 It gives me great pleasure to introduce Dr. Maureen Hameed. This is our 18th lecture in the McLean Center for Clinical Medical Ethics lecture series on trauma, violence, and surgery and it's hard to believe it's been 18 lectures already in the series and I hope that many in the room and those who will video stream and see them later have been enriched on this journey of the University of Chicago Medicine becoming an adult trauma center. So without further delay Dr. Maureen Hameed comes to us from the way of Vancouver but he's actually in many ways an international travel and citizen of the world. Dr. Hameed completed medical school and registered training at the University of Alberta before heading to the far south of Miami to do trauma and critical care fellowship at Jackson Memorial Hospital and then migrating north to Boston to do his massive public health at Harvard before rising to ranks at Vancouver General Hospital where he's now the division chief of general surgery and having before that been the division chief for trauma acute care surgery and before that the program director of Vancouver General Hospital so he is indeed invested in the far north west one of the great cities in the world that I had the benefit of being a visiting professor at under Dr. Hameed's two ledge over a decade ago. Dr. Hameed his research focus is on a intersection of health care informatics information technology surgical disparities and trauma systems and he is going to give us a very compelling talk with I got I gotta say how many people from Vancouver start a talk with Tupac I don't know where this is going but the future of injury control is precise and I hope that we can learn something from this limiting talk so we've given him a chance to think about the biathlon he went from running now he has a slowdown heart rate to giving this lecture so good afternoon everybody thank you so much Salvin for that incredibly generous introduction and thank you for your friendship and mentorship for all these years if I had sound right now you would be hearing one of my favorite songs by Tupac Chacour so just imagine life goes on in the background it's awe inspiring for me to be invited here and to have an opportunity to spend some time with you all as dr. Rogers mentioned I'm a trauma surgeon but not an ethicist or a philosopher my field or our field is one in which decades and centuries of experience and judgment have organized into established protocols and clear algorithms it is a field of the universal language and closed-loop communication of seamless teamwork and precise flow when a patient comes to our doors shot in the chest with barely measurable vital signs we can afford to be cool because the protocols and the conventions of our profession kick in and cost us through we can establish wide bore I the access intubate and place bilateral chest tubes we can shoot and interpret x-rays and perform point of care fast ultrasound exams to detect bleeding and to direct our next actions we can even open a chest in a few seconds to release and control bleeding often with only a few fleeting clues to go on we can do all of these things without much thought or reflection Daniel Kahneman the winner of the 2002 Nobel Prize for his work on behavioral economics describes fast and effortless thinking based on pattern recognition and automatic analysis it skims the surface of the world often moving us along well trodden past forward it is useful but dr. Kahneman points out it is prone to oversimplification and bias then there slow thinking thinking that requires presence awareness effort this is a thinking that dives deep and soars and that often changes the world in preparing this talk I was reminded that I probably gravitated to trauma surgery for this exact reason to take shelter in the near certainty of protocols and algorithms and to avoid the pain and struggle and effort of thinking deeply I am in all of this lecture series that has given focus to ethics and of all the speakers in the lecture series that preceded me and by those that will follow me and by all of you who've committed yourselves to this struggle of effortful thinking and to creating the principles that will shape the future of medicine and surgery in public health thank you for doing this so with that I conclude my remarks thank you very much I'm just kidding I wish it could be so easy for all of us but the only reason that I get to be here today is because my friendship with dr. Rogers about seven or eight years ago dr. Rogers accepted our invitation to be our visiting professor at the University of British Columbia general surgery resident research day he of course brought the house down with a keynote address with a thoughtful assessments of our research programs and by his compassion and warmth in the afternoon we went for a walk along English Bay seen here and stopped to reflect about our careers and about our duties to our profession it was an inspiring moment since then he's been a great role model and champion for me every so often I get a message from him out of the blue about how I am moving forward and why I haven't been promoted yet I suspect that I might be getting another email like that soon the reason that I know Selwyn is because of Susan Krajewski and because of one of the best papers that I've ever had the privilege of being involved with Susan was a surgical resident at the University of British Columbia who during her training did a master's degree in public health at Harvard with Selwyn she connected us in a joint study of the Canadian and US health systems she decided to focus on a typically surgical problem acute appendicitis and she hypothesized that the chance of having an attack of appendicitis that proceeded all the way to perforation would be higher in patients with low socioeconomic status using an elegant analysis of national inpatient sample data and Canadian Institute of Health Information data Susan discovered that the risk of perforation was higher in low socioeconomic status patients regardless of the metric to use to measure SES and that included income insurance status education and even race but this finding applied only in the US in Canada the story was different in Canada there was no correlation between perforation and SES risk it was an interesting study that was published during the height of the health care debates in the US and that made us all reflect on health system design most importantly it was my introduction to Dr. Rogers and to the study unrelenting and idealistic struggle to identify and address disparities in access to health care by the way we also found that Canadian perforation rates although not related to socioeconomic status were overall higher than those in the US which was a reminder that these issues are never totally straightforward Dr. Krebsky study made some interesting connections like between the Canadian and US health care systems or perforation rates and socioeconomic status but it also made clear the connection between the experience of individual surgical patients and surgeons and the experience of entire populations for surgeons it is tempting and easy to focus on the suffering of individual patients and on the anatomic and physiologic principles and the protocols and algorithms that we know alleviate the suffering it is rewarding to repair wounds or get the source of sepsis and to help restore patients to independence and to the pursuit of their dreams but does this work really get to the deeper sources of suffering and as surgeons or trauma care providers is it our duty to slow down and think deeply to get to this source is it our duty to bridge the gap between the care of individuals and the care of societies Dr. Rogers asked me to prepare a talk examining ethical considerations and violence trauma and trauma surgery in preparing these remarks I read the Canadian Medical Association code of ethics and I'm embarrassed to say for the first time to see if we are guided in balancing our duties to patients and to society so the the CMA code recognizes that quote physicians may experience tension between different ethical principles between ethical and legal or regulatory requirements or between their own ethical convictions and the demands of other parties after that disclaimer about the tension between ethical priorities guess what the very first fundamental responsibility is in that code of ethics does anyone want to take a guess Canadian the the very first principle in the CMA code of ethics is consider first the well-being of the patient our patients needs because our patients needs come before our own when I was a trauma fellow at the University of Miami one of my attendings Nick nemias gave me a pearl that has guided me throughout my life since then whenever you find yourself in the middle of the night torn between two options and looking after your patient always pick the option that is more personally inconvenient for you it really works I never thought of Dr. nemias as a medical ethicist but in preparing this talk I found that he is further down the code goes on to say recognize that community society and the environment are important factors in the health of individual patients and it also says recognize the profession's responsibility to society in matters relating to public health health education environmental protection legislation affecting the health or well-being of the community and finally it says use health resources prudently I decided to focus my thoughts today on the intersection between individual and society in the context of injury control there are so many exciting things happening right now in acute care and public health is there a trade-off between them as trauma care for individuals gets more sophisticated and more complex especially as it moves into the resource intensive realms of predictive and precision medicine does it distract us from our duties to our larger communities and societies as someone who has lived at the front lines of care of individual patients I have always wondered about how to reconcile high tech care with the unchecked hardships hardships of people in our own communities and those around the world it's certainly tempting to continue to focus on achieving excellence in the care of our patients our knowledge is better our technology driven by market forces is more capable of achieving miracles and our health care is more integrated than ever before the exciting thing is that we're on the threshold of another phase of exponential growth of knowledge and capability the sequencing of the human genome a phenomenon a phenomenal achievement that one once cost close to a billion dollars is now available for about a thousand dollars and it will touch off a new era of precision medicine in which diagnostics and therapeutics will be uniquely targeted to individuals and which efficacy of therapies will be high and side effects low this explosion of knowledge has taken place in parallel with literally exponential growth in computing power data storage and integration capacity and data analytics speed and sophistication that has been governed by Moore's law that our computing capacity doubles every year better computing power will make it possible to link genomic data with clinical data to make new connections between investigators clinicians and patients and to create new insights and new breakthroughs for increasingly specific and precise problems precision medicine has captured the imagination of the medical community with unprecedented public and private investment and a national initiative launched in 2010 by President Obama to bring the right therapies to the right patient at the right time every time precision medicine which is identified as exactly as President Obama said the right therapies to the right patient at the right time every time using advanced technologies including genomics and computing power is the direction in which our commitment to the care of our individual patients will lead it's exciting and it's hard to admit the precision medicine as transformational as it is is unlikely to significantly change the health of our society the returns on investment in health care are already diminishing in the US health care costs are high and continue to rise every year and Canada the stories very same and they've been some landmark studies both in the UK and the United States that show that advances in medical care rarely moved the needle on population health in general critics of precision medicine argue that investments in precision medicine might be better directed toward public health if we could somehow identify everyone in the United States for example that could benefit for intervention for current tier one precision medicine recommendations and that is screening for patients with the BRCA one and BRCA two mutations who respectively have a 65 and 45% risk lifetime risk of breast cancer or people who have Lynch syndrome with DNA mismatch repair mutations or who have familial hypercholesterolemia those four conditions account for only about two million people in the United States meanwhile public health measures promoting healthy eating active living blood pressure reduction smoking sensation cessation and injury control have the potential to touch up touch the lives of literally literally billions of people around the world probably with greater cost effectiveness and precision medicine so you can see the tension begin to develop between precision medicine or individual directed care and population based care focusing on trauma the story of how society confronted trauma as a public health crisis is a good one in the 1960s it was an era of steady urbanization and urban sprawl industrialization escalations in road traffic apparent income inequality and civil unrest many cities in North America and around the world were seeing unprecedented volumes of injury an example was Baltimore a city with burglary assault and homicide rates many times above the national average amazingly no one in public health or healthcare viewed this advancing epidemic injury as a problem but the publication of the National Academy of Sciences accidental death and disability the neglected disease of modern society in 1966 marked a major turning point in our approach to injury control their statement that public at apathy to the mounting toll from accidents must be transformed into an action program under strong leadership inspired a generation of surgeons to do just that transforming the way society confronts injury in fact according to Avery Nathan's who's coming here in a few weeks surgeons returning home from wars in Korea and Vietnam with their organizational and technical skills honed in combat and the college advocating reform and improvements of standards at home gained a preeminent role in the care of injured patients perhaps no one gained as preeminent to rule as our Adams Cowley Dr. Cowley was a resent a relentless innovator whose contributions led to the development of traumas golden hour concept he developed dedicated shock and trauma units dedicated trauma centers military style helicopter emergency medical services and statewide emergency medical systems every one of these ideas spread across the world and disrupted the status quo and transform the way we approach trauma and to some extent other forms of critical illness Dr. Cowley and others developed the concept of systems of trauma care an organized public health approach based on the constant collection and analysis of data that spans prevention re-hospital care acute trauma care and rehabilitation in business terms these principles disrupted health care and public health creating new paradigms of data driven and systematic approaches to a dangerous pervasive but ultimately modifiable problem in trauma there's much nothing more important than the system and the trends have been remarkable since 1966 mortality from unintentional injury in the US has fallen from five from 55 per 100,000 population 1965 to 37.7 per 100,000 in 2004 as innovative energy injury prevention strategies have been broadly implemented and access to sophisticated trauma care within an hour of injury has been provided to 84.1 percent of all Americans so that's a large part of the American population that's covered by access to definitive trauma care when the burden of injury is shared between acute hospitals and inclusive and integrated systems of trauma care outcomes get even better the most inclusive of trauma systems have shown the lowest odds of mortality with about a 23 percent reduction in mortality when trauma centers are working well and working together in a Canadian study the development of an inclusive system of trauma care where the efforts of level one and levels three trauma centers were closely integrated on a provincial level patient mortality was observed to fall to its lowest level in 10 years I've heard trauma surgeons say that the biggest advance in trauma care in the past four decades is the development of systems but probably the most important question is what has been the public health impact of over five decades of trauma systems development we've been doing well with trauma systems development but the truth is that 5.1 million people still die of injuries every year and as all of you know injury is the fourth leading cause of death and morbidity in in North America and it's the leading cause of potential years of life lost the fact is that despite all these advances trauma is still the world's number one cause of potential years of life lost people in low middle and low and middle income countries sustain a disproportionate burden of injury of all deaths worldwide 89 percent of trauma deaths occur in low and middle income countries as compared to 84 percent from all causes injuries account for 12 percent of deaths in low and middle income countries but only 6 percent in high income countries the problem of injury is especially bad in Africa where injury is the second overall leading cause of disability and death as you might know Africa with one of the lowest motorization rates already has a high rate of road traffic mortality both African and South America both Africa and South America face high rates of mortality from interpersonal violence and even in Dr. Cowley's city Baltimore the impact of poverty education race or geography on injury risk remains breathtakingly high despite all the progress and trauma systems last year Baltimore hit an all-time high and homicide with startlingly high vulnerability among African Americans public health approaches to injury control may be beginning to fail actually in addition to glaring residual disparities even the successes may be starting to level off motor vehicle crash fatalities for example which are often reported as deaths per 100,000 miles driven may seem to be declining because most commuters must endure miles and miles of stop and go bumper to bumper traffic so at low velocity mortality for motor vehicle crashes could be under reported if we measure it per 100,000 miles traveled in this case the indicator injury burden may be flawed I'm aware that at the moment I am standing in the city that is the birthplace of trauma systems speaking to the people who know more about the burden of injury than I will ever know here it's estimated that 39,000 people have been killed in the past six decades and that the number of murders has not fallen significantly despite increasingly capable trauma centers and trauma systems so how good we are at resuscitating and operating on trauma patients is in some ways masking the heavy burden of violence that our society faces so we've seen so what's the solution if public health is beginning beginning to level off in its impact or even if it's beginning to fail well we've seen increasingly complex and sophisticated systems of diagnosis and treatment and escalating health care expenditure set in the midst of a stormy and unrelenting pandemic what is our duty and where do we go from here how do we further optimize the performance of trauma systems how do we create new disruption and transformation in injury control I think that injury control and by that I mean injury prevention and systematic trauma care is at the threshold of a second major disruption and I think that the engine of this disruption lies at the point of interaction between patients and the health care system the same place from where precision medicine takes flight now for the first time trauma systems are poised to embrace the diversity and complexity of this patient health care system interaction and to gain deeper insights from every aspect of that interaction in 1970 basically at the dawn of modern trauma systems William Haddon a physician and graduate of MIT Harvard Medical School and the Harvard School of Public Health and an administrator at the National Traffic National Traffic Safety Agency described a framework to understand the determinants of injury risk the Haddon matrix characterizes motor vehicle crashes for example into phases pre-crash crash and post-crash and within each phase risk can be thought of as being governed by human factors vehicle and equipment factors and environmental factors violence related injury can also be conceptualized in this framework as having pre-event event and post-event phases with human vector and environmental determinants acting in each phase the matrix organizes determinants to give us insights about where there may be opportunities for action some determinants may be more modifiable than others the exciting thing is that modification of even one or two determinants or risk factors could completely change the implications of the traumatic event or prevent it all together wouldn't be amazing to build an actionable Haddon matrix for every trauma patient and every at-risk population to do this we might focus on the point of trauma care the moment that unites injured patients with health care teams the point of trauma care is fascinating in part because it brings together a patient previously completely unknown with unknown pattern and severity of injury with a diverse and multidisciplinary team possibly just assembled moments before at a moment of crisis it's a perfect storm and even though it falls back on algorithms and protocols and patients and teams must navigate a sea of data and make the most consequential and life-changing decisions with incomplete information and with uncertainty the arrival of a patient in the trauma bay touches off a series of processes both diagnostic and therapeutic each of which generates waves of data about anatomic injury physiologic state and response to resuscitation but also about individual patient factors like age comorbidity and about the social determinants of health each patient then in each interaction with the system creates a complex multidimensional data set of anatomic physiologic social and environmental information that has the potential to uniquely influence the way we understand trauma and care specifically for trauma patients and injury and to perform injury control more broadly I chose to open this lecture with Tupac song life goes on because hip hop was the way that the duty of clinicians to society was introduced to me when I was a graduate student public health and that's like about 20 years ago the professor in my urban violence class opened the first lecture with hip hop the class listened spellbound the frustration and hopelessness and tragic implications of violence were clear in the words the professor Dr. Deborah Prothrow Stith who patched up trauma patients in the emergency department herself only to send them back out into dangerous environments encourage us all to use our frontline perspectives on injury to drive action on the social determinants of health I returned to Canada from my trauma fellowship in public health training inspired to engage with the social determinants of injury risk and outcome our work benefited from the strong history of trauma system design and development we already had a regional system of trauma care organized multi-disciplinary trauma centers and most exciting to me access to data in trauma registries does anybody here use trauma registry data and in their research no one trauma registries have placed trauma systems development on a strong foundation of data and they're considered to be so essential that their presence is an essential part of trauma accreditation to get accredited by the American College of Surgeons trauma systems have to show that they're collecting data I'm I'm in awe of the early architects of trauma systems for having the foresight to build this foundation of data while we owe much of our knowledge about injury to trauma registries we also found that registries have limitations the the high cost and quality of data acquisition means that the number of fields are limited and not easily adapted to day-to-day needs most trauma registries have about a three to six month lag between the time the data is collected and the time it's analyzed which diminishes the agility and the impact of registry data insightful quality improvement in research often requires linkages between trauma registries and other sources of data and linkages limited by administrative and logistical issues the quality of data and other databases trauma registries like all registries can only answer the questions that they were designed to answer and for the most part they were not designed to answer questions on the social determinants of health but despite these limitations registry data are still very exciting in an early study using registry data we linked we linked the registry to Canadian federal data on Aboriginal status since healthcare coverage in Canada is a federal mandate the the healthcare numbers of Aboriginal Canadians have a unique identifier that indicates that federal linkage so through linking registry data with data on ethnicity we found that status Aboriginal Canadians had a four times greater risk for motor vehicle crash related injury and an 11 times greater risk for violence related injury 11 times risk the findings quantified enormous disparities in the burden of injury in the Canadian context at the time it was important news that triggered consultations and deliberations within the leadership of local Aboriginal bands we did a series of studies in metropolitan Vancouver with my research partner Professor Nadine Sherman from the Department of Geography at Simon Fraser University and we what we did is we linked trauma registry data to techniques of data visualization and analysis from geographic information systems so we took injury data from the registry and basically mapped it to the city and you'll see the map come up soon and what we found was there were high risk neighbourhoods and social gradients for violence related injury just like Dr. Protzer was just predicted that we would find if any of you have been to Vancouver anyone Vancouver both you have been great so you'll remember that it's a high population density city with high pedestrian and automobile traffic in close proximity pedestrian trauma often results in devastating high energy injuries and we decided to use registry data and GIS to try to understand its determinants and to populate Haddon's Matrix a bit better our analysis revealed a single street East Hastings Street at the heart of Canada's poorest postal code in the downtown east side of the city where every single intersection lit up as a hotspot for injury the study was accomplished and as far as we knew the insight was lost but the amazing thing about the story is that somehow the data and the images were picked up by a local advocacy group advocacy group the Vancouver area network of drug users and those data those data and the maps were used to lobby the city the city to institute changes to the built environment along the corridor the study actually resulted in speed limits and traffic calming measures along East Hastings and anecdotally fewer pedestrian injuries there the story is one of my favorite examples of how simple analysis of the social determinants in this case neighborhood have the potential to support the advocacy policy change with real data that populates Haddon's Matrix we took her excitement about the potential of trauma registries to one of my favorite places in the world Cape Town South Africa as we've seen South African South Africa continues to face an enormous burden of injury both intentional and non-intentional projects such as a national injury mortality surveillance system have used mortuary based data to capture injury related deaths based on the global burden of injury classifications for 2007 that system recorded 33 484 injury related deaths more than one third of those were due to violence followed by traffic injuries at 32% other injuries at 13% and undetermined suicide at 10% and undetermined causes at 8.8% although trending downward the murder rate in South Africa is still 30.9 per 100,000 population and that's 4.5 times the global average the escalating rate of traffic related deaths 33.2 per 100,000 in 2011 suggests the need for proportionate research efforts surrounding prevention and education grew to secure hospital at the University of Cape Town is one of the most clinically and academically productive trauma centers in the world and one of two hubs in an inclusive trauma system in the western Cape when we got there in 2005 we found that because of extremely high volumes and cost they were unable to prioritize the creation of a trauma registry almost all of their research mainly case reviews was done on paper and there was no outreach into the surrounding communities that were generating waves upon waves of trauma for the trauma center they were literally too busy to collect data on the massive volumes of trauma that were coming through the door together with the director of the Kyrgyz Skiro trauma unit professor Andrew Nickel we embarked on the process of creating a trauma registry there from scratch we surveyed clinical and public health leaders for what fields they wanted collected and embedded these fields in a paper admission record that their residents were asked to complete as part of clinical documentation so when patients would come in instead of writing on a on a blank sheet of paper they would fill out a paper trauma record we designed the form with a carbon copy backing that we would eventually collect enter into a database and analyze the form launched successfully and we went home about a year past before we could go back and by then we had stopped hearing about the form and assume that it wasn't being used anymore on the first day back when I greeted Dr. Nickel's assistant she said to me what I wanted to do what did I want to do with the papers I didn't actually get her meeting it was so long before that I didn't even know what she's talking about I said what papers she looked at me incredulously you know the papers everyone has been collecting and bringing to me day after day she let us around the corner to a small co and to our surprise and excitement we saw piled from desk to ceiling three stacks of registry forms and it was a tall ceiling that they were stacked to we had to take the piles back to our hotel in several trips and eventually the forms were entered into Excel a process that took two grad students three months although there were a lot of missing fields we had over 9000 records it was one of the biggest trauma registries in Africa at the time around that time Apple released the iPad mini and we had the idea to migrate our paper form to a digital user interface this insight led to the development of ether the electronic trauma health record so if you remember that this talk is about precision medicine and public health you may be able to see where I'm going with the story ether had remarkable uptake and ran a grudges cure for three years collecting admission surgical and discharge data and generating in real time an electronic trauma registry of almost 30,000 patients there's a paper coming out in JAMA surgery today in which we report that the electronic forms were used were user-friendly enough to fill out as fast as paper with field completion rates that jump from 35 percent to 95 percent in the ether era and with high user satisfaction 88 percent of clinicians entering data at the point of care preferred using an iPad based digital documentation tool to paper we made a lot of assumptions in building a clinician entered real-time electronic trauma registry and one of the big assumptions that we made is that when physicians or clinicians entered data at the point of care that the data will be of high enough quality that people can do analysis on it and that was a big gamble at the time because most registries are collected by professional data abstractors but what we found was that the data entered into a usable interface standardized by drop-down menus enters into the background database complete already organized and for the most part ready for analysis and we used the data to model survival predictions using multivariate models and even machine learning techniques and we found that the predictions generated by clinician entered data at the point of care created better predictions than data that were better or as good predictions as data collected manually by professional data abstractors the implication here is important that data generated at the point of care in real time and entered by clinicians during the course of clinical work could be used to provide insights about the trauma system and by extension to engage frontline clinicians more broadly with the social determinants of health for the first time clinicians accrued to cure hospital could see maps generated from the data that they entered of the distribution of injury in their city and you'll see some of those maps since then we've taken this work a lot further exploring the implications of using digital technology at the point of care to inform systems development and public health we've been deeply influenced by the by the work of Dr. W. Edwards Deming Dr. Deming was a mathematician physicist and statistician who presented a paper in Japan in 1950 to a group of industrialists about a discipline called statistical process control and what Dr. Deming said you can imagine Japan in 1950 was it's sort of in its economy was in a post-war ruins there's not much industry going on and so the industrialists were eager to hear what statistical process control analysts would say to them and what Dr. Deming said is that any complex process in manufacturing can be broken down into a set of small discrete steps and within each step you can measure variability now there's natural variability and there's also unexpected variation and by reducing unexpected variation along this process Dr. Deming reasoned that you could actually control for the output of the process and not even have to measure its quality the act of controlling the process controls the quality and guess what happened in Japan after that Japanese manufacturing took off was noted to be highly reliable and Japanese automakers making the same car in the same model as US automakers actually had had better results and the reason was tolerating less variation during the process and the example that that that I read is that if you have a part that say supposed to be a foot long and the Japanese would tolerate one sixteenth inch of a variation but the Americans would tolerate one eighth of an inch those type of variations add up and car consumers would actually notice a difference in the quality of the product so once data starts to be mapped like this in real time you can start to get a true feeling for the microscopic steps in a process this work was adapted to health care by a Vita Ston Abedian 11 ease and American University and Harvard trained physician and public health scholar who developed the structure process outcome framework that we used to understand and evaluate health care systems today according to Dr. Don Abedian the measurement of process is nearly equivalent to the measurement of quality of care because process contains all acts of health care delivery so again simply by documenting your your patient experience well you have a chance to impact the entire system of health care delivery we've seen to health care teams coalesce around this digital technology and use it as a platform for communication and as a forum for collaboration we've also incorporated the work of Michael Porter from the Harvard Business School on time driven activity based costing what Dr. Porter advocates for is to take these processes break them down into microscopic steps and then to go one step further link those steps to costs so that you can then begin to estimate the true cost of health care so again by bringing digital technology one can start to integrate even cost data and start to get an idea not only of the cost but also the value of health care and we've also used point of care data to understand the contextual factors that surround injury using clinician entered data to capture demographics and comorbidity and GIS techniques to visualize the determinants and the social burden of injury this work joins a whole movement to link the point of clinical care to the health of the population I know that Dr. Marie Crandall spoke here a few years a few weeks ago on geographic information science applications and injury control and every other speaker and all of you have thought broadly and deeply about these issues I know that Dr. Rogers and Dr. Hampton are working with Dr. Sherman to map violence related injury here in Chicago this work will be essential both in planning of health care resource allocation such as deployment to paramedics and trauma center activity but also to begin to understand how the social determinants interact to create and perhaps prevent injury risk. What I'm most excited about though is the way all of you are designing the trauma system in Chicago from the ground up we have one of the oldest and best trauma centers in the world at Cook County and now the Chicago trauma the Chicago trauma center is coming up based as a hub for community engagement watching Dr. Rogers and your teams bring this idea of trauma as a public health issue into reality has been a highlight of my career. We have the potential to learn from every patient that comes through your doors and by thoughtfully considering the tip of the iceberg that is patients who are injured enough to come to the trauma center we can better understand the way the entire iceberg is affecting and disrupting the lives in the communities that surround us. This thoughtful consideration is and will be driven by better and more multi-dimensional and higher resolution data. There are some pitfalls with this emphasis on data collection and analysis. There is the issue of privacy and security. Healthcare data is sensitive and has the potential to affect employment insurability and autonomy. This is a concern that must be met with the greatest care strategies to protect and de-identify data are already well known and must be weighed against the collective utility of clinical and public health insights that can be derived from the linkage and analysis of big high resolution data sets. The cost of continuous high volume data collection analysis is also not trivial. Development and maintenance of technology and the serial analytics that are required to drive culture change are labor intensive and expensive. In many instances this work has required public-private partnerships where private contributions are profit driven. Who owns the data in these cases and in what form and what can people use the data for? These are questions for this and subsequent generations of ethicists whose work and continuous presence will be needed more and more. So I've spoken for a long time and I'm so grateful to all of you for listening to these stories. We've grappled with injury as a public health crisis forever but I think that for the first time in five decades we have an opportunity to disrupt the status quo with the technology from the point of care like this. Moving forward with injury control in my opinion depends on the reduction of disparities in the determinants of health and in the promotion of social justice. This means detailed attention to the interplay of age, race, language, gender, comorbidity, education, income, occupation, geography, housing stability and a spectrum of other factors that impact individuals and communities in the pre-event event and post-event phases as a continuum of trauma care. To do this may require diverse input and a willingness to embrace and address complexity. This is where I believe synergies with precision medicine will become useful. Precision medicine and precision public health are in my opinion complementary strategies. From precision medicine public health can adapt approaches to data collection, storage, security, linkage and analysis. It can target primary secondary and tertiary prevention policy to specific segments of diverse populations where they can be expected to have the most impact and benefit. From public health precision medicine can learn that genetic data must be linked to specific knowledge of the environment and of social determinants in order to have a true impact on society. It can remember to be inclusive in its selection of cohort populations and in the dissemination of its findings and therapies. Technology and analytics are not in and of themselves the solution to better healthcare systems. According to Dr. Donavedian, systems awareness and systems design are important for health professionals but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a systems success. Ultimately the secret of quality is love. It's an exciting time right now and technological revolutions can be applied to make meaningful improvements in societal health. I think that the apparent tension between individual and societal duties mentioned in the CMA can be resolved if we constantly recognize that what we see on the front lines of trauma is an individual and a societal issue. In the words of Martin Luther King, injustice anywhere is a threat to justice everywhere. Or from Rosemary Brown, a Canadian politician, until all of us have made it, none of us has made it. In the age of big data, these words are more relevant and exciting than ever. I'll leave with Dr. Cowling's comment which has been a guiding force in the evolution of trauma systems. Every critically ill or injured person has the right to the best medical care according to the state of the art and not according to location, severity of injury or ability to pay. In this defining comment he combines both the notion of the state of the art and the duty to society. Thank you very much. Very much on that to meet for that incredibly insightful talk. I actually there's this tension as you as you know between individual and public health especially in the context of the patient-doctor relationship. Individual surgeon, individual nurse taking care of the individual patient. How do you juxtapose that tension thinking about resources, the importance of attention to the individual patient but then being able to trip back and see the big picture if you will. Yeah thanks so and absolutely there's a tension between caring for individual patients versus groups of patients or versus society and what I noticed is that health care has become so complex now that it even takes many providers to care for one patient so the environment is getting more complex it's getting more disconnected patients don't feel that they have physicians, physicians don't feel responsible specifically to individual patients let alone to to society. So I think this complexity is getting is kind of putting in us in some ways at a distance from our patients. I think the solution to this is is better design of systems and I'm noticing that even in our division of general surgery the residents are always swamped with a million different commitments and trying to interact with a multidisciplinary team and always falling short of in these types of communications and spending less and less time with their patients. So what we're trying to do actually is standardize our work as much as possible so thinking about the the work that comes from manufacturing if there's a process that can be standardized can be automated can be done with a very little cognitive investment we'll try to standardize and automate that process and it really results in sort of a a manufacturing kind of ethos in medicine which I think clinicians tend to resist because we all value independence and creativity but I actually think that if you what what you standardize and if you can use technology to standardize a few things it actually frees your cognitive capacity to be more creative on top of that so it's like taking care of the fundamentals automatically and then on top of that building creativity so I guess it's a rambling answer but the short answer would be that I think that healthcare systems have to simplify and organize and ultimately to create more opportunity for clinicians to interact with individual patients because I think that's why we all why we all went into this I'd be invited to a chair we're going to take questions and answers and on this if you bring this water so you can catch the breath thank you no questions everything's clear to the bottom um that's very nice talk um you referenced Don Abidi in several times and he's somebody I've been familiar with for you know close to 40 years at this point um and um his structure process um leading to outcome paradigm um is you know applicable at um at sort of a macro level and it's it's an enabling paradigm it's I don't really see it as something that functions very well at all once you have an individual patient in front of an individual doctor and the the thing that I've always liked or for a long time have liked a lot more is something that's never gotten um much in the way of the fame that Don Abidi in her structure process outcome and it's a paradigm that puts together um knowledge the judgment with which it is applied and the skill with which it is applied and that that's something that works a lot better at the at the individual you know micro individual patient interaction level when you're talking about systematizing things there are many things that are certainly subject to systemization and checklists and things of that sort but when you get right down to it with things that are not routine I think it still gets down to knowledge judgment and skill what would you have to say about that yeah thank you that's that's a great comment which I which I agree with and the knowledge judgment skill is uh I think um the the qualities of a master and it was probably the way that medicine evolved initially but I think now that we've gone through this phase of industrialization where we're standardizing things so much and we have NISQIP and TQIP and lean processes and so on now knowledge uh knowledge judgment and skill probably comes back as a more modern construct you know I think that if we standardize some baseline functions of the health care system and on top of that layer our knowledge and judgment and skill I think our patients will be much better off and and I'm hoping that clinicians who are less distracted by regulatory issues and documentation and things things that may take a lot of their creative time away can then get back to this idea of applying knowledge judgment and skill and actually have more rewarding careers and achieve better patient outcomes the other the other great thing that you said is that something that follows from Dr. Porter's work at the Harvard Business School where for a long time I think we were on on this Donnabedean track of measuring process as an end in itself like just measure process and make it perfect because it's too hard to measure outcomes like what are outcomes anyways do we have to measure it 10 years out or do we measure functional independence or what measures do we use but I think we're realizing now that as the process has started to become standardized we could probably start to measure outcomes again and with technology applications and now there's so much data and patients can even report their own data we probably can start to calibrate our systems of care our knowledge judgment skill to to real outcomes that can be even patient reported and I think now we can start to move beyond sort of like this manufacturing mode to more of a value mode where are we providing our patients with valuable outcomes so I think what you said is a great comment and I think it represents sort of a maybe the next generation of thinking a focus on knowledge judgment and skill and real valuable patient outcomes and I think technology may in some ways enable this so the time that we talk is injury control how do we get more precision that there is that data acquisition is so expected especially if you push it to the foundations the immersive is that that's me yeah I think data acquisition is expensive but I think we're now you know entering this sort of big data era where a lot of places will be able to generate data now we're also developing analytics tools to separate junky data from from good data and we're also developing more computing power to link data and to analyze it and so now we have powerful computers that can apply machine learning techniques to data and so I think I think we're very good on the data collection side and I recently read about a notion called the learning health system and if you can imagine this is a national health services in the UK they talk about this learning health system that perpetually learns from every patient that comes through and in the learning health system imagine a circle and the circle has this afferent arrow and then an efferent arrow and the afferent arrow is all the data sources that come into the system so this is vital science data clinical data EHR data labs x-rays and so on and also patient reported data so that's the side where we're really good at getting and I think in the modern world with EHRs and all this stuff we're going to be able to collect massive amounts of data the problem sometimes is on the action side on the efferent side how do we get this data to actually change culture and to shift the needle on the quality of our care or the quality of our public health and I think that's where we're actually starting to get better as well because we know more about behavior change and the psychology of behavior change than we've known before we know more about the health of neighborhoods for instance we we're knowing more about social determinants of health so we need really smart people on both sides on the data side but also on the on the action side and the specific question about how can we translate that data into action so and as a I think that's really the most important defining question of our careers and my hypothesis and I wonder if you would agree and I'd actually love to know what all of you think is that if we're more precise about population health we might be better at it so if we know that you know seatbelt use in a certain community in the southwest of Arizona is very low then we can pick up on that and target it and we can target campaigns specifically to to seatbelt use in a certain population with a certain readiness for change and I know that they already do this and in our democracies the very precision messaging you know and similarly if if you if we can even move one predictor of risk in in gun violence say the age of acquisition of guns maybe that would move the needle in a community that has a lot of use violence with guns so I'm just thinking that rather than sleeping we're probably not going to identify sort of sleeping public health strategies to change population health we're probably going to find more precision strategies great I'm glad you brought up the example it's the 20th I mean it's the one-month anniversary of shooting in Portland one of the things that's has struck me about that is that there have been hundreds of thousands of shooting in Chicago and in Baltimore and Cleveland and so many American cities and we're still working on change and change hasn't happened Dr. Bendix thank you for the interesting talk I'm one of the trauma faculty here and interested in a lot of the concepts that you've been talking about today in more granular detail about some of the the data that you're interested in moving towards in a precision context how would you entertain the use of more let's say participant observation type of data some the more subjective components of what a patient tells their physician or the more sort of nuanced aspects and how you've approached that type of data rather than some of the geospatial biomedical metrics and how you've interfaced with that type of work if you have yeah thanks for another great question what I noticed about the geospatial analysis is that it only takes you so far like we've sliced our registry data every way we can and analyzed every possible sort of geographic visualization that we could but it sometimes doesn't allow us enough insight to actually change things so that that we probably have to start to develop these multifaceted strategies and I think that might mean combining geography from patient reported or citizen reported data and I know that some of our colleagues in San Francisco for example are using Twitter data to try to see if there's like hot spots for certain risky behaviors or so on and Twitter data comes in like the billions of data points like it's massive data and so I think we're just at the threshold of beginning to use sort of crowdsourced or citizen reported data I think where we might be more successful early on is patient reported data so moving closer to the healthcare system and I think Salman I'd be interested to know what you're starting to do is here with your trauma patients and families are they filling out surveys in the waiting room or are patients entering any types of data while they're waiting after surgery that's that's perhaps data that might be more immediately analyzable and actionable and we haven't done anything yet your brain at dinner it's we're 47 days away from being in the Dodd Thomas Center but maybe it can pivot that to that to Commence me who's it's the audience over at Cook County maybe he can talk well I think we you know where the guns are from we're from DNA we know the thoughts thoughts it's how we're walking there I don't know where he's to UN I think the million or the billion dollar question happy turn data and all the information that we know we have we fall into the way of problem how do you turn that to the politicians and the public policy right to the politicians have happened like we're at the table you you did get to the table with them you make the decision on the system the politicians have their view or their it turns into politics or the preconceived view of how you change them and I'm not expecting the answer no no problem I'll answer that I'm just kidding it is a billion dollar question I'm not one thing I wonder is that in in 2018 one of the lovely things about data is it's a very democratic force and so if people possess data at the grassroots perhaps they'll be more inspired to take action and so any type of data collection I think whether it's at the point of care and trauma or whether it's patient reported data should be as widely accessible as possible and the problem with registry data is it's collected nobody sees where it goes you need ethics approval to get it out it's going to be a year later before you get it you'll have to link it that's going to take more time then you'll publish it or present it in a meeting and then it'll be done so what we need to do is create systems that combine data acquisition with data analytics and data visualization so that non-scientists can see the data as it comes through and interpret it and often I feel like people on the front lines will be able to provide insights about that data that other people won't and I'm wondering if that type of data can sort of empower again, empower citizens to lobby for change and I noticed today it was a big rally for gun violence across the U.S. I don't know how big it was I didn't hear but I think that's ultimately what would have the chance maybe to make a difference but I think it would be more powerful if it's linked to real data and evidence I think I have mentioned the subjectives side every tragedy has a story some are very common and on the state law people are very careful that individuals are very common kind of start-ups a kid just a few days ago there's a story behind that if that subjective data gets captured in a negative case that's a chance basis yeah that's a great point about to see if we get the last word I wanted to thank you so much for coming and finding your way here going through some of the different neighborhoods thank you for having me pleasure thank you thank you all