Ron Teufel
1. As an associate editor of Hospital Pediatrics and someone that reviews a lot of manuscripts, what advice do you have for young pediatric hospitalists looking to publish their research? What are the most common pitfalls that you see?
Persistence is key! And for manuscripts it might be, persistence through all types of feedback. Consider all the reviewer feedback/comments. Some reviewer comments are “good” and sometimes reviewers just don’t get your project. Work hard to differentiate the comments that require a change to your project from those that suggest the reviewers doesn’t understand your point. For the latter, do revisions to help readers understand your project. I remember the first manuscript I submitted and its reviews. The reviews were 40% positive and 60% suggested changes. And they asked for resubmission. I was disappointed despite being asked to resubmit at a very good journal. I think that is a common pitfall. All feedback can be reframed as “good” and any request to resubmit is overall positive.
2. Along the same lines, with new technology, there are more and more publications and discoveries every day. How do you stay up to date on the literature, and where do you focus your attention when doing your scholarly reading?
That is a very good question. I wonder how much this varies among faculty. For me personally, I love Evidence-Based Medicine (EBM) as a mechanism to keep up with clinically relevant literature. If a question comes up on rounds, well, that’s worth reading about. I appreciate all the residents that work on our PHM teams and their patience when an EBM type question comes up. I honestly get very excited, maybe too excited. With practice, EBM searches are a great tool to keep up to date on clinically relevant reading. To keep up with my research areas of interest (e.g., asthma, technology, and PHM) I learn a lot when writing and reviewing. Ensuring your literature review is up to date throughout those activities really helps. When you use Pubmed to search you may find an article in a journal from a different discipline that you don’t tend to read. Those are some of the best articles! I do peruse specific journal but likely spend more time on Pubmed than others for both clinical knowledge and scholarly projects.
3. In May 2018, you published “Enhancing Postdischarge Asthma Care by Using Pharmacy Claims and Telephone Follow-up” in Hospital Pediatrics. The idea was using access to claims data and follow-up phone calls to decrease readmission rates and preventative care measures. Can you tell us more about this study?
Some projects in life are fully supported by outside funds. Sometimes a group of providers come together and decide to do what they think is best for kids no matter how much funding exists. That project fits more so into the second category and evolved with the help of a great team. Anita Shuler is one of our respiratory therapists that is so incredibly engaged and dedicated. She is constantly working with kids in the hospital and ED with asthma. She is incredibly talented, creative, and knows what kids need. For years our research team had done projects on preventive care for asthma in the hospital and afterward. These efforts included a team of residents early on, Dr. David Mills and Andrea Preston, and then added momentum as our team expanded to Anita Shuler and Dr. Annie Andrews. This project was our attempt to do something about the problem of low rates of asthma preventive care - move beyond just pointing out a problem. A local insurer decided to join our team and gave us some money and access to the real-time claims data. Honestly, it was a bit messy as we were evolving the project over years like a QI project but then tried to analyze it like a health services research project with Medicaid data. In the end, I am proud of the work we did to improve care and excited that we are still moving it forward with mHealth technology to replace follow up phone calls.
4. Many of your publications focus on improving asthma care, particularly in the outpatient setting and readmissions. If you could wave a magic wand and change one thing about asthma care across North America, what would it be and why?
If we could all see the world from a patient perspective and let that drive each of our individual actions day to day and our health system design. Most of our asthma work has really been about doing our part to encourage prescribing and adherence for the same population of children. Either, during admission, after discharge, or finding the population of children that are likely to be admitted, again. A population of children with asthma that tend to fall through the cracks in our system. To design our healthcare system to function better from the patient’s perspective take a lot of understanding of another’s perspective and point of view. We should go beyond the basics of information exchange (e.g., medication refills) to include mHealth use at home and designs that understand youth goals and motivate them to improved their health behavior. Hitchhikers Guide to the Galaxy has the point of view gun (https://www.youtube.com/watch?v=zxo3Jy3p8zo). If you are giving me a magic wand then I get that gun. Might be super valuable beyond asthma and suspect it would help everyone see the world differently.
5. As the senior author on a study, “Association of electronic health records with cost savings in a national sample” (Am J Manag Care 2014 Jun 1;20(6):e183-90), you found that patients treated in hospitals with advanced EHRs cost, on average, 9.66% less than patients admitted to hospitals without advanced EHRs, after controlling for patient and hospital characteristics. Some pediatric hospitalists have been vocal in their dislike of the EHR. How can we use it to our advantage, and where are these cost-savings found?
Technology was proposed as a solution that could save an estimated $81 billion US dollars to our healthcare system. Our team was a bit cynical of this estimate and attempted investigate if that potential was being realized after technology was partially implemented. We looked for evidence of cost savings in both adults (Reference above) and children (e.g., Academic Pediatric 2012). The investigation into children’s care did not show a positive association like the adult study. For pediatric hospitals, as the research has evolved it seems EHR’s have some benefits to safety if implemented effectively and less likely any benefit to cost. Adult hospitals may be different.
In my opinion, the benefits to health services research and having a better understanding of the healthcare system via EHRs data seems advantageous to PHM. We have the potential to create a learning health system. The use of big data would not be where it is today without EHRs. We seem much more capable of using the health system data to learn how the health system is functioning and how it could function better. Our field sees so many projects focused on local and national inpatient datasets (e.g., PHIS) that honestly seem to be improving the system. This is due, at least in part, to the more granular data from EHRs (e.g., time of medication dosing, etc). Technology is a tool and how we implement it may be the most important question. Honestly, I don’t know if it’s good or bad at this point. It just exists and I hope we use it to advance the health system in a way that improves care for children.
6. In 2015, you published a Pediatrics article focusing on meaningful use (MU) incentives and electronic health record (EHR) barriers. For those readers that don’t understand, what is MU, and why should pediatric hospitalists care? How might the barriers you identified lead to QI projects?
That was one of my favorite manuscripts. One important lesson to me was the benefit of working with individuals with a different and broader perspective. I was fortunate to get to work with Dr. Nir Menachemi and Dr. Abby Kazley. Having a great team really helps make your project fun and more compelling. The government incentives were an attempt to incentive hospitals to adopt technology and that seemed to be achieved, for the most part. In addition, one take away for me was regarding health information exchange. From my clinical perspective, the goal of using EHRs to facilitate information exchange across settings was an aspect of EHRs that could really change clinical care. Imagine if we knew when a child refilled their medications or if we could read an MRI scan they received on the other side of the country last week. Unfortunately, that component of EHRs was one the most significant hospital barriers to MU incentive payments. Ultimately, it seems like that is where providers need to focus. EHRs just deliver a bunch of information. We can guide what information is delivered and how it is delivered.
7. One of my favorite publications of yours is one regarding overuse: “Overuse in Pediatrics: Time to ‘Pull the Trigger’?” In it, you discuss unnecessary routine testing: the repeat abdominal radiograph after a constipation clean out, the posttransfusion hemoglobin, and the daily white blood cell count. You discuss using “trigger tools” to identify opportunities to improve overuse. Do you know if these tools are actively being used? Any suggestions for 2 or 3 that would be ideal QI projects for our readers?
In full disclosure, I want to give 100% of the credit on that manuscript to Dr. David Mills. He works as an IT medical director at MUSC and came up with all those innovative ideas. We are working to enhance our clinical decision support in Epic. We have done it for asthma and hope to take our evidence based ordersets to the next level. We hope to use trigger tools to support aspects of the order sets that are high-value and use EHR data to better report on metrics surrounding those ordersets (e.g., no albuterol or CXR with bronchiolitis, ampicillin for pneumonia, etc). I do believe some themes surface surrounding a good QI project but they might be more specific to an individual as compared to one size fits all. QI projects should be focused on implementing EBM, on a topic that individuals are enthusiastic about, and sometimes you take baby steps and don’t change the world in one big first project.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Follow your moral compass. Find what your true north is and work hard to move in that direction. It is ok if you re-evaluate yourself over time and realize maybe you were going a little off track. Self-reflect and find north again. For me, I ask myself “What is best for the kids in my community? My state? The world?” Sometimes to answer that question you need to travel and see the world. Have fun, travel, and follow your moral compass!
Persistence is key! And for manuscripts it might be, persistence through all types of feedback. Consider all the reviewer feedback/comments. Some reviewer comments are “good” and sometimes reviewers just don’t get your project. Work hard to differentiate the comments that require a change to your project from those that suggest the reviewers doesn’t understand your point. For the latter, do revisions to help readers understand your project. I remember the first manuscript I submitted and its reviews. The reviews were 40% positive and 60% suggested changes. And they asked for resubmission. I was disappointed despite being asked to resubmit at a very good journal. I think that is a common pitfall. All feedback can be reframed as “good” and any request to resubmit is overall positive.
2. Along the same lines, with new technology, there are more and more publications and discoveries every day. How do you stay up to date on the literature, and where do you focus your attention when doing your scholarly reading?
That is a very good question. I wonder how much this varies among faculty. For me personally, I love Evidence-Based Medicine (EBM) as a mechanism to keep up with clinically relevant literature. If a question comes up on rounds, well, that’s worth reading about. I appreciate all the residents that work on our PHM teams and their patience when an EBM type question comes up. I honestly get very excited, maybe too excited. With practice, EBM searches are a great tool to keep up to date on clinically relevant reading. To keep up with my research areas of interest (e.g., asthma, technology, and PHM) I learn a lot when writing and reviewing. Ensuring your literature review is up to date throughout those activities really helps. When you use Pubmed to search you may find an article in a journal from a different discipline that you don’t tend to read. Those are some of the best articles! I do peruse specific journal but likely spend more time on Pubmed than others for both clinical knowledge and scholarly projects.
3. In May 2018, you published “Enhancing Postdischarge Asthma Care by Using Pharmacy Claims and Telephone Follow-up” in Hospital Pediatrics. The idea was using access to claims data and follow-up phone calls to decrease readmission rates and preventative care measures. Can you tell us more about this study?
Some projects in life are fully supported by outside funds. Sometimes a group of providers come together and decide to do what they think is best for kids no matter how much funding exists. That project fits more so into the second category and evolved with the help of a great team. Anita Shuler is one of our respiratory therapists that is so incredibly engaged and dedicated. She is constantly working with kids in the hospital and ED with asthma. She is incredibly talented, creative, and knows what kids need. For years our research team had done projects on preventive care for asthma in the hospital and afterward. These efforts included a team of residents early on, Dr. David Mills and Andrea Preston, and then added momentum as our team expanded to Anita Shuler and Dr. Annie Andrews. This project was our attempt to do something about the problem of low rates of asthma preventive care - move beyond just pointing out a problem. A local insurer decided to join our team and gave us some money and access to the real-time claims data. Honestly, it was a bit messy as we were evolving the project over years like a QI project but then tried to analyze it like a health services research project with Medicaid data. In the end, I am proud of the work we did to improve care and excited that we are still moving it forward with mHealth technology to replace follow up phone calls.
4. Many of your publications focus on improving asthma care, particularly in the outpatient setting and readmissions. If you could wave a magic wand and change one thing about asthma care across North America, what would it be and why?
If we could all see the world from a patient perspective and let that drive each of our individual actions day to day and our health system design. Most of our asthma work has really been about doing our part to encourage prescribing and adherence for the same population of children. Either, during admission, after discharge, or finding the population of children that are likely to be admitted, again. A population of children with asthma that tend to fall through the cracks in our system. To design our healthcare system to function better from the patient’s perspective take a lot of understanding of another’s perspective and point of view. We should go beyond the basics of information exchange (e.g., medication refills) to include mHealth use at home and designs that understand youth goals and motivate them to improved their health behavior. Hitchhikers Guide to the Galaxy has the point of view gun (https://www.youtube.com/watch?v=zxo3Jy3p8zo). If you are giving me a magic wand then I get that gun. Might be super valuable beyond asthma and suspect it would help everyone see the world differently.
5. As the senior author on a study, “Association of electronic health records with cost savings in a national sample” (Am J Manag Care 2014 Jun 1;20(6):e183-90), you found that patients treated in hospitals with advanced EHRs cost, on average, 9.66% less than patients admitted to hospitals without advanced EHRs, after controlling for patient and hospital characteristics. Some pediatric hospitalists have been vocal in their dislike of the EHR. How can we use it to our advantage, and where are these cost-savings found?
Technology was proposed as a solution that could save an estimated $81 billion US dollars to our healthcare system. Our team was a bit cynical of this estimate and attempted investigate if that potential was being realized after technology was partially implemented. We looked for evidence of cost savings in both adults (Reference above) and children (e.g., Academic Pediatric 2012). The investigation into children’s care did not show a positive association like the adult study. For pediatric hospitals, as the research has evolved it seems EHR’s have some benefits to safety if implemented effectively and less likely any benefit to cost. Adult hospitals may be different.
In my opinion, the benefits to health services research and having a better understanding of the healthcare system via EHRs data seems advantageous to PHM. We have the potential to create a learning health system. The use of big data would not be where it is today without EHRs. We seem much more capable of using the health system data to learn how the health system is functioning and how it could function better. Our field sees so many projects focused on local and national inpatient datasets (e.g., PHIS) that honestly seem to be improving the system. This is due, at least in part, to the more granular data from EHRs (e.g., time of medication dosing, etc). Technology is a tool and how we implement it may be the most important question. Honestly, I don’t know if it’s good or bad at this point. It just exists and I hope we use it to advance the health system in a way that improves care for children.
6. In 2015, you published a Pediatrics article focusing on meaningful use (MU) incentives and electronic health record (EHR) barriers. For those readers that don’t understand, what is MU, and why should pediatric hospitalists care? How might the barriers you identified lead to QI projects?
That was one of my favorite manuscripts. One important lesson to me was the benefit of working with individuals with a different and broader perspective. I was fortunate to get to work with Dr. Nir Menachemi and Dr. Abby Kazley. Having a great team really helps make your project fun and more compelling. The government incentives were an attempt to incentive hospitals to adopt technology and that seemed to be achieved, for the most part. In addition, one take away for me was regarding health information exchange. From my clinical perspective, the goal of using EHRs to facilitate information exchange across settings was an aspect of EHRs that could really change clinical care. Imagine if we knew when a child refilled their medications or if we could read an MRI scan they received on the other side of the country last week. Unfortunately, that component of EHRs was one the most significant hospital barriers to MU incentive payments. Ultimately, it seems like that is where providers need to focus. EHRs just deliver a bunch of information. We can guide what information is delivered and how it is delivered.
7. One of my favorite publications of yours is one regarding overuse: “Overuse in Pediatrics: Time to ‘Pull the Trigger’?” In it, you discuss unnecessary routine testing: the repeat abdominal radiograph after a constipation clean out, the posttransfusion hemoglobin, and the daily white blood cell count. You discuss using “trigger tools” to identify opportunities to improve overuse. Do you know if these tools are actively being used? Any suggestions for 2 or 3 that would be ideal QI projects for our readers?
In full disclosure, I want to give 100% of the credit on that manuscript to Dr. David Mills. He works as an IT medical director at MUSC and came up with all those innovative ideas. We are working to enhance our clinical decision support in Epic. We have done it for asthma and hope to take our evidence based ordersets to the next level. We hope to use trigger tools to support aspects of the order sets that are high-value and use EHR data to better report on metrics surrounding those ordersets (e.g., no albuterol or CXR with bronchiolitis, ampicillin for pneumonia, etc). I do believe some themes surface surrounding a good QI project but they might be more specific to an individual as compared to one size fits all. QI projects should be focused on implementing EBM, on a topic that individuals are enthusiastic about, and sometimes you take baby steps and don’t change the world in one big first project.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
Follow your moral compass. Find what your true north is and work hard to move in that direction. It is ok if you re-evaluate yourself over time and realize maybe you were going a little off track. Self-reflect and find north again. For me, I ask myself “What is best for the kids in my community? My state? The world?” Sometimes to answer that question you need to travel and see the world. Have fun, travel, and follow your moral compass!