Dr. Peter Margolis, M.D., Ph.D. Center For Health Care Quality, Cincinnati Children's Hospital Medical CNTR 08-05-09 Interview Transcription

1
Interview and transcription August 05, 2009
Dr. Peter Margolis, M.D., Ph.D., Co-Director, Center for Health

Care Quality, Cincinnati Children's Hospital Medical Center,
Cincinnati, Ohio
Collaborative Health Care Transforming Systems of Care

Delivery for Children
INTRODUCTION
I’m Peter Margolis, and I’m Co-Director of the Center for Health Care
Quality at the Cincinnati Children’s Hospital Medical Center. I am a
general pediatrician and epidemiologist. The work that I do is focused
on transforming systems of care delivery for children. We work in
many different parts of the country with many different types of
settings, everything from hospitals to primary care practices to
communities, states, early child care centers, social services, trying to
help create better systems of care that produce better outcomes for
children. This is part of Cincinnati Children’s Mission to improve care
and transform care delivery for children. The way that we operate is
by forming and bringing together groups of clinical sites generally to
work on specific problems.
A. CATEGORY
What are you passionate about now?
Copyright 2009 Betsey Merkel and I-Open. Creative Commons 3.0 Attribution-
Noncommercial-No Derivative Works. Institute for Open Economic Networks (I-
Open) 4415 Euclid Ave 3rd Fl Cleveland, Ohio 44103 USA
2
[00:01:38] My own passion comes out of my experiences as a

pediatrician recognizing how hard it is for individual physicians to
produce the kinds of outcomes that we’d like to produce for children
without being part of a supportive system. I’m very interested in how
to create the infrastructure, the things that surround one on one
medical practice to help people improve. That’s work that we’ve done
for probably close to twenty years now.
[00:02:29] Some specific examples of the kinds of things we’re

pursuing passionately now include trying to connect subspecialty
pediatricians who take care of kids with chronic illnesses together
better so that they can share knowledge about how to create more
effective care delivery systems. We’re also very passionately
interested in population health; not just taking care of the people who
come in the door but also creating ways to affect the health of entire
communities. Early childhood education and outcomes and behaviors
are a big area of focus; better use of drugs and other therapeutic
devices is another focus, and we’re also interested in developing
innovative ways of providing care so we are starting to look at ways
of using social networking platforms to enable patients to
communicate better with each other, provide better social support for
each other, also, potentially to communicate better with physicians,
so that the interaction between patients and physicians is not based
so much on episodes of care, but it is more continuous over time.
Some of the social networking platforms offer an opportunity to do
that.
What would you like people to know, think, feel and do?
[00:04:07] The kinds of things we’d like to see people and society do
is to put greater investment into the development of network based
approaches to care delivery. Probably the best, a couple of really
great examples in medicine already exist for this concept. Probably
the best example comes from children’s cancer, so there, pretty much
every child with cancer in the country is involved in a large network of
care providers so that the care a child in Idaho gets really looks pretty
much identical to the care of the child in New York City. That comes
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from the fact there’s an infrastructure that enables proto calls and
treatments and best knowledge to be disseminated very rapidly to
everybody who provides care for patients with cancer. The particular
problem in children that we have is that there are very few children
with serious chronic illnesses in any place. So that, as a clinician, if
you want to make sure somebody’s getting the best possible care, it’s
really impossible to do it based on just the information from your own
center. There may be just too few children to really study and
evaluate the effectiveness of the various treatments. So, by linking
people, linking care providers, and physicians up across multiple
sites, it provides the sample size, the number of patients you need to
really study and evaluate what is working and what isn’t. That also
provides a way; the standardization of care actually provides a way of
improving care. A lot of patients fall through the cracks because of a
lack of communication; doctors and nurses working as hard as they
can but not being able to deliver the best care because of the
limitations of the system. So, those are the things we like people to
know about.
What do you see for the future?
[00:06:16] This whole issue of how to improve care delivery is

extremely hot right now with the emphasis on health care reform, the
need to develop better systems of health care delivery. I think there’s
growing interest in the potential of understanding how network
effects, at all levels – both at a social level as well as a molecular
level are important in determining health outcomes, so I think this
area is only going to grow.
B. TOPIC – Innovation Framework
What category of the Innovation Framework do you primarily

invest your time and attention? Brainpower? Networks? Quality,
Connected Place? Dialogue and Inclusion? Or, Branding
Stories?
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[00:06:53] I think the things we work most on are creating a technical

and social platform for networks to form and develop so that when we
work in a particular area we identify a number of sites who want to
work together, we provide them with a framework and structure for
linking specific activities that they’re doing in delivering health care to
the outcomes we are trying to achieve, so for example when we’re
working with ICU’s (intensive care units) on reducing blood stream
infections we may identify particular care activities like how they
insert IV’s or catheters into the body, or how they clean them and
maintain them, or how they monitor their performance, we provide
them with that framework as a way of enabling them to, a word I use
is “calibrate” so that they have a set of common words and tools and
way of looking at the task at hand so that they can actually
communicate with each other. That is part of the technical platform.
What secondary categories are you interested in?
[00:08:22] Then there are ways of communicating, which again, I

think you call “inclusion and dialogue”, so we provide them with, they
may come together several times during the year: face-to-face
meetings, we include social components in the meetings so they get
to know each other on a personal level, we support their ongoing
interactions through conference calls, email, there is usually a web
site that they can go to where they can interact. We also stimulate
interaction by feeding back data to them about their performance so
they can see whether or not their actions are related to the outcomes
they are trying to achieve.
Which category would you like to collaborate with next?
[00:09:03] The area that we’re finding that we need to get into more is
that we’ve been taking an approach that’s really kind of science and
data focused and we’re realizing that we’re in order to get this style of
working to spread, we’re going to need to start to communicate in
stories and connect sort of the day-to-day work of delivering care to
the emotional aspects of what we’re trying to do and why people went
into medicine and that sort of thing.
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C. ACTIVITY – Strategic Doing

Explore and Research
What research areas interest you? Why?
[00:09:36] Let me give you an example of networks. I had mentioned

before that we’re working on the sub-specialty care of children’s
chronic illness. We currently have networks forming of physicians to
work on inflammatory bowel disease, intensive care emergency
medicine, and the treatment of pain in children, supporting children
with severe cardiac problems who are undergoing surgery and
recovering from surgery. Each area, each topic, is it’s own network of
anywhere from fifteen to forty clinical sites working together.
Our hope is that we could expand the participation to get virtually all
care sites working on a particular topic and so for example, for
pediatric ICU’s, that would be about 350 ICU’s across the country, for
inflammatory bowel disease it’s probably about 250 care sites that
deliver care for children with that condition.
[00:10:56] I think our expertise developed over the last twenty years
has been really in developing and running distributed projects, large-
scale efforts that depend on collaborative partnerships among
groups. Our major research now is learning how to scale up what
we’ve been able to do at a scale of twenty to forty sites at once to a
much larger scale potentially involving thousands of sites at once.
Our research is really on a variety of different dimensions. One

dimension has to do with using specific methods: in our field we use
quality proven methods which have not been used widely in medicine
as a way of rapidly adapting new ideas to clinical care. On a
methodological side, we’re interested in understanding the contextual
factors that enable specific teams to succeed in being able to improve
care. So, what we observe, is that some sites that participate in these
networks are much more successful in proving outcomes for kids
than others and that may have to do with the amount of resources
they have, the kind of leadership that’s at their center, the team
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dynamics, they may have the expertise that the team has the
knowledge about the application of quality improvement methods, or
the kind of data management system they have. So, we’re interested
in actually starting to study that systematically. In order to do that, we
have to have the relevant observations that take place at the clinical
site, not at the patient level, they need to have a lot of clinical sites
involved in the network in order to do the studies. So, that’s one area
of pretty intensive research.
[00:13:09] Another area of research is working on the patient side to

get to hold more practices, more clinical sites into active efforts to
improve care. And that’s how we’ve gotten into social networking, the
ideas of social network. So, connecting patients with each other,
connecting patients with doctors, increasing the demand side on the
patient’s side. And we’re starting to look, as I mentioned, at the use of
social networking platforms as a way of making that happen. And
that’s also lead to this interest of you being here, which is the use of
open source methods and in some ways to summarize it, we need
more Linux and less Microsoft in medicine. Traditionally, researchers
have been taught to kind of hold on to their ideas and what we’re
learning is what’s appealing about open source is that there may be
another set of incentives that are going to be necessary in order to
drive academic productivity, particularly in medicine.
[00:14:26] We try to share as much information as we can in lots of

different ways with others that’s a feature of academics that’s our job
to share information, we do it through publications, presentations, we
do it on websites, and again, we’re starting to try to share more with
the public, with public oriented websites.
[00:14:41] I think virtually every project that we do is done

collaboratively with other organizations and other individuals. So, the
leadership of every project includes people with a variety of different
skills, we may have a clinical expert, somebody who’s an expert in
inflammatory bowel disease, we might have a QI (quality
improvement) expert like myself who’s expert in the technical
components, we always establish partnerships among various
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organizations, we have strong partnerships with a number of the

certifying boards of medicine as well as the professional
organizations. We realize that that’s key to being able to do this work
effectively.
[00:15:39] I think the kinds of connections we’re finding we need are

more connections with the public and more connections with policy
makers, who I think are less familiar with this kind of style of work. I
think we have not taken advantage of the public’s interest in ensuring
that the scientific knowledge that’s generated by the kind of work we
do actually gets translated into improved health of the population,
which is in fact, what our tax dollars are going towards.
Focus and Networks
What networks are you building? Why? How?
[00:16:22] We probably have about twenty networks in development

right now. So, actually, that’s what we’re just learning how to do, is to
do a bit more use of formal network mapping tools, so that’s a set of
expertise that we need. We understand that there’s, I don’t know if
you’re aware of this, there were a series of articles in “Science” this
week, many of them published from Indiana University who do
network mathematics. I think that’s a set of skills we don’t have right
now.
What criteria do you use for mapping knowledge networks?
[00:16:59] So, in terms of how do we map, how do we use networks?

One of the advantages that I think we have in medicine is that we
often have pretty concrete outcomes that we’re after. I mean, it can
be even living or dying. So, when you collect data at a site level, we
take advantage of the variation across sites in their performing and
achieving outcomes. We all think that doctors do it right all the time
and it turns out there’s a lot of variation across centers in the
outcomes they can produce. So, one of the ways that we can use a
network, take advantage of the network, is that by measuring the
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outcomes that different sites are producing, you can identify those
sites that are outperforming everybody else and those are the groups
that have knowledge that others don’t have. Probably the best
example of this that has come up in my career, was a project that we
did on cystic fibrosis a number of years ago focused on improving the
quality of care for kids with that condition. At the time, there were data
about the life expectancy of kids with CF (cystic fibrosis) at different
care centers, but they were not available to the research community,
that was kept as private, so when we were starting the project, one of
the pulmonologists that we knew, who was involved with the
leadership, and I were talking about where we could go look to find
really good outcomes. So, we just sat down one day and Googled – I
asked him, where’s the best place in the country –and so we did a
Google search for the University of Minnesota’s CF Center and it
turned out there was a graph on their website showing the average
life expectancy for kids at the University of Minnesota was fourteen
years longer than the national average. That kind of information was
instrumental in helping us identify the specific care activities with
verifiable results, the tacit knowledge that individual centers have that
we needed to surface so that other centers could adopt it.
What criteria do you use to identify best practices in those

networks? (See above)
Execute and Enterprise
What is the next enterprise opportunity that you see? Why?
[00:19:32] We think there’s a very big opportunity to create, we have

had to create, to use networks in a new way. In medicine, as I
mentioned, there have been research networks, thee are also
improvement networks, those are centers who work on improving
care. When you bring together the research networks and what you
might call “learning by doing” networks, you get the, use the
opportunity to also identify and create innovation about how to do
care delivery, so there are a lot cool discoveries coming out of
medicine that may have to actually be translated into practice that’s
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going to require new ways of delivering care. So, the way we’ve done
this in the past in medicine is that academics have assumed the guys
in the lab have assumed that if they write their results up that
somebody would read it and figure out how to put it into practice.
What we’re realizing is that you really have to have a different care
delivery system, so people earlier in the research trajectory, the ones
who are making the break through discoveries need to be in
communication with the people who are designing care delivery
systems so that they can accommodate the new discoveries. Sort of
like Intel working with Hewlett Packard so that the Hewlett Packard
people prepare their computers to accept the new capabilities for the
next new Intel chip.
How much time would you like to spend on this opportunity,

from idea to execution?
[00:21:09] How long will it take to get innovation networks spawned in

medicine? How long would I like to spend on it, or how long will it
actually take? I’d like to spend three to five years on it; I think it’ll take
twenty years.
Whose insights and guidance do you/would you engage?
[00:21:24] I think one place that we’re starting to look now is to look to
all these experts in networks, network people like Peter Gloor, Von
Hippel [Eric von Hippel] and Thomas Malone at the MIT Center [for
Collective Intelligence]. We’re working with the Science Commons.
We’re starting to work with economists at the University of Chicago
and we’re also working with creative people out of Los Angeles who
are good at telling stories. We’ve engaged some creative movie talent
in developing our stories.
What benchmarks and measurements do you use in your work?
[00:22:07] Okay, so I talked a little bit about the benchmarks and

measurements: the biggest measurement is the improved care,
improved health outcomes for the patients that we see.
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Performance and Education
What next steps do you envision to pro-actively respond in

education, economic and workforce development?
[00:22:15] One of the opportunities in Ohio is that there are eight

children’s hospitals in Ohio, we’re very interested in the potential for
Ohio to be, what we’re calling a collaboratory, that engages all the
children’s hospitals in working together to make children in the state
some of the healthiest in the country. We also think there’s also the
opportunity to work at a population level with primary care practices
throughout the state to again demonstrate what’s possible if you
scale some of the results we’re accomplished up to full scale and
impact health in the entire state. It seems like there’s willingness and
passion within the state to start to make that happen, there is
willingness in the government across the children’s hospitals at the
level of the pediatric health care providers and among family
physicians who also take care of children, so we think that’s a really
cool opportunity. So, if you guys at I-Open in Cleveland want to do
something that would be a great way to get involved.
[00:23:35] So education and workforce development’s obviously a big

piece of what we do at an academic medical center. We are actually
starting a treatment program for fellows in various medical
specialties, as well as nurses, pharmacist, allied health professionals
to learn these methods and apply them in their various venues.
Really, at the moment, we think there are only two or three programs
in the country that are focused on creating the skills sets that enable
people to learn to do this in health care.
What next steps do you envision to pro-actively respond to the

powerful topics affecting communities and their regions, such
as: climate change, green job creation, water, land, energy,
technology, and health care?
[00:24:13] So, the content focus is what we call ‘quality improvement’.

It’s similar to your cyclical framework of knowledge building or
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learning by doing; it’s really an application of scientific method in real

time to enable people to change care systems. That’s the focus; it’s
the science of essentially engineering care delivery systems to
implement knowledge, reliable. It’s not something that in the past
we’ve assumed that if doctors had the right knowledge they could do
the right thing. What we’ve learned over the last twenty or more years
are that knowledge isn’t enough, we need to know how to do it. The
tools and methods of quality improvement are very important for that
‘how to’ knowledge. So, it’s not only knowing what to do, it’s knowing
how to do it. You might think of our fellowship as almost creating
health care systems engineers who learn how to get knowledge into
practice.
[00:25:28] There are probably two or three other places that are
focused on this: the VA (Veterans Administration) has something they
call the VA Quality Scholars Program, it runs at about ten or fifteen
VA Centers. The VA itself is starting to use this approach. Dartmouth
Center for Clinical Effectiveness is one of the leading places; the
other place that I think is doing some training in this area is
Intermountain Health.
Who would you like to be connected to that you are not?
[00:26:03] So, connections, for example, the person who’s leading

our fellowship today is up at Dartmouth talking to them about how to
share and integrate our curricula. We have established connections
with the VA and a looser connection with Intermountain Health,
although we do work with them.
[00:26:27] Sure, I mean our curriculum is not so much about network
development as it is about quality improvement methods. We have a
formal training process that includes experiential learning of actually
making changes in care delivery, and a sequence of courses that we
offer here that goes over the science and the methods of improving
care delivery. We have an intermediate course and an advanced
course focused more on research, coupled very strongly with learning
by doing.
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How will your research/business serve the sustainability of

communities and their regions 50 years from now?
[00:27:12] Our goal is to create a sustainable way of continuously

improving the practice, so what we’re trying to do is to build
sustainable systems so that physicians come to view participation in
an ongoing effort to constantly improve practices as a central part of
their job.
Closing questions:
[00:27:37] When you incorporate patients and their families with

health care providers, how do you do that, online? Are they also
participating, or do you really address the health care provider
nodes?
Our major focus up until now has been the health care provider
nodes. We often include, on some of our projects we include families,
parents, and kids on the teams that are redesigning care. So, some
of the best projects actually have families participating in the design
activities and the tests. One of my colleagues runs a center on
chronic illness innovation, and there are a number of parents who
participate on the design teams, they do the experiments themselves,
they cook up this stuff themselves. One of their projects is using,
working with adolescents to design a set of text messages for kids
with asthma that amount to reminders to the kids, but the kids
actually design, what they’ve done is work with the kids. Certain
adolescents like to have certain kinds of text messages as reminders,
so some adolescents prefer to have ones that are demanding, “Take
your medicines, dammit!” “It’s time to take your medicine.” Or, others
want a more, touchy, feely approach, “Maybe you should take your
medicine” or, “This would be a good time to think about taking your
medicine.” We’re working with some cell phone companies to develop
customized messages based on kid’s preferences for how they like to
have reminders.
Our generous thanks to Dr. Peter Margolis

13
The Institute for Open Economic Networks (I-Open)

4415 Euclid Ave 3rd Floor Cleveland Ohio 44103 USA
Copyright 2009 Betsey Merkel and I-Open Creative Commons
License Attribution-Noncommercial No Derivative Works 3.0 United
States
Keywords
Collaborative health care, networks, pediatrics, social networking
platforms, quality improvement, medicine, education
Related Links
I-Open
http://i-open-2.strategy-nets.net/wiki/peter-margolis-co-director-
center-for-health-care-quality-cincinnati-children-s-hospital-medical-
center
Facebook I-Open
http://www.facebook.com/group.php?gid=35942064712&ref=ts
Flickr
http://www.flickr.com/photos/i-open/sets/72157621958893970/
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Scribd
http://www.scribd.com/doc/23383940/Peter-Margolis-MD-PhD-Co-
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Interview
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Contact Information
14
Peter Margolis, MD, PhD

Professor of Pediatrics
Cincinnati Children's Hospital Medical Center
Center for Health Care Quality Cincinnati, OH 45229-3039
Rebecca Boerger
Administrative Assistant
Center for Health Care Quality
3333 Burnet Ave., MLC 7014
Cincinnati, OH 45229
Rebecca.Boerger@cchmc.org
Ph 513-803-2187
Fax 513-636-0171
Website
http://www.cincinnatichildrens.org/research/div/health-
quality/default.htm
Biographical Information
http://www.cincinnatichildrens.org/svc/find-professional/m/peter-
margolis.htm

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Interview and transcription August 05, 2009

Dr. Peter Margolis, M.D., Ph.D., Co-Director, Center for Health

Collaborative Health Care Transforming Systems of Care

What are you passionate about now?

[00:01:38] My own passion comes out of my experiences as a

[00:02:29] Some specific examples of the kinds of things we’re

What do you see for the future?

[00:06:16] This whole issue of how to improve care delivery is

B. TOPIC – Innovation Framework

What category of the Innovation Framework do you primarily

[00:06:53] I think the things we work most on are creating a technical

What secondary categories are you interested in?

[00:08:22] Then there are ways of communicating, which again, I

Which category would you like to collaborate with next?

C. ACTIVITY – Strategic Doing

What research areas interest you? Why?

[00:09:36] Let me give you an example of networks. I had mentioned

Our research is really on a variety of different dimensions. One

[00:13:09] Another area of research is working on the patient side to

[00:14:26] We try to share as much information as we can in lots of

[00:14:41] I think virtually every project that we do is done

organizations, we have strong partnerships with a number of the

[00:15:39] I think the kinds of connections we’re finding we need are

Focus and Networks

What networks are you building? Why? How?

[00:16:22] We probably have about twenty networks in development

What criteria do you use for mapping knowledge networks?

[00:16:59] So, in terms of how do we map, how do we use networks?

What criteria do you use to identify best practices in those

Execute and Enterprise

What is the next enterprise opportunity that you see? Why?

[00:19:32] We think there’s a very big opportunity to create, we have

How much time would you like to spend on this opportunity,

[00:21:09] How long will it take to get innovation networks spawned in

Whose insights and guidance do you/would you engage?

What benchmarks and measurements do you use in your work?

[00:22:07] Okay, so I talked a little bit about the benchmarks and

Performance and Education

What next steps do you envision to pro-actively respond in

[00:22:15] One of the opportunities in Ohio is that there are eight

[00:23:35] So education and workforce development’s obviously a big

What next steps do you envision to pro-actively respond to the

[00:24:13] So, the content focus is what we call ‘quality improvement’.

learning by doing; it’s really an application of scientific method in real

Who would you like to be connected to that you are not?

[00:26:03] So, connections, for example, the person who’s leading

How will your research/business serve the sustainability of

[00:27:12] Our goal is to create a sustainable way of continuously

[00:27:37] When you incorporate patients and their families with

Our generous thanks to Dr. Peter Margolis

The Institute for Open Economic Networks (I-Open)

You Tube http://www.youtube.com/user/IOpen2

Peter Margolis, MD, PhD

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