Dr. Marc Harrison: Hi, I'm Dr. Marc Harrison, CEO of Intermountain Healthcare. Today, I'm with Dr. Eddie Stenehjem, our medical director of Antibiotic Stewardship and Dr. Tony Wallin, medical director of urgent care, as well as Dr. Adam Hersh, pediatric infectious diseases from the University of Utah. Thank you three for coming. Can you please tell us a little bit about yourself and your roles, and then we'll talk a bit about Antibiotic Stewardship and telehealth? So, Eddie, you want to lead off?

Dr. Eddie Stenehjem: Sure, thanks. I’m Eddie Stenehjem, an adult infectious disease physician. I work in the Office of Patient Experience and I'm the medical director of Stewardship, so I oversee antibiotic prescribing across Intermountain Healthcare, inpatient, outpatient, and transitions in care.

Dr. Marc Harrison:Great. Well, thank you. Adam, you want to…?

Dr. Adam Hersh: Yeah, thanks for having me. Adam Hersh, and I work at the University of Utah in pediatric infectious diseases, and I collaborate with Eddie and others around the area of antibiotic stewardship. I have an interest in health services research in clinical epidemiology. And great to be able to bridge the gap between the University of Utah and Intermountain for research collaboration.

Dr. Marc Harrison:Excellent. And I guess clinically as well, right?

Dr. Adam Hersh: That's correct, yeah.

Dr. Marc Harrison:Do you do your practice at Primary-

Dr. Adam Hersh: Primary Children's, that's correct.

Dr. Marc Harrison:Wonderful. And Tony?

Dr. Tony Wallin: Yeah. I'm the medical director for urgent care services for Intermountain. I've been in leadership probably 20 years now at Intermountain, and I've also worked on these kinds of projects, mainly antibiotic stewardship projects all of those 20 years with Intermountain and clinical programs.

Dr. Marc Harrison:And Tony, how many urgent cares do we have in the system?

Dr. Tony Wallin: So, depending on how you define that with ski clinics and whatever, it's around 38.

Dr. Marc Harrison:So, that's a lot of patients who get served and a lot of opportunities to either make good or bad decisions.

Dr. Tony Wallin: Yeah, close to 600,000 encounters in a year.

Dr. Marc Harrison:Wow. When I read the newspaper or when I listen to the radio, I'm hearing a lot about superbugs, and the real evolving risk to humans, both in the acute and chronic sense from antibiotic resistance. Can you talk a little bit about what we're doing here at Intermountain to try and get ahead of this problem or manage it? Because, probably, we can't eliminate it altogether.

Dr. Eddie Stenehjem: Right. No, absolutely, we cannot. It's a nature of antibiotic prescribing. We will see drug resistance as we use antibiotics. And antibiotics are lifesavers. They save people's lives. And so we can't get that to zero. That's not the intent. But what we do know is that what drives resistance is the amount of antibiotics we use. And so if we can really minimize the amount of antibiotics we use in our communities, in our hospitals, we're going to slow the resistance.
And we're in a fortunate position here in Utah where our resistance rates are relatively low compared to our neighbors, but they're increasing. And so we are at a point where we're ahead of the game, where we're really trying to focus on this. And so we can extend that time period where we have good functional antibiotics that can help cure people.

Dr. Marc Harrison: Adam, my kids are pretty much grown up now, but I remember, and I'm a pediatrician myself, pediatric intensivist. I remember having a miserable kid, it's 11:00 at night, and you look in their ear and there's a bulging red eardrum. And you're thinking, "Geez, I got to get to work tomorrow. My wife has to get to work. This kid's miserable. Should we get him on antibiotics right now?" Have things changed in the last 10, 20, 30 years about our approach to simple things like an ear infection with regard to antibiotic stewardship?

Dr. Adam Hersh: Yeah, I think you nailed it. I think 10, 20 years ago, the perspective that both docs and patients and parents alike often took was, well we want to do the safe thing. We want to do the right thing for our patient. And the safe thing to do is to prescribe an antibiotic because it can't hurt and it might help. And I think we've kind of changed our perspective and almost, we're advocating to change the default approach to what we do, which is the safe thing to do for most uncomplicated respiratory tract infections is to not prescribe an antibiotic and to help that child or, whether it's a child or an older patient with symptomatic therapies to relieve the symptoms, but to not prescribe an antibiotic. Because more often than not, an antibiotic would have the tendency to cause a harmful event rather than actually help the patient.

Dr. Marc Harrison:Is that a pretty tough sell with parents and with other folks?

Dr. Adam Hersh: No.

Dr. Marc Harrison: Okay. Talk a little bit more about that because I would've guessed that the answer would've been yes.

Dr. Adam Hersh: Yeah. And I think that's the perspective that a lot of docs have, which is that I'm kind of stuck. My hands are tied, my patients are demanding antibiotics. But in fact, there's a very consistent and growing body of evidence that patients are quite comfortable with the idea of not having an antibiotic prescribed because they're better and better educated about the harms associated with antibiotics. Patients want to be heard and taken care of and have a plan. But there's a lot of reason to know that patients are okay with a plan not to treat with an antibiotic.

Dr. Marc Harrison:That is really good news. Tony, you've got this huge leadership challenge. You've got 38 sites. How many providers probably working across us between advanced practice providers and physicians?

Dr. Tony Wallin: And moonlighters and PRN — over 200.

Dr. Marc Harrison:So how the heck do you get 200 people to act in a consistent and rational fashion around something that we used to think of as pretty innocuous, just some oral antibiotics, but now something that we understand increasingly is really important from both a health and a safety standpoint? How do you do that from a leadership standpoint?

Dr. Tony Wallin: Yeah, it's a lot of conversations. It's a lot of educating and it's also empowerment. And for example, the idea that it's not a hard conversation doesn't resonate at first. When you say that to a urgent care physician, they'll argue with Adam and say, "Oh, there's no way. It's going to be a difficult conversation to have, that they don't need an antibiotic." And so what we do is help them along with information from people that are doing it well. And so they can have conversations with the people, that their own colleagues that do it well and how are they doing it well. And also we give them tools, things that help, like data on themselves. That's probably one of the biggest things is to show data.

Dr. Marc Harrison:It's interesting, when I had one of my first leadership jobs back in Ohio, I was associate chief of staff for our system. So, it's 3,500 spirited doctors who all had really strong opinions about everything. And we used to say you could change behavior because physicians are data-driven, goal oriented and competitive, and you have to share with them exactly how they're doing. You got to make the why obvious, and then to some extent, no one wants to be the bottom of the class. And it really does help, but it is an ongoing effort to make those sorts of changes, isn't it?

Dr. Tony Wallin: Yeah. One of the biggest challenges, that idea of transparency as well. When they see themselves and they see their peers and it's transparent, that's when that nature comes in, the competitiveness. But also the idea that I don't want to be the outlier. The idea to be transparent though is tough.

Dr. Marc Harrison:Right. Eddie, can you talk a little bit about the role of telehealth in Antibiotic Stewardship and how you help? Now, our day to day footprint is over 500 miles long.

Dr. Eddie Stenehjem: Absolutely.

Dr. Marc Harrison: And growing. And excellent infectious disease doctors don't grow on trees and nor should they. So how do we manage this system via distance?

Dr. Eddie Stenehjem: Right. We've created a tele infectious disease and stewardship program to get to your point exactly. Small hospitals, small clinics are the most likely to not have these resources because of the point you just brought up. We don't have infectious disease physicians in our smallest communities, and so we support them and we support all of our hospitals and all the smaller facilities that don't have infectious disease physicians with ID trained personnel, whether it be a pharmacist and a physician.
And we're able to do that and provide them consultation in their challenging patients so they can remain in their communities. But we also do it in their stewardship programs and we focus those on the hospitals and we really help manage them, so the care they're receiving in these small communities from an infectious disease and stewardship standpoint is the same as Intermountain Medical Center. We're proud of that. We were one of the pioneers in that work. Now, as we shift into urgent care, we're using telemedicine with Connect Care. And Connect Care is one of our largest urgent care clinics, and it is actually one of the lowest antibiotic prescribing clinics, urgent care clinics that we have in the system.

Dr. Marc Harrison:Nice. Let me riff on that for a second with Adam. I've heard lots of pediatricians really not like telehealth because the allegation that I've heard is that, they just hand out antibiotics right and left. And I guess the question is, is that generically true and Intermountain is an exception based on what Eddie said? Or is that sort of a systematic falsehood that people were just not ready to make change in their practices? Do you have a sense for how that plays out, Adam?

Dr. Adam Hersh: Yeah, it's a really important and timely issue because there's not only the issue of antibiotic stewardship, but there's the broader issue of the medical home. The fact is, a lot of telemedicine takes patients outside of their medical home. And the disintegration and the disorganization of our healthcare system really raises a real concern for, I think, pediatricians and any primary care doc about the fragmentation of the care that patients receive.
In an integrated care delivery system like Intermountain, however, it's quite a bit different. And we've been able to demonstrate, as Eddie was just mentioning, that the antibiotic prescribing that happens by telehealth in Intermountain is quite a bit lower than average. And you add to it the advantage of an integrated medical system, an integrated care delivery system in a shared EHR [electronic health record]. And the concerns about care happening outside the medical home, I think are attenuated. Outside of an integrated care delivery system, I think this is a real issue and it's an argument. It's an argument for more integration of care and it's an important issue in pediatrics.

Dr. Marc Harrison:Well, I think those are really thoughtful comments. What's interesting to me is the majority of our pediatric patients, their parents are now Millennials or younger. And what we know increasingly about Millennials is that they're interested in access, so convenience, and affordability, and that they'll forgo continuity in the interest of access and affordability.

I think you're right that if they do that in the context of a really well organized system like ours that you can still get really good care. I think in the absence of that, it could raise some real challenges, and I'm glad to hear that you're a proponent of increased integration. I guess we've got three smart folks here who are driving transformation. What advice do you have for me? Sitting in my chair, walking in my shoes, what would you do differently, particularly around the area of antibiotic stewardship?

Dr. Eddie Stenehjem: I think it's continuing to focus on it. This is a very large issue that if we forecast ahead and we look forward to what if we don't do anything? What if we continue the status quo? What is our health going to look like in 20 years, 30 years, 50 years? And we know that when people get infected with drug resistant organisms, their death rates are higher, their morbidity is higher, their cost of care is higher.
And it's really up to us to really highlight that and say, "What is our role as Intermountain Healthcare in terms of our population?" And having that in focus as the ‘why,’ I think really changes the way we frame antibiotic stewardship and how we talk about it and how we can expand out not just within our Intermountain population but in the community at large. We know that patients that come from non-Intermountain facilities, they end up in our hospitals.

Dr. Marc Harrison: Unless I'm mistaken, Eddie, you're actually representing us on both the national and the international front on this, right?

Dr. Eddie Stenehjem: That's right. Intermountain's been very supportive and we've committed both to the Obama administration, and also to the United Nations that we're going to focus on this. This is going to be a priority for Intermountain Healthcare.

Dr. Marc Harrison:Great. Any advice for me, Adam?

Dr. Adam Hersh: Only to continue to allow us to have a seat at the table because I think having a voice, and I think this topic and this issue is important to patients. It's important to our docs. And I think the work that we've been able to do supported by the organization has been impactful.

Dr. Marc Harrison: Well, thank you. That's not going to go away. The way I view it is our first priority is to the people in the communities we serve. I mean, number one. And right on the heels of that are the caregivers who actually do that work. Once we fulfill those obligations, I also think we have an obligation to share what we've learned and participate in the dialogue. Some people are traditionally academic, and that's great. That is a contribution. But I think other folks are interested in policy and how health care's delivered and participating in some of these really important decision making bodies. And so that's something that's a priority for me and for Intermountain. So, that's not going to go away for sure. How about from you, Tony? Any advice or…?

Dr. Tony Wallin: Yeah, well I think what resonates for me is having someone as our CEO support value based decisions like this is probably the most important thing. And remember we're not only keeping in mind our patients in our community, but we are that community. So, the caregivers are part of that community. So, I think it affects all of us. And being value-based like this in those decisions and being supportive of these kinds of value-oriented programs is most helpful.

Dr. Marc Harrison: Well, thank you for saying that. That is something that certainly the other 38,000 people in the organization believe in besides me, too. Let's face it, there are real economics for our friends, our families, for our neighbors. We have, I think it's the second highest penetration of high deductible plans in the US here in Utah. And we know that those deductibles, more than 90% of people never reach them. So, that course of antibiotics that's prescribed, it may actually have a significant economic impact. In addition to being maybe ineffectual or even harmful, it could hurt people's pocketbooks too. Most people in the US think their healthcare is way too expensive and many people have unaffordable healthcare, even here in Utah. So, I think it would be irresponsible of all of us not to pay attention to value. It would be really selfish. And that's not the kind of organization that I think we are. So, thank you guys very much for a great conversation and more importantly, thanks for your leadership. I appreciate it.

Dr. Eddie Stenehjem: Absolutely.

Dr. Tony Wallin: Thank you.

Dr. Adam Hersh: Thanks.