 So, our next speaker is Stacey Lindow, and Stacey has the real quality of being an international expert in two pretty different areas. First, she is known as, basically, the international expert on sex, particularly in older people and women who have had gynecological cancer and also serious cardiac conditions. And then second, Stacey is like, as one of the pieces of this morning, she is basically one of the go-to people now in terms of social, in terms of health. In particular, she's one of the leaders in the identification of both social needs in the community and then social assets in the community and the linkage of those assets to those needs. And so, Stacey will be talking this afternoon on community determines health, not medicine. Stacey. Well, I know you all want to talk about sex now, but that's good for cocktail hour. Let's start by defining what is a community. It's a group of people who come together with a shared concern and a desire to take action collectively to protect the values and to address concerns. Every time I've had the privilege to stand at this podium, at this conference, which is now many years too many to count, I've thanked Mark for creating an intellectual home for me at the University of Chicago. And really, of all the conferences I have the privilege to present at, this is the one where I feel like I'm with my people, I'm with my community. And so, Mark, thank you for creating this community. And what we all owe to you is to keep it together, to keep it going. And I'm certainly willing to help on that charge. So let me start with acknowledgement of disclosures and funding, the journey of understanding how it is that community drives health led to an innovation award which had an expectation for a sustainable business model which resulted in founding not one, but two companies, one of for-profit companies, which leads to this disclosure slide. And for those of you who heard Monica Peek this morning, she just did my disclosure for me. I did not pay for advertising, but you've had a chance to look at that. And then funding for the research comes from a variety of federal sources. I don't know if Albert Wong is still here, but he's one of my dear collaborators on the work we're going to share today as are many, many others. The good news is that you have my favorite disease. And what this doctor means by favorite, of course, is he knows just what pill he's going to prescribe or what procedure he's going to do, and he's going to generate some revenue, some fee for service. There's not a lot of beneficence in this cartoon, nor autonomy, nor justice, but it's emblematic of the healthcare system I joined when I completed my training in medicine. Sick care has been our business. Sick care is about the drugs, the devices, the procedures, the facilities we can bill for. Sick care is where the patient is a disease. The community in the sick care model is a place for charitable care, for charitable contribution. The community is the other, and it's typically referred to the geographic population surrounding the hospital. Technology in this context silos. Healthcare, which, you know, Harold Pollock gave me some hope that maybe it's still there in our future. Healthcare, the business of health, is more about education, delivering information, prevention, and more and more of it happens at home and in the community. Value-based payment means we pay based on outcomes rather than procedures and devices and drugs. The patient is a whole person. The community is a care partner. We share responsibility with community-based service providers, human and social service professionals. We're not alone. The community is us, and technology in this scenario connects. It's inclusive. We all can see what's going on. We can share information efficiently and we can improve quality over time. The fee for service world, the patient is pregnant. I don't mean to call pregnancy a disease, but I'm an obstetrician, so it's a good example. The patient is pregnant, and I have some folic acid for her, and I'll see her next time. I could do an ultrasound. That generates some revenue, and the more ultrasounds we do, the better. The value-based world is a little more colorful. It might be a little more complicated, or it might make us feel like we're actually the carers we signed up to be. In this world, the patient is not just pregnant. She's a pregnant mom. She has children at home to care for. She's a caregiver of a dad with dementia. She's recently unemployed. And she has a lot on her mind. She has medical needs and wants to adhere to those recommendations. She has economic needs, behavioral needs, self-care needs, caregiving needs. And if we're going to develop solutions to address this whole person's needs, we should think like we did when we built a solution to address people's pharmaceutical needs. We didn't develop one technology to prescribe antihypertensive drugs and a different technology to connect people to asthma medications. We created one solution that would allow us to care for whole people. And one of the things that's happening as we try to integrate the idea of addressing social needs or basic needs or social risks into our daily practice of care is we're thinking about those needs and how we're going to incorporate them, but we're forgetting to think about how we're going to address all the other needs a human person has, which is going to prove ineffective. So what is value-based payment? This is a paper just published, October 29th, lead author from Penn. They used a Delphi method to survey leaders across the country to come to a consensus statement about what is value-based payment. Value-based payment aligns reimbursement with achievement of value-based care in a defined population with providers held accountable for achieving financial goals and health outcomes. It encourages optimal care delivery, including coordination across health care disciplines and between the health care system and community resources to improve health outcomes for both individuals and populations. The yellow sentence? I wasn't part of the Delphi conversations, but I imagine if this conversation happened five years ago, the yellow sentence might not have been there. The idea that community resources ought to be in the business of health care is a relatively new idea, even though we've been working on it for a long time. In our own work, we started with this, I mentioned this innovation award and I've shared this slide, I think in the past. We employed youth and trained youth from our communities to conduct an annual census, feed on the street, technology-based, to document every business and organization open and operating to serve our communities. Why did we have to do that? Because Google and other mainstream data sources don't have high-quality data when it comes to higher-poverty communities, so we can't rely on that. We took the data that the youth collected about community resources and plugged them into electronic medical record systems using medication e-prescribing as the frame of reference. And we generated more than 113,000, what we called healthy prescriptions, a list of resources generated to meet a person's needs as they were defined in the electronic medical record. This wasn't obviously a full scope of needs, but it was the place we started. And one of the most interesting findings from this work was that when people were permitted to call in to be surveyed, so these were volunteers, a few hundred of them, and we asked them, what did you do with the information on your Health ERX, 49% of these volunteers told us they told somebody else or used the information to help somebody else, which I found fascinating. And I started to think about beneficence. We recently repeated a study, but this time using experimental method. So we conducted a real-world controlled clinical trial of what we called CommunityRX, this Community Resource Referral Intervention. In that trial, we randomized people by alternating calendar week, and people either got usual care or if they came in during the week when the system was turned on, they got this auto-generated list of resources personalized to them based on everything we knew about them in the electronic medical record. Everybody got it. You didn't have to be high risk for something. You didn't have to have a special condition. If you came in on that week, you got the intervention. It was delivered by nurses in the ED who handled discharge and by clerks in the primary care unit who were responsible for discharge. And in the primary care clinic, the physician could opt to use this tool. She didn't have to. So this was a way to indicate adoption, sort of natural adoption. So I'm really interested in this resource sharing, this information sharing, because when we deliver a drug or device, it's really a one-to-one situation. Although I do know sometimes people share their Viagra with other people, but in the delivery of information, we have the opportunity for information to spread well beyond the clinician or the patient involved in the intervention. So do clinicians share community resource information? Well, these are some data that are actually in review now. So the tables are intentionally difficult to read, because I don't want you taking pictures and tweeting them out until they're peer reviewed. But here's a description of the nurses and physicians who participated or who are exposed to this intervention. You see some of their sociodemographic characteristics and occupational characteristics and some expected differences. 50% of doctors and nurses exposed to this intervention told us that they shared information from the HealthyRx. Remember I told you it was 49% in the Volunteer Collins survey study of patients who got the intervention? One of these groups was more likely to share than the other. Who do you think? Nurses or physicians? Nurses. So let's look at, let's see if I can make this work. Let's look at the rows right here. So clinicians shared HealthyRx information, 50% of all providers. It was actually 57% of primary care physicians and 42% of nurses. We also asked you generally share community resource information. And where's Sharon Markman? So think about what you talk to people about, especially if you live in the same neighborhood. I didn't orchestrate it. You started it. But standing in the back of the room, we live in the same neighborhood. Two minutes into the conversation, we probably shared 10 different community resources. People are excited about the assets of their communities. How confident are you in your ability to address your patients' unmet social needs? Not so confident. 28% of physicians versus 9% of nurses said they weren't confident. 25% is the median estimated time nurses and physicians said they spend addressing their patients' unmet needs. The range was 5% to 90%. Let's assume it was just 5%. Imagine in dollar amounts what it would be if we told a 5% of all nurse and physician time in the United States spent on caring for patients unmet social needs. Could we identify interventions that cost less than that, that connect people to community-based supports and alleviate the burden on the health care workforce? Well, what about patients? In this trial setting, what proportion of patients shared community resource information? So here you see the enrollment flow chart. We had a subset of people, about 117 people, for whom we had longitudinal data at all three time points. Half of those shared healthy RX information. And there weren't a whole lot of differences between sharers and not sharers. We looked really hard to figure out, what are the characteristics of people who share? Because if you can identify that, you might target the intervention to those people. To use the Yiddish, these are mavens in a community. People you can count on to do what Sharon is for Sharer maven. You know, the chit chat in the back of the room, or when we run into each other on the street, or at the grocery store, we're going to share information. Remember, this is health-promoting information. So we didn't see a lot here in terms of differences in sharers by their sociodemographic characteristics. Although, as you would expect, there's a trend. People with larger social networks look like. They would be more likely to share. 49% of patients shared information from the healthy RX. And 21% of people told us that they gave their healthy RX to another person. We learned a little more about that in our qualitative interviews with people. But remember, this isn't just a generic resource list. This is a resource list targeting the conditions a person has. So you have to be willing to tell something about yourself when you share this information with somebody else. Patient sharers were more likely to have gone to a place on their healthy RX. So if they actually used the information for themselves, they were more likely to share it with somebody else. 26% of sharers went somewhere versus 6% of non-sharers. Overall, it was somewhere between 12% and 15% of people within three months told us they used the information to go somewhere. Interestingly, it was people in poorer physical health who were more likely to share information. This was a sick population. The national mean on this physical component score of the health-related quality of life measure is 50. So the whole population was really sick. But the sicker you were, the more likely you were to share information. Why would that be? People who gained or retained information specifically about mental health-related resources like counseling, stress management resources were substantially more likely to share. Here's a way of looking at the information spread. The gray box are people over time who got a healthy RX and didn't share it with anybody. The purple are people in the community who received information from the healthy RX who were not directly exposed to the intervention. Of the 117 people who were able to follow over three time points, 59 people shared with 183 others. And this has to be a conservative estimate because it's based on people's recollection. It's very possible people shared more than they remembered. And this doesn't include nurses or doctors sharing just the patients. The other colors tell you how people's state changed over time, how many time points they shared, and it is a little more nuanced and takes a few more seconds to take in. But people's states did change over time. So we've created this concept called social dosing, or we're sort of expanding the application of this concept. Some of you who work with illicit drugs might know the term is used to describe micro dosing of psychedelics, for example, or peer-to-peer dosing of drugs. We're taking back the night on that term, and so we're talking about social dosing of information versus clinical dosing. And we define it as the diffusion of health-promoting resource information from patients who got a clinical dose to the broader population who didn't get a clinical dose. People showed others they're a healthy RX, so when they 21% told us they gave it to somebody else, they let somebody else look at it. But only a few people described actually giving it away. They wanted to hold on to it. So you see a quote here. He read what he liked, so he wrote it down, and he's planning to call for more information. But I'm not giving it away, so people seem to value this information. People emphasize the locality of the resource. People were proud to say these are resources that are near us and our neighborhood on the south side of Chicago. People valued, in addition to the information about basic needs and their social needs, they value it having health-specific information. And like I said, in sharing their healthy RX, they were revealing something about their own health conditions, but they really wanted to be able to help people who they knew had serious conditions and needed resources. And it was interesting, there were some insights, and we need to do more in-depth work on this, that the healthy RX helps legitimize or credentialize these recommendations people were making to their peers. It has good points on it, or I'll even go with you if you don't want to go alone. To understand this social dosing concept better, we've been working with computation scientists at Argonne National Labs. We've been using an agent-based model, a computational model to simulate the same dynamics we saw in the clinic, but at the level of the whole population. The study I just shared were people ages 45 to 74, and they were, as I mentioned, really pretty sick people, but we wanted to think about how would information spread in the whole population if everybody could be exposed to the intervention. So here are the results of the simulation, and it's very, it's risky of me to present this to you and just expect you to believe the whole black box of the computation piece, but I'll do my best to answer questions if you have them. What we did is we looked at how information spread by clinical dosing alone, and we generated a model looking at physicians delivering it, nurses delivering it, and clerks delivering it, and the map looked almost exactly the same. It didn't seem that who delivered the information in this very low intensity way really determined the spread of information, so I just show you the map for physicians. Look at the increase in breach to individuals. These are individual households that were exposed to the information when we simulate the intervention across the whole population over a several week period. Here we see about a four-fold increase in reach. In the clinical trial, it was three-fold. Remember, 59 people reached about 183 others in three months. So the findings, whether it's a computation-based model scaled to the whole population or an empirical study looking just at the 45 to 74-year-olds, the magnitude of impact is about the same. Why do people share? Why would sick people socially isolated compared to the general population living in poverty? Why are people sharing? And that's what I think is really fascinating. We can draw on information science. There's a body of literature that looks at information sharing and what motivates information sharing using data in online communities. It's a great place to go for data because you can literally see exactly what people share because they're doing it digitally. So you see somebody shares and you see how people respond and that's the kind of data that is behind the science. But it gives us some insights. People might share because they're looking to promote their reputation. Sharing information might be a commodity. A sick person might be dependent on somebody else and this is something they can give back. It might be about reciprocity. There was certainly evidence of empathy in the qualitative data. So what are the conclusions? Clinicians spend real time addressing non-medical needs and I know in an audience of humanitarians we spend way more time than most people do. This is not something new. SDOH, social determinants of health, structural determinants of health, that phrase is new but don't let anyone tell you that you never did this work before. We've just been doing it in the most inefficient and not joyful way. Personalized information delivered in a clinical setting spreads. How can we leverage that as we move more to an information and prevention intervention world? At scale, the mode of delivery might matter less than who has access to it. So the message is let's get as many people access to community resource information as possible. The shift to value-based care presents a new opportunity of forced multiply beneficence. Can we start to deputize our patients to be sharers of this information intervention to benefit their community? And lastly, if we evaluate information interventions and technologies like we do drugs and devices, we're unlikely to capture the population level impact and they will be undervalued. Thank you so much.