Member Reflections from APHA 2016

By Abbas Alawieh, Ali Abazeed

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Ali Abazeed (MPH/MPP ‘17) and Abbas Alawieh (MPH ‘17)

Each year, the APHA Annual Meeting and Expo brings together more than 12,000 public health experts, educators, and practitioners from across the U.S. and around the world to network, educate, and share their experiences. Following a year in which the Flint Water Crisis and the opioid epidemic dominated the news, this year’s meeting theme was aptly chosen: "Creating the Healthiest Nation: Ensuring the Right to Health.” For a public health student, the APHA Annual Meeting is the premier event to network with peers, colleagues, and experts that you only read about in classroom contexts. This year’s meeting was in Denver, Colorado, and it was an especially unique opportunity for the both of us as we presented the findings of a paper we are working to co-author entitled “Arab-American Health Disparities: A Review of the Literature.”

Since beginning our public health careers, we have partnered to bring Middle East and North African Public Health to the fore of our University’s public health paradigm. Against the backdrop of the largest refugee crisis since WWII and considering our presence in southeastern Michigan, home to the highest concentration of Arab-Americans in the country, we felt there needed to be a larger focus on relevant topics. Working with Dean Philbert and other mentors throughout University leadership, we have advocated for the hiring of faculty experts in MENA health, curriculum choices in related topics, and support of student scholarship in this realm of research. Through this work, we have increased access to research opportunities and are proud that our work was selected for oral presentation at APHA.

We both found the annual meeting to be an incredibly enriching opportunity. We were able to network with leaders we have only known as giants in the field, including a public health hero of ours in Dr. Ayman El-Mohandes, Dean of the City University in New York School of Public Health. We both attended the opening session, which was headlined by Presidents of APHA, Planned Parenthood, and Kaiser-Permanente, as well as the Governor of Colorado.

Our trip culminated in presenting our work at the Displaced Populations & Refugee Health session. The session was very well-attended, and among the audience members were our good friends from the ACCESS Community Health and Research Center in Dearborn, whom we have had the pleasure of working closely with on various projects. Presenting alongside prolific researchers doing critical global health work was both a privilege and a unique learning experience. It served as an important reminder that our work is but a very tiny part of a large, colorful global health mosaic of efforts aimed at improving the health of vulnerable populations worldwide.

One highlight of the trip for Ali was meeting Assistant Secretary of Health, Karen DeSalvo, whose innovation has led to the critical Public Health 3.0 initiative, which emphasizes cross-sectoral policy and systems-level actions that directly impact the social determinants of health. Abbas enjoyed reconnecting with his friend and deskmate Lisa Streinz from his summer internship in Copenhagen at WHO’s Regional Office for Europe. She was representing West Virginia University’s School of Public Health at the Meeting, and we visited her WVU booth at the Expo and invited her to visit our special UM SPH corner.

Indeed, the UM SPH booth was where we were able to connect with UM alums, staff, and faculty, including Associate Dean Jane Banaszak-Holl, who has been a strong ally for our work on MENA health, and Megan Edmonds, our good friend and a recent UM SPH alum who is now a doctoral student at VCU Department of Family Medicine and Population Health. In a conference that felt overwhelming at times with so many overlapping panels, presentations, and events, we made sure to end our trip with a visit back to the UM SPH booth, which felt like a small piece of home away from hoMe.

 Our trip would not have been possible without the support of our research mentor, Professor Carlos Mendes de Leon, and our collaborators Farah Erzouki, Phoebe Harpainter, and Ella August. Additionally, we owe a great deal of gratitude to HPSA and to the HBHE and HMP departments for making our APHA experience possible.

 Go Blue!

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Abbas Alawieh (MPH ‘17), Megan Edmonds (MPH ‘16), and Ali Abazeed (MPH/MPP ‘17)

HPSA Conference Funding in Action: Washington D.C.

Each year the Ford School’s Graduate Career Services and Alumni Relation offices organize a professional development trip to assist current graduate students in exploring policy careers and networking with alumni in the field of public policy. The trip is organized similarly to a conference, where panels are held all day in various locations across D.C. to introduce students to a variety of public policy sectors and career paths. The different conferences and events included a panel session on analytics and evaluation, international development, urban policy, social policy, a tour of the State Department building and time with Foreign Service Officers, and more. Katy and myself both have a strong interest in international health policy issues. Therefore, Washington D.C. serves an important source of knowledge and career opportunities in the field.

We both found the trip to be educational. With Katy’s background in the non-profit sector, she was able to explore careers in the federal government, consulting, international development, and social policy arenas. Through the trip, she was able to discuss career opportunities and learn about specific sectors in context. The Ford School and other schools at the University of Michigan bring in alumni and speakers, but traveling to D.C. allowed us to meet alumni in their places of work, in order to really understand different work cultures and practices on-site. The trip allowed Katy to create a strong connection with alumni working with USAID and at the US Department of State. Personally, I was also able to cultivate relationships with alumni that will prove important, such as discussing potential internships with USAID, Department of Health and Human Services, and some smaller NGOs.

The trip highlighted the importance of that oft-dreaded graduate school theme: networking. That many of those in attendance were alumni was an immediate icebreaker, which was important to somewhat like myself who is relatively new and inexperienced with cultivating these types of professional relationships. When I discuss the University of Michigan with prospective students, I tend to finish my emails or discussions about its pros and cons with a serious note about its alumni base. Michigan not only has the largest alumni network in the world, but the alumni culture is also very active and supportive. The trip brought this concept to life for both Katy and myself in a new way. We greatly appreciate support from HPSA to attend the trip and encourage all dual or MPP students to seek out HPSA support in the future.

--Michael Budros, MPH, MPP 2017

Meaningful Differences in Meaningful Use

After Adoption, Organizational Differences Still Predict Electronic Health Record Utilization

The Institute of Medicine’s report To err is human (Kohn & Corrigan 1999) estimated that  98,000 patients die each year from preventable medical errors. More recently, at a congressional hearing on the subject, Ashish Jha, MD, professor at Harvard School of Public Health suggested that this number is “clearly” a large underestimate of the toll brought by preventable medical errors (McCann, 2014; James, 2013).

“98,000 patients die each year from preventable medical errors… a large underestimate.”

A growing body of research suggests that well designed IT systems and electronic health records (EHR) have the potential to reduce medical errors and streamline delivery. Using data of IT-enabled productivity gains in other industries, some estimate that HIT could reduce annual health care spending by $346-$813 billion. A particular EHR function, computerized physician order entry, allows physicians to make prescriptions through the hospital’s EHR system and has the potential to eliminate as many as 200,000 adverse drug events each year by reducing human errors and harmful drug interactions (Hillestad et al, 2005).

“HIT could reduce annual healthcare spending by $346-$813 billion... [And] eliminate as many as 200,000 adverse drug events.”

Given these projections and others, the Center for Medicare and Medicaid (CMS) has developed the EHR Incentive Program, which reimburses eligible professionals and hospitals for adopting and utilizing authorized EHR systems. More than 545,000 professionals and hospitals are actively registered in the program as of August 2015, which has given out more than $30 billion in payments (CMS, 2016). This significant public investment has clearly motivated providers to implement EHR within their organizations.

“CMS has given out more than $30 billion in payments. This significant public investment has certainly motivated providers to implement EHR.”

In 2014, 3 out of 4 (76%) of hospitals had adopted at least a Basic EHR system. This represents an increase of 27% from 2013 and an eight-fold increase since 2008 (Charles et al 2015). Research on HIT adoption up to and following the incentive program has focused almost entirely on whether or not an EHR system exists in a hospital. This may have been proper in a time period where many hospitals did not adopt EHR but in our present state (largely thanks to the incentive program) most hospitals have EHR systems.

In 2014, 3 out of 4 (76%) hospitals had adopted at least a Basic EHR system. This represents an increase of 27% from 2013 and an eight-fold increase since 2008.

My research used the EHR incentive program’s performance metrics to study utilization levels instead of adoption. Whereas adoption is measured as a yes or no response, utilization level through these performance metrics is measured as the percent of cases in which an EHR function could be used for which the EHR function was actually used. For example; if a hospital makes 100,000 prescriptions a year and only used the EHR’s computerized provider order entry function to make 25,000 orders, the utilization level for that function would be 25%.

Factors supporting the utilization of EHR as described above are less understood. It should not be taken for granted that the predictors of adoption are the same predictors of utilization. My research describes variations in the utilization of EHR functions among acute-care hospitals enrolled in the EHR Incentive program and explores correlations between their organizational characteristics and performance on utilization metrics. It is important to understand EHR utilization because its benefits can only be realized by utilization and not simply by adoption.

From my analyses it turns out that simply adopting EHR doesn’t guarantee utilization, and not all predictors of adoption are predictors of utilization.

  • Teaching status and system membership are correlated with greater utilization. 
  • Larger size and for-profit status are correlated with less utilization. 
  • Clinician workload is not correlated with utilization but the presence of contractual relationships is correlated with utilization. 
  • Furthermore, tighter physician contractual relationships are correlated with greater utilization of most EHR functions.
It turns out that simply adopting doesn’t guarantee utilization and not all predictors of EHR adoption are predictors of EHR utilization.

We infer from the results and existing theory that although larger hospitals have the resources to adopt EHR they are slower to change clinical processes for its utilization. For-profit hospitals may respond to incentive payments but may like-wise have difficulty prioritizing process change. Supporting the process-change concept is evidence that hospitals with contractual relationships with physicians, i.e. greater clinical alignment perform better for those functions requiring process change. Methodologically, this research supports the use of utilization level as a more useful measure of EHR adoption.

Overall, these results suggest that it is important to consider factors impacting process change in general and in the delivery of healthcare in particular. 

I will be presenting my findings in more detail at the 2016 AcademyHealth Annual Research Meeting. You can find me speaking at the Healthcare Organization and Delivery session of the Health IT interest group and at the poster-session for Healthcare Organizational Behavior and Management.

By: Rekar K. Taymour, MS Candidate, Health Services Research, University of Michigan School of Public Health, Department of Health Management and Policy

References

Kohn, L. T., Corrigan, J. M., & Molla, S. (1999). To Err Is Human. Medicine, 126(November), 312. http://doi.org/10.1017/S095026880100509X

McCann, E. (2014). Death by medical mistake at record high. Healthcare IT News. Retrieved from http://www.healthcareitnews.com/news/death-medical-mistake-record-high

James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122–8. http://doi.org/10.1097/PTS.0b013e3182948a69

Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., et al. (2005). Can electronic medical record systems transform healthcare? Potential health benefits, savings, and costs. Health Affairs, 24(5), 1103—1117.

CMS 2016, Centers for Medicare & Medicaid Services, EHR Incentive Programs, Data and Program Reports, https://www.cms.gov/Regulations-and-guidance/legislation/EHRIncentivePrograms/DataAndReports.html

Charles, D., Gabriel, M., Searcy, T., Carolina, N., & Carolina, S. (2015). Adoption of Electronic Health Record Systems among U . S . Non - Federal Acute Care Hospitals : 2008 -2014 

The Health Information Technology for Economic and Clinical Health ( HITECH ) Act of 2009 directed the Office of the National Coordinator for Health, 4(23), 2008–2014.

HPSA Executive Board Elections 2016-2017

Another year is wrapping up, and we're looking for a new set of students to lead the organization into the 2016-2017. Joining the Executive Board gives students the opportunity to lead an organization, as well as the ability to influence how the University of Michigan School of Public Health participates in health policy. If you are interested in running for a position, please reach out to any current Executive Board to learn more about what each position entails. We are happy to set up a short meeting! To learn more about each position or apply for a position, please go to this application page.

Health Policy Day

HPSA finished off 2015 with Health Policy Day, promoting our #WhyHealthPolicyMatters campaign. The campaign is our attempt to create a dialogue throughout the SPH community, highlighting why health policy is relevant to students interested in public health and the healthcare industry. For a little stress-busting before finals, we passed out hot chocolate and cookies, and asked folks to let us know #WhyHealthPolicyMatters to them. As a tribute to the great David Letterman, here are the Top 10 responses:

  1. Because policy can be an effective long term, positive, healthy equitable intervention.
  2. Because it can change the structures that determine population health.
  3. Because it helps fight for environmental justice.
  4. Because everyone deserves access to preventable care.
  5. Health policy provides sustainable changes in healthcare.
  6. Because it applies research towards improving health in populations.
  7. Because it impacts every part of our lives from womb to tomb.
  8. Because treating a problem (medicine) is less effective than solving it (policy).
  9. Because it is the responsibility of a state or any organized institution to ensure the wellbeing of its citizens. Healthy citizens = a healthy and more productive society.
  10. Because we won’t achieve health for all without it!

Below are student photos from Health Policy Day, but the #WhyHealthPolicyMatters campaign is an ongoing effort. Stop by our display near JavaBlu in SPH to see #WhyHealthPolicyMatters to several SPH faculty members. Thank you to all who participated!

APHA 2015: “Health in All Policies”

Editors note: We are delighted to host a guest contributor blog from Abby Schachter, who was a recipient of a HPSA scholarship to attend the APHA meeting this month. She shares her experiences at the conference below. Thanks, Abby!

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Last week, I attended the American Public Health Association (APHA) Annual Meeting in Chicago. It was a whirlwind event with 13,000 attendees and hundreds of panels, poster sessions, and film screenings. It was difficult to choose which of the dozens of interesting presentations to attend during any given session! The sessions I did attend exemplified the theme of this year’s meeting, Health in All Policies.

Health in All Policies is “an approach to public policies that systematically takes into account health and health systems implications of decisions, seeks synergies and avoids harmful health, in order to improve population health and health equity” (WHO). The opening general session began with a keynote address by U.S. Surgeon General Vivek Murthy, who coupled humorous remarks (e.g., “Keep an eye out for my upcoming report, ‘Why physical activity is overrated’”) with an earnest plea for each of us to begin valuing each other as much as we value ourselves when it comes to protecting and promoting health.

The author (back row, far right, in teal) with other students from the University of Michigan School of Public Health at the conference.

The author (back row, far right, in teal) with other students from the University of Michigan School of Public Health at the conference.

In a clear manifestation of the conference theme, two of the other keynote speakers were not public health professionals at all: Actor and environmentalist Ed Begley Jr. spoke about how he has long advocated for environmental protection due to the inextricable relationships among the natural and built and environments and human health, and renowned educator Dr. Freeman Hrabowski, president of the University of Maryland, Baltimore County, gave a rousing address that exemplified the importance of higher education to foster curious minds, a healthy population, and an equitable society. 

I attended many panel sessions focused on food access and food security, which together highlighted the flip side of the conference theme: not only should all public policies consider health impact, but many different policies also affect any given health issue. A few examples…

  • One speaker presented an impact analysis of the “Healthy Happy Meals” bill proposed in New York City on the nutritional content of children’s fast food meals.
  • Several presenters focused on how food marketing and labeling can inform or deceive customers when it comes to nutritional quality, and how regulations can guide these practices toward improving consumers’ food choices.
  • A talk on food industry donations to academic and health institutions emphasized how requiring disclosures of conflicts of interest can enhance public accountability and trust.
  • Multiple speakers spoke of recent efforts to improve food access through urban agriculture and farmers markets, and the challenges they have faced with land use policies and zoning restrictions.
  • One panelist talked about how lax antitrust laws have resulted in only a handful of big food companies acquiring many brands, creating an “illusion of choice” when it comes to the grocery store.
  • A researcher demonstrated how monthly SNAP (i.e. food stamps) payments lead to cyclical patterns of food insecurity and called for alternate disbursement schedules to eliminate this “SNAP cycle.”

These presentations demonstrate how policies across a wide range of domains can have tremendous impact on food systems, food security, industry, and nutritional quality of the American diet.

The view from the conference's main hall with busy exhibits at APHA 2015.

The view from the conference's main hall with busy exhibits at APHA 2015.

One of the last panels I attended addressed how the policymaking process relates to another timely topic: vaccinations. Dr. Ross Silverman from Indiana University spoke about the state policy creation process for determining allowable exemptions to required vaccinations. He noted that these decisions are purely political; that is, while medical exemptions are standard, states are not required to allow for religious or “personal belief” exemptions. As we have seen with the Disneyland measles outbreak, these policies are consequential; states with personal belief exemptions have roughly 2.5 times as many opt-outs than states with only religious exemptions. Given the politically charged debates surrounding vaccinations, some states have gone through regulatory rather than legislative processes to eliminate personal belief exemptions in order to strengthen protections against vaccine-preventable diseases.

The APHA Annual Meeting was overwhelming, enlightening, and inspiring. It was reaffirming to be in a place with so many professionals from varied disciplines who are working together toward the same goal, echoing APHA’s mission to make America “the healthiest nation in one generation.” Thank you to the Health Policy Student Association for their support of my attendance to the conference.

By: Abby Schachter, MPH Candidate, University of Michigan School of Public Health, Department of Health Behavior and Health Education

Beyond Obamacare: Life, Death, and Social Policy

A Summary of October’s Book Talk @ The Ford School

“All social policies are health policies.” – James S. House, Professor Emeritus of Survey Research, Public Policy, and Sociology and author of Beyond Obamacare: Life, Death, and Social Policy

This statement was one of the last remarks made by James House to an audience of both seasoned policy professionals and curious Michigan students in the Annenberg Auditorium at the Gerald R. Ford School of Public Policy two weeks ago. Discussion of House’s book “Beyond Obamacare: Life, Death and Social Policy,” included the shift to a demand-side approach to health care (catering to what populations actually need as opposed to what providers want to or can offer) in order to reign in national health care spending and address major social determinants of health that influence population health.

The tone of the event was set by a projection of the book’s cover: an IV bag containing a pile of $100 bills within its therapeutic fluid, as a metaphor that would soon become apparent over the course of the talk.

After a brief introduction, House stepped up to the podium, got right down to business, and began with, “Effective health policy requires effective social policy.” He then outlined problems plaguing the United States health services system dating back to the year 1900, starting with the birth of exclusively supply-side health policy that seemed to work up until 1970 when spending exploded. He referenced how poorly the U.S. performs both relatively and absolutely in life expectancy compared to other developed countries.

His call to action married key ideas when it comes to improving the equity and efficiency of health and health care: a demand-side approach to health care and the social determinants of population health. Some major determinants he cited include environmental exposures, health behaviors, psychosocial stress, psychological disposition, and social roles and productive activities.

House pointed out that the Patient Protection and Affordable Care Act of 2010 is still very much a supply-side policy. Helen Levy, a Professor of Public Policy at Ford, commented that the ACA had two main goals at its inception: to reduce the number of uninsured and to bend the cost curve of burgeoning health care spending. Evidence of accomplishing the former has been clear; the latter presents a greater problem. Professor of Health Management and Policy Richard Lichtenstein added that addressing issues of medical care and insurance, including implementation of pay-for-performance, penalties for hospital-acquired infections and readmissions, and applying the Cadillac tax on lavish plans is not a be-all, end-all solution to the deteriorating health of populations.

Prior to the Q&A, the panel discussion wound down with a “(re)discovery” of social disparities in health such as education, income, occupation, assets, race, and gender. All four panel members – Paula Lantz, Associate Dean for Research and Policy Engagement at the Ford School, in addition to the three aforementioned – emphasized the need for social policies in education at all levels, incomes over people’s lifetimes, employment, civil rights, and housing and neighborhoods in order to redefine and rebuild the health status of populations.

The panel acknowledged the forthcoming challenges in improving population health on a large-scale at the national level. House called for top-down national policy, preferable to policies that struggle to make it from communities upward. Upon the conclusion of the talk, we were left with the realization of the need to move beyond Obamacare and the reformation of health care into the equally, if not more, crucial reformation of the social determinants of health.

By: Peter Chu, MHSA Candidate, University of Michigan School of Public Health, Department of Health Management and Policy