Experienced physician with a focus on healthcare delivery innovation. Strong clinical experience in internal medicine, pediatrics, obstetrics, geriatrics, and focused training in integrative/functional medicine & global health. Broad business experience in health technology, medical devices & entrepreneurship. MD from Stanford School of Medicine with concentration in Health Policy and Bioinformatics. MBA from Stanford Graduate School of Business with Certificate in Public Management & Social Innovation.
- Family Medicine
Instructor, Medicine - Primary Care and Population Health
Medical Education: Stanford University School of Medicine (2015) CA
Board Certification: American Board of Family Medicine, Family Medicine (2018)
Residency: Sutter Santa Rosa Medical Center (2018) CA
Inpatient telemedicine implementation as an infection control response to COVID-19: A qualitative process evaluation.
JMIR formative research
BACKGROUND: The COVID-19 pandemic created new challenges to delivering safe and effective healthcare while minimizing staff and non-COVID-19 patient exposure to the virus. Health systems worldwide have moved quickly to implement telemedicine in diverse settings to reduce infection, but little is understood about how best to connect acutely ill patients with nearby clinical team members, even in the next room.OBJECTIVE: To inform these efforts, this paper provides an early example of inpatient telemedicine implementation and its perceived acceptability and effectiveness.METHODS: Using purposive sampling, this study conducted 15 semi-structured interviews with nurses (n=5) and attending (n=5) and resident (n=15) physicians on a single COVID-19 unit within Stanford Health Care to evaluate implementation outcomes and perceived effectiveness of inpatient telemedicine. Semi-structured interview protocols and qualitative analysis were framed around the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework and identified key themes using a rapid analytic process and consensus approach.RESULTS: All clinical team members reported wide reach of inpatient telemedicine, with some use for almost all COVID-19 patients. Inpatient telemedicine was perceived to be effective in reducing COVID-19 exposure and personal protective equipment (PPE) use without significantly compromising quality of care. Physician workflows remained relatively stable as most standard clinical activities were conducted via telemedicine following the initial intake examination, though resident physicians reported reduced educational opportunities given limited opportunities to conduct physical exams. Nurse workflows required significant adaptations to cover non-nursing duties such as food delivery and facilitating technology connections for patients and physicians alike. Perceived patient impact included consistent care quality, with some considerations around privacy. Reported challenges included: patient-clinical team communication and personal connection with the patient, perceptions of patient isolation, ongoing technical challenges, and certain aspects of the physical exam.CONCLUSIONS: Clinical team members reported inpatient telemedicine encounters as acceptable and effective in reducing COVID-19 exposure and PPE use. Nurses adapted their workflows more than physicians to implement the new technology and bore a higher burden of in-person care and technical support. Recommendations for improved inpatient telemedicine use include information technology (IT) support and training, increased technical functionality, and remote access for the clinical team.CLINICALTRIAL:
View details for DOI 10.2196/26452
View details for PubMedID 34033576
Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool.
BACKGROUND: Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility.METHODS: This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n= 20) and surgeons (n= 10) to explore stakeholder perspectives on video visits.RESULTS: During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics.CONCLUSION: Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.
View details for DOI 10.1016/j.surg.2021.03.029
View details for PubMedID 33941389
- How Can Health Systems Develop Physician Leaders to Implement Better? Lessons From the Stanford-Intermountain Fellowship in Population Health, Delivery Science, and Primary Care. Quality management in health care ; 30 (2): 140–43
Supporting First Responders and Essential Workers During a Pandemic: Needs Assessment and Mixed-Methods Implementation Evaluation of a COVID-19 App-Based Intervention.
Journal of medical Internet research
The COVID-19 pandemic has created unprecedented challenges for first responders (e.g., police, fire, and emergency medical services) and non-medical essential workers (e.g., food, transportation and other industries). Health systems may be uniquely suited to support these workers given their medical expertise, and mobile applications ("apps") can reach local communities despite social distancing requirements. Formal evaluation of real-world mobile app-based interventions are lacking.We aimed to evaluate the adoption, acceptability and appropriateness of an academic medical center's app-based intervention (COVID-19 Guide App) designed to support first responders and essential workers' access to COVID-19 information and testing services. We also sought to better understand the COVID-19 related needs of these workers early in the pandemic.To understand overall community adoption, COVID-19 Guide App views and download data were described. To understand adoption, appropriateness and acceptability of the app and workers' unmet needs, semi-structured qualitative interviews were conducted by phone, video and in-person with first responder and essential workers in the San Francisco Bay Area, recruited through purposive, convenience, and snowball sampling. Interview transcripts and field notes were qualitatively analyzed and presented using an implementation outcomes framework.From April 2020 launch to September 2020, the app received 8,262 views from unique devices and 6,640 downloads (80.4% conversion rate, 0.61% adoption rate across the Bay Area). App acceptability was mixed amongst 17 first responders interviewed and high amongst 10 essential workers interviewed. Select themes included the need for personalized and accurate information, access to testing, and securing personal safety. First responders faced additional challenges related to inter-professional coordination and a culture of heroism that could both protect against and exacerbate health vulnerability.First responders and essential workers both report challenges related to obtaining accurate information, testing services, and other resources. A mobile app intervention has the potential to combat these challenges through the provision of disease-specific information and access to testing services but may be most effective if delivered as part of a larger ecosystem of support. Differentiated interventions that acknowledge and address the divergent needs between first responders and non-first responder essential workers may optimize acceptance and adoption.
View details for DOI 10.2196/26573
View details for PubMedID 33878023
Employers' Role in Employee Health: Why They Do What They Do.
Journal of occupational and environmental medicine
OBJECTIVE: Employers affect the health of employees and their families through work environments and employee benefits. We sought to understand employer decisions around those topics.METHODS: Interviews with 21 executives from diverse, purposely-sampled, progressive companies with transcripts analyzed using inductive and deductive methods.RESULTS: Companies often viewed keeping employees healthy primarily as a means to profitability rather than an end in itself and rationalized stressful workplaces as necessary and non-changeable. Many possible actions including job redesign and changing benefits administrators were seen as infeasible. Even large, resource-rich organizations were strikingly nonagentic.CONCLUSIONS: Companies seem less committed to the goal of increasing employee health than they claim or than they should be, given the significant relationship between employee health and economic performance, and see external and internal barriers to improving health that are often self-created.
View details for DOI 10.1097/JOM.0000000000001967
View details for PubMedID 32769791
An Incentive to Innovate: Improving Health Care Value and Restoring Physician Autonomy Through Physician-Directed Reinvestment.
Academic medicine : journal of the Association of American Medical Colleges
PROBLEM: Many health care systems in the United States are shifting from a fee-for-service reimbursement model to a value-based payment model. To remain competitive, health care administrators must engage frontline clinicians in their efforts to reduce costs and improve patient outcomes. Engaging physicians and other clinicians is challenging, however, as many feel overwhelmed with clinical responsibilities and do not view cost reduction as in their purview. Even if they are willing, providing a direct financial incentive to clinicians to control costs poses ethical and legal challenges. An effective incentive in the current system must motivate clinicians to engage in creative problem solving and mitigate ethical and legal risk.APPROACH: Evidence suggests the most successful behavior change interventions in physicians are multi-faceted and combine intrinsic motivators, such as increased autonomy, with extrinsic motivators, such as access to funding or social recognition. Two academic health centers-the University of Utah Health and Stanford Health Care-have begun experimenting with an alternative value-sharing arrangement. Physician-directed reinvestment is an explicit agreement in which a health care system reinvests a portion of savings attributed to physician-led cost reduction initiatives back into areas of the physician's choosing, such as capital investment, research, or education.OUTCOMES: Both organizations reported similar positive outcomes, including increased engagement from clinicians and administrators, sustained or improved quality of care, reduced costs of care, and benefits from reinvested funds. Many savings opportunities were previously unknown to administrators.NEXT STEPS: Physician-directed reinvestment appears to effectively engage physicians in ongoing efforts to improve value in health care, although formal evaluation is still needed. This incentive structure may hold promise in other configurations, such as inviting non-physicians to apply as project leaders (clinician-directed reinvestment) and expanding the program to non-academic and ambulatory settings.
View details for DOI 10.1097/ACM.0000000000003650
View details for PubMedID 32739931
PPE Portraits-a Way to Humanize Personal Protective Equipment.
Journal of general internal medicine
The use of personal protective equipment (PPE) has skyrocketed, as providers don masks, glasses, and gowns to protect their eyes, noses, and mouths from COVID-19. Yet these same facial features express human individuality, and are crucial to nonverbal communication. Isolated ICU patients may develop "post intensive-care syndrome," which mimics PTSD with sometimes debilitating consequences. While far from a complete solution, PPE Portraits (disposable portrait picture stickers- 4" * 5") have the potential to humanize care. Preparing for a larger effectiveness evaluation on patient and provider experience, we collected initial qualitative implementation insights during Spring 2020's chaotic surge preparation. Front-line providers reported more comfort with patient interactions while wearing PPE Portraits: "It makes it feel less like a disaster zone [for the patient]." A brief pilot showed signs of significant adoption: a participating physician requested PPE Portraits at their clinic, shift nurses had taken PPE Portraits with them to inpatient services, and masked medical assistant team-members requested PPE Portraits to wear over scrubs. We believe PPE Portraits may support patient care and health, and even potentially healthcare team function and provider wellness. While we await data on these effects, we hope hospitals can use our findings to speed their own implementation testing.
View details for DOI 10.1007/s11606-020-05875-2
View details for PubMedID 32410125
Qualitative Assessment of Rapid System Transformation to Primary Care Video Visits at an Academic Medical Center.
Annals of internal medicine
The coronavirus disease 2019 pandemic spurred health systems across the world to quickly shift from in-person visits to safer video visits.To seek stakeholder perspectives on video visits' acceptability and effect 3 weeks after near-total transition to video visits.Semistructured qualitative interviews.6 Stanford general primary care and express care clinics at 6 northern California sites, with 81 providers, 123 staff, and 97 614 patient visits in 2019.Fifty-three program participants (overlapping roles as medical providers [n = 20], medical assistants [n = 16], nurses [n = 4], technologists [n = 4], and administrators [n = 13]) were interviewed about video visit transition and challenges.In 3 weeks, express care and primary care video visits increased from less than 10% to greater than 80% and from less than 10% to greater than 75%, respectively. New video visit providers received video visit training and care quality feedback. New system workflows were created to accommodate the new visit method.Nine faculty, trained in qualitative research methods, conducted 53 stakeholder interviews in 4 days using purposeful (administrators and technologists) and convenience (medical assistant, nurses, and providers) sampling. A rapid qualitative analytic approach for thematic analysis was used.The analysis revealed 12 themes, including Pandemic as Catalyst; Joy in Medicine; Safety in Medicine; Slipping Through the Cracks; My Role, Redefined; and The New Normal. Themes were analyzed using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to identify critical issues for continued program utilization.Evaluation was done immediately after deployment. Although viewpoints may have evolved later, immediate evaluation allowed for prompt program changes and identified broader issues to address for program sustainability.After pandemic-related systems transformation at Stanford, critical issues to sustain video visit long-term viability were identified. Specifically, technology ease of use must improve and support multiparty videoconferencing. Providers should be able to care for their patients, regardless of geography. Providers need decision-making support with virtual examination training and home-based patient diagnostics. Finally, ongoing video visit reimbursement should be commensurate with value to the patients' health and well-being.Stanford Department of Medicine and Stanford Health Care.
View details for DOI 10.7326/M20-1814
View details for PubMedID 32628536
Rapid Deployment of Inpatient Telemedicine In Response to COVID-19 Across Three Health Systems.
Journal of the American Medical Informatics Association : JAMIA
To reduce pathogen exposure, conserve personal protective equipment, and facilitate health care personnel work participation in the setting of the COVID-19 pandemic, three affiliated institutions rapidly and independently deployed inpatient telemedicine programs during March 2020. We describe key features and early learnings of these programs in the hospital setting.Relevant clinical and operational leadership from an academic medical center, pediatric teaching hospital, and safety net county health system met to share learnings shortly after deploying inpatient telemedicine. A summative analysis of their learnings was re-circulated for approval.All three institutions faced pressure to urgently standup new telemedicine systems while still maintaining secure information exchange. Differences across patient demographics and technological capabilities led to variation in solution design, though key technical considerations were similar. Rapid deployment in each system relied on readily available consumer-grade technology, given the existing familiarity to patients and clinicians and minimal infrastructure investment. Preliminary data from the academic medical center over one month suggested positive adoption with 631 inpatient video calls lasting an average (standard deviation) of 16.5 minutes (19.6) based on inclusion criteria.The threat of an imminent surge of COVID-19 patients drove three institutions to rapidly develop inpatient telemedicine solutions. Concurrently, federal and state regulators temporarily relaxed restrictions that would have previously limited these efforts. Strategic direction from executive leadership, leveraging off-the-shelf hardware, vendor engagement, and clinical workflow integration facilitated rapid deployment.The rapid deployment of inpatient telemedicine is feasible across diverse settings as a response to the COVID-19 pandemic.
View details for DOI 10.1093/jamia/ocaa077
View details for PubMedID 32495830
Two treatments, one disease: childhood malaria management in Tanga, Tanzania
In the Tanga District of coastal Tanzania, malaria is one of the primary causes of mortality for children under the age of five. While some children are treated with malaria medications in biomedical facilities, as the World Health Organization recommends, others receive home-care or treatment from traditional healers. Recognition of malaria is difficult because symptoms can range from fever with uncomplicated malaria to convulsions with severe malaria. This study explores why caregivers in the Tanga District of Tanzania pursue particular courses of action to deal with malaria in their children.Qualitative data were collected through interviews with three samples: female caregivers of children under five (N = 61), medical practitioners (N = 28), and traditional healers (N = 18) in urban, peri-urban, and rural areas. The female caregiver sample is intentionally stratified to reflect the greater population of the Tanga District in level of education, marital status, gender of household head, religion, and tribal group affiliation. Qualitative data were counted, coded and analysed using NVivo7 software.Results indicate that a variety of factors influence treatment choice, including socio-cultural beliefs about malaria symptoms, associations with spiritual affliction requiring traditional healing, knowledge of malaria, and fear of certain anti-malaria treatment procedures. Most notably, some caregivers identified convulsions as a spiritual condition, unrelated to malaria. While nearly all caregivers reported attending biomedical facilities to treat children with fever (N = 60/61), many caregivers stated that convulsions are best treated by traditional healers (N = 26/61). Qualitative interviews with medical practitioners and traditional healers confirmed this belief.Results offer insight into current trends in malaria management and have implications in healthcare policy, educational campaigns, and the importance of integrating traditional and biomedical approaches.
View details for DOI 10.1186/1475-2875-8-240
View details for Web of Science ID 000272254600001
View details for PubMedID 19860900
View details for PubMedCentralID PMC2779815