{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/rn3028rm84/manifest","type":"Manifest","label":{"en":["Dr. Steven Waldren"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer:  The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}},{"label":{"en":["Description"]},"value":{"en":["\u003cp\u003eDr. Waldren has a unique background a perspective on medicine through the lens of informatics and computer science. Not only does he talk about his time as a family physician, but he explains how he received a position on the FMAH initiative because of his background in coding and computer work. He speaks about his time in Health Care IT and his time on the Technology Tactic Team with the FMAH by saying that they were both great ways to understand the health care system from the inside-out. In the future he hopes to see more positive projects and initiatives through the use of technology so the health care field can keep moving forward. \u003c/p\u003e (summary)"]}},{"label":{"en":["Date"]},"value":{"en":["2018-04-16 (created)"]}},{"label":{"en":["Type"]},"value":{"en":["oral history"]}},{"label":{"en":["Agent"]},"value":{"en":["Dr. Herbert Young (Interviewer)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["family medicine","family physician","American Academy of Family Physicians","Family Medicine for America's Health"]}},{"label":{"en":["Subject"]},"value":{"en":["Steven Waldren, MD (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["english (primary)"]}}],"summary":{"en":["\u003cp\u003eDr. Waldren has a unique background a perspective on medicine through the lens of informatics and computer science. Not only does he talk about his time as a family physician, but he explains how he received a position on the FMAH initiative because of his background in coding and computer work. He speaks about his time in Health Care IT and his time on the Technology Tactic Team with the FMAH by saying that they were both great ways to understand the health care system from the inside-out. In the future he hopes to see more positive projects and initiatives through the use of technology so the health care field can keep moving forward.\u0026nbsp;\u003c/p\u003e"]},"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162274/file/295061","type":"Canvas","label":{"en":["Media File 1 of 1 - WaldrenSteven_01_Access.mp3"]},"duration":2669.3514,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162274/file/295061/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162274/file/295061/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/295/061/original/WaldrenSteven_01_Access.mp3?1760555021","type":"Audio","format":"audio/mpeg","duration":2669.3514,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162274/file/295061","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162274/file/295061/transcript/85357","type":"AnnotationPage","label":{"en":["Dr. Steven Waldren interview transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162274/file/295061/transcript/85357/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Side 1\n\nDr. Young: This is side 1 of tape 1 of the Oral History of Dr. Steven Waldren, the leader of the Technology Core Team of Family Medicine for America’s Health, recorded on April 26, 2018. I’m Dr. Herbert Young, a volunteer at the Center for the History of Family Medicine.\n\nDr. Waldren, do we have your permission to record this interview?\n\nDr. Waldren: Yes.\n\nDr. Young: First could you give us your name in full?\n\nDr. Waldren: Steven E. Waldren.\n\nDr. Young: And what’s your present title and position?\n\nDr. Waldren: Director, Alliance for eHealth Innovation of the American Academy of Family Physicians and past chair of the Technology Tactic Team of Family Medicine for America’s Health.  \n\nDr. Young: Can you tell us a little bit about your professional background?\n\nDr. Waldren: I’m a family physician by training. I consider myself a family physician formaticist since I no longer see patients. After my residency training at the Wesley Family Medicine in Wichita I did a post doctoral fellowship in medical informatics which was done by the National Library of Medicine but it was at the University of Missouri-Columbia. And also got a master’s degree in informatics and worked for the Academy in doing health IT policy and standards and have worked in physician education for the last decade plus.\n\nDr. Young: When you arrived at the Academy you were part of the beginnings really of this type of activity. Can you talk just a little about that?\n\nDr. Waldren. Yes. I think it was really after the Future of Family Medicine 1.0 that the Academy was kind of tasked with looking at how do they add capacity around health information technology and drive that inside of family medicine. So they the Center for Health Information Technology. And within the first month or two of that being established, I was hired to be the Assistant Director of that new entity.  \n\nDr. Young: And has that work continued?\n\nDr. Waldren: Yes, it has and we have kind of done a migration. So when we started in I think around 2005 the adoption of technology in family medicine was somewhere around 7% to 10% of docs use electronic health record. We’re now well over 80% and likely in the 90% range. We changed our kind of core strategy from focusing on the technology and adoption of technology to really looking at how do we use the technology to deliver on family medicine. So that’s why we changed the name of the Center for Health Technology to the Alliance for eHealth Innovation. So it’s really about eHealth and about driving innovation. And the Academy knows that it can’t do it by itself, so that’s why we called it the Alliance and working with external entities to try and drive\n\nthat.\n\nDr. Young: And all of this in a very changing healthcare environment.\n\nDr. Waldren: Yeah. So not only is the technology rapidly changing but also the healthcare environment, moving from volume-based, fee-for-service based payments to value-based payments where there’s really an opportunity for the technology to really help family physicians. And unfortunately also during that time we’ve seen some of the policy changes to try to drive adoption of the technologies such as the   Program. And we’ve actually seen a decrease in satisfaction of the EHRs and they really haven’t lived up to the promise. So there’s a significant amount of work that the Academy needs to do. And some of the work that we did at the Family Medicine for America’s Health to try to drive toward a better, sort of a health IT for family docs. And hopefully we’ll get closer to that promise that we were promised back in the early 2000’s for technology.\n\nDr. Young: So how did you get involved in Family Medicine for America’s Health?\n\nDr. Waldren: I think being part of the AAFP and helping lead our activities around healthcare technology. I was asked to participate and then asked to be the Chair of the Technology Tactic Team. \n\nDr. Young: We’ve sort of heard a little about this next question in terms of the answer, but any particular knowledge and skills that you would identify that you have brought to this project?\n\nDr. Waldren: I think my formal training in informatics. So I can also code computers, I coded in Python and JAVA. I’ve done XML work. So back in 2006 was part of the team that did the technical work around the ASTM international standard  Continuity of Care ecord standard which is an XML data set. So if you were seeing a patient in the ER, didn’t know that patient, what’s that 20% of the data that you would need 80% of the time? So it’s a problem list, med list, family/social history. Who are the providers taking care of them? What recent encounters have they had or hospitalization? So that data set kind of put together that piece and that standard morphed into currently some of the standards that are required for exchange and  program and -- required exchanges. \n\nDr. Young: Taking a couple of steps backward for a bigger picture, what’s your assessment for the state of health in America right now and what needs to be done not just in the technology area, but certainly there, to move it to what we want as a system?\n\nDr. Waldren: That’s a huge question really. And I think if you think about it from the standard of health, for me it’s a really wide definition. So you can have … At the forefront of medicine we’re doing some great work and really saving people’s lives. And not only from the standpoint of making sure that they’re alive, but they are actually to live their lives. And at the other side of the spectrum, we’re still causing harm and causing issue while we’re delivering on these promises and we still have gaps in delivering care. There’s the  divide that’s still inside of the U.S. as it relates to healthcare. So I think in many areas we’re excelling into it great and I think other areas that we really have some opportunities to really improve what we’re doing and really have an impetus to do that because of the morbidity and mortality that’s out there.\n\nDr. Young: And is family medicine right there in the middle of where the greatest need is?\n\nDr. Waldren: Yeah, I think because of the breadth of what we do and the fact that we’re frontline in regards to primary care. And I think also our intent to not only help the patients that are in front of us but also to be members of communities and help communities as well. So I think family medicine is well-positioned to be able to be the tip of the .\n\nDr. Young: I know that people have commented in the past that the investment in research and all has often been in the part of (?) from bench to beside which doesn’t recognize that only a fraction of patients are in bedsides in hospitals. That the community, as you point out, is where a huge amount of health care occurs and yet that hasn’t been where the investment has been.\n\nDr. Waldren: Yeah. And I think that is one of the roles for health information technology that we’ve yet to realize. But the fact that now that we can store and capture information at the point of care, no matter where that point of care is – in the family practice office in the middle of Kansas or that be in a urban, federally-qualified healthcare center, all those places now can be collecting that information and we start to pull that data and start asking those questions. So very interesting to what we can be able to learn moving forward. The real question is how do we get that learning integrated back and make it easy for family docs to be able to act on that and individualize it for individual patients and manage large populations of patients. \n\nDr. Young: Let’s turn specifically to the Technology Core Team. What was the charge of your group? Let me also ask what is its status today, April 26th in 2018 – because, of course, we’re doing these interviews over a period of time about the whole Family Medicine for America Health Project.\n\nDr. Waldren: The Technology Tactic Team has completed its charge and was completed at the end of 2017, so December of 2017. The charge for the group really was in a couple of different buckets. So we were given a set of tactics to start our work. We were also able to take a look at those tactics and say are those really the right tactics that we should be working on from a technology standpoint. The first tactic was to create a new Center for Primary Care Health IT. So the intent there was to look beyond just family medicine but also how do we bring together the work of the supporting organizations for family medicine in a way that really helps move the technology forward. \n\nDr. Young: So is that the Family of Medical Medicine organizations or beyond that?\n\nDr. Waldren: I think the original envision was to look even beyond the family. So also look at internal medicine, pediatrics. Anybody that was doing primary care-related work and needed the use of technology. As we looked at that, the work there was a little bit bigger than a group of five folks, of volunteers, could really do. And the AAFP had a new Alliance for eHealth Innovation and had started to make that transition in saying the Center for Health IT, which is really about the Academy’s work and about the technology, it’s really about what do we need as a specialty and how does that fit with inside the larger primary care. So we worked to create an advisory council so there would be representatives from those family medicine organizations that would help advise the Alliance for eHealth Innovation with regards to strategy. And additionally we would be able to better understand what is the work that is being done by those organizations and what work needs to be done in those domains of the other organizations so that hopefully they would be able to kind of work together. So that work is still a work in progress and trying to get that really off the ground. But that’s how that tactic changed. \n\nThe next tactic that we had was to improve the current EH technology. And as we looked at that, we felt like we had an opportunity to think differently and say do we really want to focus on improving the current technology or do we really want to talk about what’s the next generation of technology that we really need - essence do we want to try to improve the flip phone or do we want to talk about what a Smartphone would really look like for health IT for family medicine. So we decided to change the tactic slightly and the FMA Health board agreed. So we looked at what is the vision of the next generation of technology that we need. So we actually published a vision for a principled redesign of health IT in The Annals of Family Medicine this year that talks about that. It talks about what that vision should look like and provide some action -- to be able to move us in that direction.            \n\nDr. Young: And is that addressing all of health care or very specifically the family physician in his or her office? So what’s the scope?\n\nDr. Waldren: The scope is, I think, primary care with a bent toward really family medicine because you’ll see in there the notion of getting the ability to connect back to the community and the family doc. So going back to our roots in the sixties when we talked about the notion of the doc was part of the community and worked in the community, how do we bring that back together now in the 21st century relative to that? So again, it was focused on primary care but really had that bent of the family doc.\n\nDr. Young: So was there interchange with public health in terms of that?\n\nDr. Waldren: The document does go into this notion of the public health piece of it and how do we integrate those better with kind of every day primary care. So there’s work to be done in that space. \n\nDr. Young: And this is at a time when on the one hand many physicians are becoming employed, part of the larger health care systems, integrated systems, and others are doing direct primary care contracting directly with patients. All of this has to be considered in the sort of work you all are doing?\n\nDr. Waldren: Yeah, it does. I think there’s a lot of the core family medicine that goes across those different environments. One of the things, and I don’t remember if we talked about this specifically in the FMA Health work, but the AAFP, in our Alliance work, we talk about this as we move to not thinking about just the technology but really thinking about this as a work system. So we’ve started to try to partner with folks in the industrial systems engineering disciplines. How do we bring some of that into family medicine? And one of the concepts there is that of a work system. So it is the people, the skills they bring, the technology and tools they need to use, the physical environment in which they work, the organizational environment in which they work, so if they’re employed or if they’re independent, and the external environment in which that organization sits. You have to look at all of those things if you really want to optimize the system. If you only work on one or two of those things, it’s like a balloon – you push on it one way and it’s going to expand the other way. So you have to think about it as that entire work system. So that’s one of the things that we’re working on. And I think as you read that vision document, it starts to allude to those types of things, although it’s not as explicit as I just mentioned on that notion of a work system and what that represents.\n\nDr. Young: Any other comments on tactics?\n\nDr. Waldren: Yeah, so we actually have two more tactics, one that we worked on and one that we decided that we couldn’t work on. One that we worked on was this notion of how do you bring innovation into primary care in a more purposeful way. So we had started to work on trying to create a process to bringing innovation into family medicine better and actually partnered with the Society of Teachers of Family Medicine to do a couple of workshops at their Conference on Improving Practice to try to talk about how do you take family docs and let them understand about the innovation process, understand about what an entrepreneur is thinking about so they can do a better job of talking about that. And we’ve tried to work with the entrepreneur community to bring them in and say here’s the value family medicine can bring, not only just being able to use product once you develop product and test it, but rather how do we get into that process, into the office digs (?) to talk about design and those types of things. So that work has actually been passed off to the AAFP to try to continue to do that work. So this notion of how do you make innovation work better for family docs or make the primary care focus understood in the early process of that entrepreneurial work. \n\nThe last tactic that we weren’t able to work on was really about the operability. And as a group of five volunteers, we felt like if the federal government spent $36 billion on it and had trouble getting that to be done, there would be little that we would be able to do in a couple of years time. And that our time was probably better served focusing on creating that vision, focusing on getting a community of innovation to happen into family medicine and to get a process together that all of family medicine was working together in growing in the same direction of health IT. \n\nDr. Young: Can you talk a little bit about your Core Team members and where they came from, the skill sets that were brought to the work? \n\nDr. Waldren: Yeah, that was a really great team. I’ll mention one of our members that was participating was Dr. Andrew Carroll, a practicing doc in Arizona. Actually, during the process he was there early with us and had some changes in his practice and needed to spend more time in his practice, so he discontinued participation in the group. We added then to that group a physician by the name of Jewel Carr, who is in North Carolina and is part of the residency program there, so was able to bring us that residency kind of perspective and training perspective into the process. And actually she was our representative also on the cross-divisional team before it became an actual tactic team of the Diversity and Equity group. So that was good for her to be able to bring that kind of perspective back to the group and provide that as part of our team. Jen Brull, who was our board member of FMA Health and our liaison to the tactic team ended up being an integral part of the team and actually participated just as another tactic team member as well giving her expertise. Jacob , who is a family doc, was an ex-ONC member at the federal government, at the Office of the National Coordinator, and had been a Deputy National Coordinator for a time, was able to give us that experience of the federal government in that piece. Also had been in the senior leadership of a couple of different EHR companies as well, so gave us that. And has been an entrepreneur (?) himself, so gave us that view. iran  and I never say his name correctly even after multiple years – but a great guy. So he’s a guy that was a distinguished engineer at IBM - where if you’re in academics, if you’ve heard of, a tenured professor, that’s the equivalent at IBM. It requires a lot of work to be able to do that. And worked on multiple projects and actually was working with Paul Grundy, who is a big fan of primary care and family medicine and the Patient-Centered Medical Home. And he said, well, , if you really want to do that work here, you’re going to be limited by the fact that you don’t have that clinical understanding. So decided to go back and went to medical school, so he became a family physician. Had just recently graduated when he joined us at the work. So that new physician, that really depth of understanding of the technology piece was critical to us as part of the team. So it was really a great team to bring together to do the work. And the last person that we had a part of the group was Deb Cohen who was at the Oregon Health Sciences University and is a researcher in kind of communications and use of technology. So gave us a nice breadth of understanding of thinking about how do we approach some of these things and think about those. And also was able to say, oh, well, I know that there’s research in this area in this way or if you approach it in a particular way, here’s how we could approach it in a way that we could better understand the issues. And was just fabulous in helping us kind of navigate those types of issues. \n\nDr. Young: Taking again a step back to look at the bigger picture, within family medicine we have Future of Family Medicine which was, what, ten, fifteen years ago. Yeah, 1999 to 2001, I think, if I remember correctly. And at the conclusion of that activity there were at least ten areas identified to move forward on. And you referenced that the Academy really got going in the technology area as sort of a handoff to the Academy. How is it working this time around in terms of carrying forward with what has been recommended after quite an extensive journey in an ever-changing environment for the overall Family Medicine for America’s Health? But focusing on technology, how is that going to work in the future?\n\nDr. Waldren: This time actually the entity that was doing the Future of Family Medicine 2.0, the FMA Health work, actually ended up doing some of the work as opposed to just handing it straight back off to the supporting organizations to do all the work. But we know that we’re not going to be able to get finished. And actually we were able to get finished a little bit sooner than was originally envisioned. But to continue this work, we actually did a process of handing off specific deliverables to the supporting organizations. So AAFP and ABFM ended up taking the vast majority of that work. STFM also participated in that. So we actually have two documents that lay out that type of work and what needs to be done. And there’s plans in place to report back on that work to the FMA Health board as it continues to finish its work. \n\nDr. Young: Do you know what the timeframe is in terms of those report-backs?\n\nDr. Waldren: I know the next one is July of 2018 because we’re starting to kind of work on that. But I think it’s this notion of kind of a yearly official report-back and kind of quarterly catch up.\n\nDr. Young: And will that continue, do you know, beyond the end of Family Medicine for America’s Health structure? Because my impression was that would have a sunset at some point.\n\nDr. Waldren: I would answer that both yes and no. So I would say, yes, it will end because FMA Health, as an entity, will end. But I would say no because I think the work will continue. So I think the work aligns well with the supporting organizations and what they want to get accomplished. So I think the work will continue even when there is not that kind of official responsibility back to the FMA Health.\n\nDr. Young: Can you talk a bit about what the Academy will be doing and what the American Board of Family Medicine will be doing?\n\nDr. Waldren: The board I can talk a little bit about. The has really taken over a lot of activities that related to kind of data with their work in the Prime Registry. So how do we collect data, how do we measure data? What’s the process for defining the data that we need in family medicine? So those types of activities are the ones that the board accepted moving forward. From the AAFP, it was kind of like taking it from my left hand and putting it over to my right hand, as I’m the Director of the Alliance for eHealth Innovation, responsible for our activities around health IT. So that I have been a little bit more intimately involved in and really understand. But it’s really a couple of different things. So the main issues are, one, continue that advisory council as it relates to trying to coordinate the work across the Family of Family Medicine. The next is around innovation. So how do we drive further innovation into family medicine? So how do we create a community of primary care docs and entrepreneurs to cross-pollinate and talk to those issues? So we’re working on that right now and trying to figure out how to do that well. We have an annual exhibit called the Office of the Future that really talks about some of those technology things and is a nice hub for us to start to do that work. And we’ve had some initial conversations with different venture capital firms and health accelerators on how we might be able to do that work. And we’ve started to explore some of the AMA’s work as well, that they’re looking at, trying to create some similar types of communities.\n\nDr. Young: Are you talking with the employers, the systems? And I must admit, I can’t describe the state of America health now, how many places are sort of a Kaiser model versus other models. But it seems, as a layman looking at this from the outside, wow, this is a huge amount of opportunity and challenge.\n\nDr. Waldren: Yeah, and I think the AAFP in general is also looking at innovation beyond just the technology piece of it. So, actually, Shawn Martin, our vice president, and I went out to Silicon Valley to have some conversations with startups. But we also talked with a physician at , Steve , that’s doing some very interesting stuff. We also had a meeting with Kaiser-Permanente and talked about what they’re doing because they employ a large number of family physicians. We also talked with that has a different kind of model on employing physicians and thinking about practice. So I think the Academy is really interested in thinking about all those different types of innovation, how they fit. We also just released a model of a new advanced payment model that got picked up by PTAC and said that we really should do some testing on that in the real world. So the PTAC is the entity that’s looking at a new payment model. So they were established by the federal government so that when a new alternative payment model would come around this group, which is a physician led kind of group, advisory council, would look at these say we think this makes sense, it fits within the vision of what we think needs to happen in heath care. And CMS, we’re recommending that it be tested as part of the CMMI type of Center for Innovation that the CMS has. So we’re hopeful that that will work. So I think innovation in general in the AAFP is well-represented from the technology, from practice models to payment models.\n\nDr. Young: How does the patient fit into the work you all have been doing or anticipate doing? And I say that as a patient impressed with the health care system that I’m getting care from, with how much interchange of information to me and from me to them occurs. And now that I’m seeing more than my primary care, my family doctor, involved with many other facets of the health care system.\n\nDr. Waldren: Yeah, and I think if you look through the Vision Document that the tactic team put together and published in the Annals, it starts to allude to some of those issues. So one, how do you continue to be patient-centered and think about the patient experience, patient satisfaction. We talk about the notion of how do you think about telemedicine, as an example. And I know that’s something the Academy is really interested in promoting and moving forward to make sense. So I think we think about it from that standpoint. From the data standpoint, we also talk about how do we put together data so that the patient has access to their data across multiple places. Right now your record is made up of multiple, different business records that sit in every health care provider you have, either that be a physician’s office or a hospital, as opposed to your banking records which don’t sit in each retail space that you work in, but rather that they’re centralized and under your control. So how do we move to a model that that works so that your primary care family doc has access to all the information they need to help make the right decision. So I think that’s part and parcel of all the stuff that we’re doing at the AAFP that’s seen to being patient-centered.\n\nDr. Young: Where will we be five, ten years from now?\n\nDr. Waldren: That’s hard to say really. There’s something called a Amara’s Law, which is the last name of the individual. And he says that as it relates to technology, and I think for health care really the law holds true, that we overestimate the ability of technology in the short term and we underestimate its ability in the long term. So I think what we think will happen, I think we’ll have fundamental changes in the way that we deliver family medicine and primary care to patients over the next decade plus. But I think as we thought the technology with the EHRs would revolution and make it easy for us to really take care of our diabetics and our people with asthma and be able to track all the things that we needed to track and realized that it just fell really short. But on the horizon we have these things of natural language processing, speech recognition, machine learning and some of the semantic modeling that we’re doing currently and some of the work the Academy is working in has the ability to really do it. So like right now if I opened up my Smartphone and I push the button to ask Google, I could ask the Google assistant is it going to rain in the next three days and it’s not going to pull up a website that shows the forecast, it’s going to say, no, I think there’s a low level chance of rain in the next three days. I think in the next decade we’ll be able to get the technology to work like that for us in saying I have a forty-five year old African-American male here with no co-morbidities with nuance in hypertension, what’s the first line drug? And they would be able to say evidence says that the first line drug is a diuretic. That type of technology I think will happen over the next decade plus. And I put the plus because it’s hard to estimate exactly when that will happen.\n\nDr. Young: So it’s not just moving patient information around from one place to another, it’s also integrating evidence-based clinical practice guidelines and other medical knowledge into the system. Is that correct?\n\nDr. Waldren: Yeah. We’ve focused on over the last decade as moving clinical data, sharing clinical data. What we’ll be working on over the next decade is sharing clinical knowledge. So how do we make it such that if there’s a guideline, instead of putting it a PDF and making it available on the website, they actually make it so that it can be integrated into the EHR. And when a patient is underneath that population and says, oh, they should be doing this, but the system say I know that this patient should be doing this – and how do we do it in a way that we make sure that we understand the comorbidities as well. So it’s like, well, here’s what you should do because they’re hypertensive, here’s what you should do because they have coronary artery disease, here’s what you should do because they’re a diabetic. But start to pull that together and say because they are a diabetic with hypertension and coronary artery disease and they have low back pain, this is how you should think about treating them based on the evidence. And then you can interpret that and customize it for that individual patient. \n\nDr. Young: And will the system be a partner to the patient for compliance, for knowledge when the patient has a question at 3:00 in the morning?\n\nDr. Waldren: Yeah, we’re seeing that today with hatbo and Virtual Assistants, that they can start to ask some of those questions. And we understand enough about that that we can encode our guidance and assistance and the systems can be able to do that work for us.\n\nDr. Young: Including Fitbits?\n\nDr. Waldren: Well, again, I think the question becomes how do you think about really incorporating that technology into the care and health of people as opposed to just making sure that data is available. So there’s been some evidence that shows that having Fitbit data really doesn’t improve patients health in general. But one question I have as we talk about our vision doctrine, as we discussed, the tactic team, what we don’t want as family docs is to be able to say here’s the equivalent of a spreadsheet with everyday the number of steps that you had. That’s not helpful. But if you can take that stream of data, bring that together with a steam of, let’s say the patient has diabetes, with a stream of their blood sugars, you bring in their medication list so you know what it is, and then you ask them to just take pictures of the meals that they have that are correlated in time. Now you can see you would have a machine learning piece. It doesn’t have to be all that sophisticated. You could find those outliers and you look at that and say, hey, look, their diabetes management has changed, their blood sugar management has changed, here’s what happened. And I’m going to show you, doc, this graph that shows this spike in blood sugars. And I could say like, okay, well, let me look and say, oh, did they change their level of activity? Did they go on vacation from work where at work they usually do physical labor, so that’s the issue? Or can I take a look at the picture of their meals and say, oh, it’s a volume problem or it’s a quality problem in what they’re eating. How do you bring all that together? Don’t just give us another big, long list of data. But understand it, pull it together and provide us with the knowledge of what’s going on so that we can interpret that and make an appropriate decision with a patient on what we need to do.\n\nDr. Young: Did your core team talks with the other core teams about any particular issues?\n\nDr. Waldren: Yeah, we did. We talked a fair amount with the practice team and the payment team because it’s kind of the, although I hate this phrase “chicken and egg” because the egg always came first because reptiles laid eggs before chickens were around. But the chicken and the egg issue is do you make the technology work and then enable practice change and payment change or do you make payment change and practice change and therefore create the demand to change the technology? So it’s really that interplay that we have this kind of conversation about saying where do we push on the balloon first and second.\n\nDr. Young: And what was the nature of those interchanges? Meetings, --?\n\nDr. Waldren: We had all-hands meetings. So all tactic teams kind of came together a couple of times throughout the year. And in those we had dedicated time to talk with And in the beginning, in the early part of the process it was really about the practice team or the payment team and we’d have those conversations. And then it became later, as understanding it’s really that triangle. So we ended up having joint meetings of individuals of all three tactic teams come together and talk about specific issues and say, alright, how do we do this on the payment? What are you trying to do on payment? What the technology needs to be able to drive that. Then what does that mean in practice. So we had those kinds of conversations, all three of us together.\n\nDr. Young: Did those conversations change any of the directions that you were headed?\n\nDr. Waldren: I think it helped us in regards to kind of priority. It helped us with the vision document and figuring out of all the things that we could put in the vision, what are the things that we should put into the vision to try to drive things of where the conversation is at today. And I think there are some things that we’ve talked about in the technology that as they thought about the vision work they were doing, the work they were doing, understand, oh, what is the art of possible given the current technology.\n\nDr. Young: Did you have interchange with the research core group?\n\nDr. Waldren: We did talk a little bit with the research team. Not as much as with practice and payment. For me, the challenge was the EHR as a … Something that you would test and say does the EHR really approve care or does it help us with the quadruple aim. The problem is that EHRs don’t have a high fidelity, so there’s a lot of differences between those. So it’s like saying is transportation fast. Well, if you did a study of planes, you would say yes. If you did a study of razor scooters, you would say no. And what we have in the EHR space is that. So I think that was one of the challenges of working with research from the standpoint of what we have today. And we really are at the point where we need to have that vision before we think about how do we put together a research agenda moving forward.\n\nDr. Young: So again, looking at the transition as your core team has official sunset but obviously you’re continuing to do some reporting back to Family Medicine for America’s Health, how does that look like it will work? And perhaps compared to the previous Future of Family Medicine project?\n\nDr. Waldren: I think it’s interesting, I wasn’t here when FMA Health 1.0 was in but I was here kind of as the work started to be pushed back to the supporting organizations. So I feel like I have some experience with both efforts. And it’s interesting to see the evolution between the two efforts. So the first effort really was about bringing people together and creating a strategic plan and going back to the supporting organizations and do the work. And hindsight is always better than foresight. So after that I think there was some conversation about saying maybe if we pooled resources together and create an entity to do the work, that we’d be able to do some things that we weren’t able to do, like pushing it back, because there is competing priorities inside the organizations. They’re already established to do a certain set of work, so maybe creating this new entity would work. So it’s been interesting to see, as an experiment that we created, this new entity. And I think that the supporting organizations and the leadership was very forward thinking to say, okay, if you look at the literature on disruptive innovation and really making some change, those incumbent entities are very difficult to be able to drive a leap forward, a really big change. So I think for them to understand that and say, okay, we’re going to give a substantial amount of money to this new entity and we’re going to let them go forth and do what they think needs to be done I think was really visionary on the supporting organizations. I think what we’ve now seen is that now that work has to come back to the supporting organizations and there’s a little bit of a challenge there, kind of where does it fit and why were you doing this. The supporting organizations saying, well, we were doing something similar in this way. Now how do we stitch these together?    So, again, now, as we’re starting to get to the point that we can have some hindsight of the 2.0 process, I do wonder about if we think about this as a potential 3.0 process in the future, how do we get some middle ground in between those. So it was nice, from the technology team, as an employee of the AAFP I was involved in the process from the get-go, so I knew exactly what the conversations were, why we made the decisions that we made. So now as I pick up that work as an AAFP employee, it’s easy for me to do that. So I wonder about making sure that there is some involvement of the staff in the supporting organizations as we think about that. \n\nThe other thing that was interesting at the last kind of meeting of those tactic teams that discontinued in the summer of 2017, there was a lot of discussion of thinking about looking at what we did and trying to get some guidance from that. And there was really this discussion about should there be an entity, and it doesn’t have to be a free-standing entity, but there’s some organizational structure in the specialty of family medicine that was really looking at the future of family medicine. So we have a history of the family  medicine history but do we have a center for the future of family medicine. And the question is should we have that or should we continue what we’re doing and every ten years say, hey, maybe we should start thinking about are we on the right future moving forward. \n\nDr. Young: Certainly the future comes quickly. \n\nDr. Waldren: Yes, I find that. There was a saying that I heard and I’m starting to make sure that I understand it fully now, that as you get older the days get shorter and the years get longer. And it seems like that’s what’s happening now. We just don’t have time to get things done and all of a sudden you’re farther along than you thought you would be. \n\nDr. Young: Dr. Waldren, I really appreciate that you have participated in this Oral History. Any parting comments as we complete this tape?\n\nDr. Waldren: I appreciate the ability to provide such an interview. It was fun. I enjoyed talking about these things. And I think the future for family medicine is bright. \n\nDr. Young: Indeed, indeed. Thank you so much.","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162274/file/295061#t=0.0,2669.3514"}]}]}]}