.” Rooming staff, front desk workers, and office managers are all part of the team who can take on improvement projects, lifting some of the burden from physicians.
In addition, quality improvement can quickly get more complicated than it needs to be. ICSI always suggests that teams start small – test your improvement idea on a few patients, or for just part of a day. Stop and see what you learn from that effort and then try the next thing. Too often we try to fix everything at once, which can lead to paralysis.
You can also find support from other organizations to help with improvement projects. Certainly, ICSI supports its members with training, tools, and professional practice facilitators. The Minnesota Department of Health also has excellent resources to help clinics improve their immunization rates, among other topics.
5. With many of the large MN health systems now moving to a single EHR system, what impact do you think that will have?
I hope that this will improve the ease of sharing patient information between providers and organizations. But even if everyone was on the same system (which will not be the case as Children’s in on Cerner and the other major player is on Epic), there are still challenges with easily sharing information between systems and storing it effectively. Patient privacy laws continue to place limitations on some information sharing. Getting past this will require a wider discussion about privacy needs that will need to include patients, systems, and clinicians.
6. When did you know you wanted to become a pediatrician?
I’ve always been a bit in awe of those who knew what they wanted in a career from a very early age. I did not. There was an influential pediatrician in my childhood, Dr. Corbett, who became a family friend in later years. And certainly, I have always liked children. But initially I was going to go into bench research in microbiology or genetics. However, my mother thought I should go into medicine, so I applied to medical school. There I found my fascination with the changing and developing human body, and the charm of working with all ages, from babies to teens, and their parents.
7. How did your past roles prepare you for the position you have now?
Earlier I mentioned how pediatrics has influenced my thinking about change and my leadership style. I was trained as a quality improvement (QI) facilitator many years ago, and had the opportunity to lead a number of QI projects. As I worked with QI, I came to realize that the techniques were important, but equally important was how teams communicate and function together. This led me to learn more about both physician-patient communication and team functioning. I had the opportunity to be on the faculty for communication workshops for many years, including motivational interviewing. Becoming comfortable with effective listening, understanding what motivates others, and being able to quickly synthesize this has been invaluable in working with clinicians and others to build effective coalitions for change.
Additionally, I’ve had the opportunity to hold various leadership positions in primary care. Being responsible for clinics with internal medicine, family practice, OB/Gyn and urgent care, gave me a clearer picture of the challenges faced by primary care as a whole and a better understanding of the impact of chronic disease on the health of an entire population. A few years ago, I had the opportunity to lead a multi-state project to improve the care for adults with depression and concurrent poorly managed medical disease. Understanding adult medicine practice as well as the challenges of running a successful primary care clinic were vital as ICSI worked with practices across the country to implement a new model of care. This experience in leading a project focused just on adults provided an opportunity for others to see that, while I advocate for children’s needs, I understand and speak to the needs of the larger population as well.
8. What do you enjoy doing in your spare time?
The short answer is ‘travel.’ Whether is it is to go to all 72 Minnesota State Parks (my husband, John Butler, and I have done it – you get a very nice plaque), or visiting other countries (we’ve been to more than 50), we enjoy experiencing new places. And recently, we’ve been working to improve our photographs of our travels by taking workshops to build our skills and creativity.
Here in Minneapolis, I like to take advantage of theater, foodie restaurants, baseball games, and yarn shops, and also have a nascent interest in opera.