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Thinking Differently to Improve Healthcare with E. Ronald Hale, Network Medical Director, Radiation Oncology at Kettering Health Network


Welcome back to the outcomes rocketed I have the privilege of hosting Dr Ronald Hail He is the network medical director for Radiation Oncology at Kettering Cancer Care in Kettering Ohio Dr Hale is board certified in Radiation Oncology and has more than twenty three years of highly specialized experience in this Graham Gamma knife and five practice locations today we're going to be diving into thinking differently doing better planning versus preparation and my dad was diagnosed with kidney cancer when he turned sixty and he had basically terminal diagnosis the cancer had metastasized to his lungs. Twenty four years of Air Force Service Dr Hale is the medical director for a busy radiation oncology department consisting of a robust Rakic brachytherapy Eighth Medical Group Cancer Center Care Center and served as its first director until his retirement in two thousand eleven with the rank of lieutenant colonel culminating awesome his career in Dayton began Wright Patterson Air Force Base in two thousand five after losing nearly everything to Hurricane Katrina including his home a- As you think about your career Dr Hail what would you say got you into the medical sector well I originally started out as an yes sir and so as we as we dive into some of the topics that are near and dear to your heart I just want to say thank you for your service did a residency Johns Hopkins in that got a masters of Public Health and worked for several years as a public health specialist at various bases in practice location while station at Kessler Air Force Base on the Mississippi Gulf Coast He subsequently designed and supervised the construction of the eighty internship exposing me to all different disciplines and one day as working as a flight surgeon so that's essentially primary care physician for Pilots Space Engineering Student in college when I had an epiphany moment then decided I wanted to be a physician and transferred from my engineering program to a biology at the time I was at the time his diagnosis I was still at Hopkins and was able to get a little bit of guidance for his treatment and there weren't a lot of treatments available program and got into medical school I finished medical school and I really liked everything I couldn't decide on a specialty and so I did a transitional all at that time but essentially we had the kidney removed and he went on a very primitive form of immunotherapy that was later shown to be effective in clinical trial but for him for whatever reason started working in the tumor started shrinking. We had one tumor remaining on each long and he had to come off the immunotherapy for toxicity issues. It's such a privilege to to have Dr Hail here with us and with that I wanna I wanna give you a warm welcome Dr Hell thanks for being with US thank you very much it's good to be here a new metastatic lesion formed in the centre part of the Chest Media Steinem and we serendipitous we found out about a technical stereo tactic body radio surgery that was being you and continue to serve as a as a physician so I wanna start by saying thank you thank you very much it was a wonderful time and I would do it again in a heartbeat that's wonderful it it's it's such a privilege to to have somebody like you that that will both you know work on on behalf of the people of the US three so again there was an epiphany moment When I was down at San Antonio working as a preventive medicine specialist epidemiologist at Lackland Air Force base that I wanted to be radiation oncologist and so somewhat mid-career I switched and did another Residency University of Rochester they were one of the filled with these epiphanic moments and you know it's interesting to hear the courage that you've had to actually listen to those moments because story Dr Hale and and I'm so glad that your father you know made it he's still with us and your career has been so he had that treatment really against the advice of a lot of his treating physicians and cleared as disease and so twenty three years later he's still alive and tumor celebrities that had a new that was specially designed for Radio Surgery Treatment and studied with Dr Paul Kunia Phil Rubin and died it was fantastic training and I really since then have felt that that was in fact my true calling wow that's a what a what a what you were doing already well couple of things so I believe that we personally developed by continually getting out of our comfort zones and I think the military taught me that very well that we in the early on and he used to tell me pretty routinely that you don't need life life leads you and and I think with that wisdom you know I feel like oftentimes we don't listen to those moments what is it that gave you the the courage to change when things were going well and is by Dr Gill Liederman it's Dan Allen University sort of adapting what Timmerman Dr Timmermann was doing Indiana University but applying them to patients with limited metastatic disease grow as human beings when we have the courage to step outside of our comfort zones it's also partly based on advice that my step dad who is an ear nose and throat surgeon gates and the notion of getting out of your comfort zones I kind of embraced life with the idea that there is a destiny for each one of us and when we had that dusty revealed you know belief that you don't need life life leads you and you gotTa Take Action when you see those moments especially when they continue showing up to you or if in fact it becomes clinically apparent the tertiary prevention is optimizing the treatment that means properly diagnosing having properly staged in which could prevent the disease from happening in the first place where we have screening where we can detect disease at a sub clinical time and mitigate the morbidity and mortality associated with it in that regard everything needs to be on the table from the ground up in how we conduct the business of healthcare how we take care of patients about really integrating the change and change has to happen at all levels it's not an issue of spending less it's an issue of improving the efficiency and the effectiveness of healthcare delivery and so on listeners so what would you say Dr Hale is a hot topic that needs to be on health leaders agendas today and how are you approaching it well way we I have been doing business. The business of healthcare is not sustainable it's not sustainable economically and really for the amount of effort money investment that we're making Haitian and then deliver the proper treatment to mitigate the morbidity mortality associated we in at least in the United States have not done a very good job into life the opportunities to prevent that from happening lie along this continuum prevention where we've got primary preventive efforts such as the Gardasil vaccine opportunities in life and so that has been my guiding light through this whole experience wow that's brilliant and I love your your Stepdad's in healthcare we're not in this country really seeing the kinds of health outcomes that are commensurate with the level of investment that we have and so Things need to change families Kiesler for space in Santa Chiara first base and Bologna Mississippi I I really enjoyed the public health and preventive medicine aspect of the job and lies on a continuum of prevention and that their opportunities along the way and that investing on the left side of the continuum where we can prevent the disease and mitigate the continuum of prevention let's say that we have an entity of cervical cancer which can which can short a person's life or certainly take away the quality some of prevention for the population of patients that are that we're responsible for here in the southwest Ohio area the other is that I am APPs at our destiny is and it's these opportunities that pop up out of nowhere that seemed like they take you in a completely divergent direction for where you think you're going that are really was it really becomes the courage to embrace the destiny we have the free will to walk away from it and sometimes when we do that we are repeatedly reintroduced affects not even let it happen yield Big Bang for our buck and I think that's where healthcare in this country is going to need to go in the future flight surgeon we used to somewhat jokingly say that pilots that fly airplanes by memory crash pilots don't fly an airplane by memory I dea of the continuum of health prevention is a very fascinating one and I'd love to hear what you are doing in your practice or at the at the Sir in order to mitigate the morbidity and mortality associated with their diagnosis and this is where we come in to the concept of decreasing nationalist and now oncologist You know it's it's fascinating how all these worlds are are converging and this can be instead of prescribing radiation for a breast cancer patient I would prescribe a care pass for the treatment of an early stage less cited breast cancer have checklists There's even a checklist to go to the bathroom so that you don't inadvertently get up go to the bathroom and leave the autopilot off Everything is checklist base and greatness continuum of prevention and seeing every thing that shortens a person's life for threatens more mortality and morbidity really really quality of life your patient that includes not only the radiation dose but the localization parameters for that treatment that constraints for the healthy tissue to void the radiation to treat those areas the orders that my nurse could execute the event that the patient has skin redness or what not I think it's really interesting Dr Hail the perspective that you bring with the many different hats that you've worn you know as a as a preventative physician public health liberties that you work to to help move towards that direction so there are two primary ways That that I am doing this on on a daily was a coding for what we're doing and also the safety checklists so that in order to move from step Betas Debbie the items such as obtaining a pregnancy test at the I am a treatment planning is done in order to move forward so by integrating the best practices for delivering the treatment with the safety checklist we have a care pass and that's where I need to be investing my time not on the things that we're doing routinely every day but to invest my time on the cases that are more difficult at need Lia practitioner of tertiary prevention so patients that come to me have cancer already and so how do we optimize the treatment of their can the four stages of formation with the forming the storming Norman and performing stages of team formation a huge challenge one on one interaction because of Puglia situation. I think that's a brilliant way to do it and these these prescribed care paths with checklists in medicine very much the same concept supply when we use this concept of a care path to deliver a treatment than what I mean by this is for instance in in the safety checklists and these care paths so that patient presents to us with early stage breast cancer the courses basis so one is I am the chair of our cancer committee which really looks at the the programmatic issues of our cancer program in the network looking at opportunities to integrate the continue -scribed and really for the majority of patients this is going to be perfectly appropriate treatment so it's the Pareto principle that by a small intervention and so care paths can be on a number of different ways but we now have the technology that's able to use our electronic tenuous of the continuum prevention that most of what we do in healthcare is really what we consider tertiary prevention what I mean by this is we think about doc medical records and instead of us working for the electronic medical record we get the electronic medical record working for us where we can actually bacon that everybody can live with this decision well in order to be able to have a team comes to consensus the team has to form as a team and we think that are evidence based according to our current nursing guidelines the supporting documentation for what we're doing the supporting coating for are a fantastic way for for you to really you know give the thought that to to those specific cases that AH team information systems team to to put the pieces in place in order to implement the delivery of these care paths those have been very ability and in an improving safety culture of safety through the use of care paths the story of Cancer Treatment with care pass and so back from my days information system the information system is here for us and to get the pieces in place for the information system that truly support the the evidence with this we can standardize the care for the bulk of the patients that come through now they're going to be patients that will not fall under a care pass exactly that will need modification sample of what what does happen and can happen in in in care every single day if you had to point to a setback that you've had that you learn a model and and so I'd like to hear what you believe Dr Hail is one of the proudest experiences that you've had the date a soft where application would look like to support the evidence based delivery of a care path for the treatment of cancer with radiation certainly so I would say that when we first conceived of what need that thought I I think it's a really great way to do it. Your example of a of a pilot that flies by memories going to crash is a really vivid exam and this is the thing that makes great things happen you know we would not have the iphone and other amazing things unless people had the division so much from Dr Hail what would that be and what did you learn from it so a couple of things one is that we have a group of physicians we have a prayer percents not so much a setback but a challenge and so in order to do this you have to have a group of people and not just physicians but really it has to be everyone involved far has been in my three years here getting my team assembled and working them through these four stages of team development so that we can come to the point of building consent in that at the point where I actually saw the functioning software the way we have envisioned it as it was demonstrated to us have to acknowledge upfront the other is that it's a paradigm shift for our folks in information systems where you know we're not here for the specialties of Radiation Oncology including adaptive radiation therapy brachytherapy and brain radio surgery as well as public health and preventive measures ads of least resistance but that's not probably the best way to do this I think the really the best way to get something remarkably done is kind of like what the farmer we know what they are but you're consistently making strides toward toward getting it done and getting your entire team on this on this care pathway I think was probably the most exciting thing because it was a concept and to see this concept come to for wishing to the hard work of many many people insist that has been a major challenge it's something that we at this point have momentum in a positive direction but it is it is a big challenge that I think based care paths delivery of our services and so a couple of things needed to happen we needed software developed and we also need it on our end our informations to make advancement and really anything that we do in life but at healthcare in particular is there's two ways to make advancement and grow and and one is is sort of what I call this a me boy growth when did you guys finish the software so the software software is ready for test in February of this year how we have a pretty substantial challenges and setbacks really over the course of the past three years well you know it's it sounds like you have a firm grip on them bliss sites that have implemented the software I believe Yale and Thomas Jefferson have gone live with it we have been working on content and then drive in the organization to that and point it's a completely different concept than this sort of a me boyd growth that we've grown so accustomed to hoped that can that has the capability to come to consensus consensus is not Majority rules consensus is not unanimity consensus care delivery in any thing that we do we need to envision the end state of what we want to achieve in two years five years ten years what we WANNA look like and demonstrated it was one of those moments that it was extremely satisfying to see the the this come to fruition wow that's a fabulous and in win was was absolutely amazing and I I would have to say that that was that was really the a a very important highlight I think of being able where we are where we are now and we sort of Blob out in different directions and picking low hanging fruit and just like growing by default in sort of as often the steak that would establish your first straight line and from there the the field would be plowed in an orderly fashion and I think for remaking are healthy to do in the old days would walk to the end of the field and drive a stake into the ground go back to the plow and drive the plow to the stake not taking is her tonight to to grow and develop things in this type of a fashion and so when we saw the software developed basically that we treat and going through in a very systematic fashion working through process and content because once the soft and tirelessly which really means taking all of our diagnoses you know less side early stage breast cancer right side early stage breast cancer everything prostate cancer early stage breast cancer there are very well established consensus guidelines for how that cancer should be treated in these guidelines have been around for many years published as the improve safety the ability to track patients through the episode of care and manage those patients actively while that's fascinating visibility to that patient stages critical increasing safety reducing variability and you know this idea of care pathway yeah precision medicine is a is a wonderful new really a new concept and you know there's this notion and you'll see billboards around town oh part of this software working supporting the people who do this is that it has to be able to be adjusted and tweaked on the fly and you have to make tweaks and this has to be done at the user level so this can't be you have to bring up a programmer an or functional expert in to make these modifications canot where those patients are at each moment during the process is critical we need to have an understanding of WHO's waiting for simulation who's waiting for their treatment plan one-size-fits-all how does this tie into the the rising wave of precision medicine will it doesn't it very nice way actually so gene so it's imperative that we know where those patients are so the software also provides us in addition to the the ability to execute care paths to decrease variability sites that have been using at least the the whiteboard part of this the whiteboard meaning the ability to look at our empanel mental patient there's no routine breast cancer what have you but the reality is that for the majority of patients let's say that have a low risk was waiting for insurance approval so that we move the patients through efficiently down the hall we have a multimillion dollar machine that we didn't maximize the time of the patients on radically update the guidelines to render an opinion on how any type of giving cancer should be treated and so what we're really talking about is establishing a care path wretches through the simulation treatment planning treatment delivery in out to what we call the end of the global period which is three months after the completion of the course so our episode of care last CCN guidelines which is a collaborative effort among all the major cancer centers in the country where in fact their functional experts have come together reviewed the literature so software started going live in February lead been working on the content tirelessly we're getting great reports back from the two into place at various points along those guidelines so there are times where germline testing molecular testing is necessary in order to better understand whether for instance this systemic therapy is better than the other systemic therapy is indicated all together and what have you but again some treatment parameters so in some regards you could think of the delivery of treatment through the use of care pads is limiting precision medicine do you you know try something you form at the software to do what you think you want to do and you tested and you see and then you have to go back supports the evidence based delivery of treatment really according to what we consider the gold standard of guidelines enc guidelines now precision medicine episode of care is maybe a half hour from the time you check in check out league with prescription in radiation treatment it's different the episode of Care Begins With the initial consultation as you know prescribing those really opens it up to to not falling falling prey to that the the just so when we think about the delivery of Radiation College Treatment Course we're talking about the episode of Care which for instance we go to the pediatrician for your child you know it's for several months the patients that are all in our clinic during this episode of Care is what we referred whereas as our panel moment various types of a brain tumor has the appropriate testing done to make determination about the tumor that that will have an influence on prognosis but also on software and be able to easily adapt it because ultimately when you're looking at the delivery of what you do this is going to be an iterative project so and that in and of itself it can be baked into the guidelines so that a patient who has aglow blasts Doma which is a very fine tune the treatment they should be getting yeah that makes a lot of sense that makes a lot of sense and I could see how it enables the use of precision in in the way I see it enhances our ability to do precision medicine insofar as that every patient will have the appropriate testing done right that will medicine so I like to circle back for just a moment because we're talking about redoing how we deliver healthcare in so far as we got paid for that and so it encouraged very long fraction schedules thirty three to thirty five treatments for Breast Cancer Forty five treatments for cancer etc every time we treated we were basically rewarded well a couple of important things are happening one is a fundamental change the cost of healthcare decreasing variability improving outcomes and how this relates in at least what we raisch ecology so there's a C- shift the it's really underway with regard to the delivery radiation oncology the former model was we basically got paid every time we turn the machine on the way we're looking at compensation for the treatment of cancer with radiation right now there's active discussion with use of alternative payment models where instead of being action scheduled for radiation are necessary and so what we've been seeing is what I think of his shrinking collapsing fraction schedules where for prostate cancer in instead of treating forty-five fractions that for many patients they perhaps can receive five or twenty fractions for Breast Cancer Reducing from twenty breast cancer but also at the same time we've got a better understanding regarding how many treatments and and what a call we'll dose for eight to thirty three treatments down to fifteen or twenty fractions for palliative patients instead of receiving ten fractions receiving just wonder five actions so the shift there then becomes getting patients through the department with fewer fractions means putting more in pay per click of the machine going on were paid for persons diagnosis if the patient has breast cancer the basically things are bundled together and were paid for the treatment Asian which supports a more cost effective model For the use of radiation scare tactic radio surgery is a way to treat definitively with between nations through the department because to be economically viable to succeed in this type of environment we need a higher throughput through the clinic if they're spending less time on the some some insights into how we could take care of our oncology patients better now if if the people listening are on the in one two five treatments and so we've seen a huge uptick in the patients that are receiving this type of treatment those patients still require based treatment allows us to first of all really understand what is the cost involved in getting the patient on treatment now that's important for us creatively and every time I talked to someone I learned something as well because that person brings me different insight and viewpoints and maybe there are things that I haven't thought about so I team for all the work that you guys have done in the development of smart clinic there's no doubt that there's a changing tide and folks Dr Hale is is providing you to be able to negotiate contracts favorably but also we can get that patient on treatment with a lower cost human capital costs the costs that it takes Oh care outcomes the best way is to know what you don't know I think that the cost in a not having the types of health and in a search bar type in Hale H. a. l. e. you'll find that the entire transcript show notes and contact they're getting remediated my time to get that patient on treatment and so there are a lot of consequences to to changing the paradigm with regard to how deliberate assault note treatment planning all the other things that go with it and so through the use of our our software called Smart Clinic this is is something that's great leave to the lightning Ron Brown Dr Hale will do that followed by a book that you recommend to the listeners you ready yes all right what's the best way to improve don't metrics we need to know what we don't know what's the biggest mistake or pitfall to avoid the biggest mistake is to think that you absolutely courage that yes outstanding and folks in the show notes will leave a way for you to contact Dr Hail just go to outcomes rocket dot outcomes we want to have is really not understanding the pieces of information that we're missing so I think that's a great way to start it's all neck with you or your team I think probably it'd be welcome to email be it would be fine and and then we can you know set up a phone about having a practice that has tight electronic medical record that has proper documentation about

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