 I'm Sonia Sarkar. I am currently a public interest technology fellow here at New America focused on this intersection of health and human services. But previously, I worked for the Baltimore City Health Department, and prior to that, I got my career start with a social enterprise organization named Healthly that also focuses on integrating patient social needs into standard quality of care. And I'm really, really excited about this conversation. I thank you all for coming out on a Friday afternoon to spend it with us talking about this topic. I know that everyone has extremely busy schedules and that it's not always easy to take time away from the real work that you guys were doing out in the field with your partners to come and brainstorm around some of these questions that I think many of us are facing in our work on a day-to-day basis. So before we dive into the actual content of the agenda, I just wanted to say a couple of quick things. First, I wanted to thank Kaiser Permanente, our sponsors, because of them, that we have this delicious food spread. So we're grateful to them, and of course grateful to them, not just for the food, but also for the work that they do around total health in general. And I also wanted to just start off, before we dive into a number of conversations that will focus on best practices and the technical aspects of why it is that health and human services could and should be integrated together a little bit of a story first, because I think often when we are focused on healthcare and focused on wellness, it's very easy to gloss over the reasons why we do this work in the first place. So for me personally, the reason that I am sort of singularly obsessed with this question of how we might integrate healthcare and social services together in order to address the real needs that patients have is because when I was an undergraduate, I had the opportunity to be a health leads advocate in a busy pediatrics clinic right in East Baltimore. And as I was there with patients, I remember one of the patients that really stood out, and I think for those of us who work in the healthcare or social services arena, there will often be that one family or that one client that opens up your horizon and teaches you something maybe that you didn't know before. This was that patient for me, so she had come into the pediatrics clinic because she and her young son had been in and out of the emergency room with several asthma exacerbations. And they were living in a dilapidated row home with asbestos dust on the floor and peeling lead paint, and she was exhausted. So I was a sophomore in college at that time. She was probably a little bit older than I was. And I remember as we were talking, I was asking her a little bit about what it was that she might need in addition to the medical care that she was receiving. And what she said, which I've shared with some of you before, is she said, I just want a house that's actually a home and that will stop killing my kids. And usually when I share this story, that's where I stopped the story and I say, well, this is great. I think now we understand that there's much more to health and healthcare than just the medical care that you receive in the clinic or a particular prescription or a diagnosis or a treatment. And this is why social services matter. But I actually wanted to continue the story a little bit this time and talk about the fact that in that moment, the person who didn't have an understanding of how the healthcare system worked was me. I was a college student. I grew up privileged, had access to the best of healthcare, understood that medicine sort of looked a certain way and that for the most part, it had delivered what it was supposed to deliver for me and my family. But what I hadn't gotten into that conversation with was a learning mentality around what it is that healthcare really looks like and what health means to people on the ground every day. And that conversation for me was the first realization of the ways in which I needed to be challenging myself about my own assumptions and also thinking about who are actual experts when it comes to healthcare and who we invite into rooms, who we actually place in the center of our design processes, as you'll hear some people talk about a little bit today. And so as we go through the afternoon, I just wanted to put that front and center because I think that in order for us to build a healthcare system that's actually focused on health and in fact, actually focused on health equity, requires us to challenge our own assumptions about what we may know and what we may be bringing to the table. Now, that said, I'm really excited that you all are bringing your experiences to the table because this conversation is not meant to be a lot of us up here talking, trying to push out information to you. We're designing it so that all of the collective expertise and all of the collective knowledge in the room is being brought to bear and can really help inform this decision of how it is specifically that technology as a tool may both accelerate, but then also pose challenges to this question of bringing together health and human services in order to address the real needs that patients have. And so I'm really excited to hear what all of you have to share. We're trying to make this as interactive as possible. So please let us know what your questions are as we go along. We do have questions that have been submitted by folks who are watching on the live stream. We have questions that have been submitted by other folks that weren't able to make it today. And we're gonna move through from our keynote panel which I'll introduce in just a second. And then we will also have a panel of innovators from Baltimore and then we will move into the working sessions after a short coffee break and refreshments. So thank you all again. We're really looking forward to it. Any questions before we launch in? Okay, so with that, I am very excited to invite up to the stage Dr. Susan Blumenthal. I've had the great privilege of being able to work with Dr. Blumenthal in her role as a senior fellow here at New America. She is leading the creation of the Health Innovations Lab and Health Policy Program here which is really the first time that New America has ventured explicitly into the health and healthcare space. She also has a number of other potentials including being a former assistant surgeon general and is a clinical professor at Tufts. And I'm really excited for her to share some of her experience with us today. So come on up, thank you. Thanks so much for being here. Well, thank you Sonya for having me. We're very proud of you as a doctorate student to really shine a spotlight on these critical issues of the intersection of health and human services. Thank you, I appreciate that. And one of the things between health and human services and then security or programs that also become homelessness or other aspects of what health might mean to someone and I'd love to hear a little bit about what drew you to the type of work and the first place and how have you been in these conversations over time? What have you been thinking about the evolution of this sector? Okay, well, very good. Well, again, thanks to everyone here for being here and for really working in this space. It's critical. In my career, I was drawn to medicine and my mother had cancer when I was 10 years old and I decided that no other woman should have to suffer the way she did. What it struck me though was that for other patients on the ward, I mean, there was no internet then. When do you, how do you get best practices? How do you find out what is the state of care? And I think that she lived long enough to see her daughter become a doctor but when I went to college, I was very interested in the intersection of health and human services. I was both a biology major and a humanities major and I think throughout my education and subsequent career, I've tried to bring those perspectives together. I started my work at the National Institutes of Health. I was chief of suicide research and mood disorder research there and it clearly became apparent then when we had these clusters of view suicides around the country that there was a set of factors including both the presence of mental illness but also social factors and experiences that were causing the rising rates. In women's health, where I had the honor of helping to expose the inequities in women's healthcare and then working to weave a focus on women's health into the fabric of our national programs at NIH and CDC and FDA, working with the private sector to move this forward, it became apparent that health was no longer in the province of just the clinic or the hospital but that you needed smart agricultural policies about food. You needed transportation so that women could get the services they needed and you needed a foreign policy that addressed health and social service needs. I've worked at the beginning of the AIDS epidemic and again, when we didn't have medications, social behavioral changes were the only tools we had to address rising rates of HIV. Once medications were available, we were able to use this as an important tool but when the president's emergency plan for AIDS relief was put into place, it was really a drug program to begin with and then evolved into a program that not only administered drugs but tried to prevent the disease in the first place and strengthened health systems and in the AIDS epidemic, with the establishment of the Ryan White Act and housing programs, it was clear that there needed to be a comprehensive approach because again, you can give people medication, you can give them social services but if you don't address the situations in which they're living, you're not going to see progress and I think you think about the community where you're getting your incredible education, you have in Baltimore some of the very best and finest hospitals and clinics in the world but Baltimore has a 30% higher mortality rate than the rest of Maryland counties and you rank at the lowest at some of your health outcomes and why should that be? And I think, again, it underscores the importance of social services in addressing the needs of people. One third of people who are hospitalized will be re-hospitalized once they leave the clinic and that just is not effective. I mean, we need to address the situations in which people are living in order for them to live well and a healthy life in their communities and I think that's what your work is all about is really addressing so many of these factors. There's a fascinating paper that shows that one third of deaths in America are due to socio-cultural factors and I think that it drives home the, that socioeconomic status is the most powerful predictor of our health every step down the income and education ladder takes you up steps in terms of premature death and disability from disease. We spend 90% of our healthcare budget on medical services and yet probably only 5% to 10% on prevention and yet 70% of disease is linked to modifiable preventable risk factors so it's all backwards and that's what building a culture of health is all about providing those innovations that can really put prevention and prevention whether it's at the primary level so to prevent disease in the first place or whether it's tertiary prevention which is managing disease more effectively in communities at the forefront. Thank you for that and I think particularly what you were saying about the fact that we know a lot of this, right? So there is medical literature, there is social policy literature that shows us that these connections exist and I'm particularly fascinated by the fact that we're now at a point in the conversation where social determinants of health have become much more of a kind of term of the day, almost a buzzword in some ways than it has been the case in the past and I'm curious if there are two things. One, any observations you have as someone who's been working on this issue from a number of different angles about why that might be and why we're now seeing a number of not just healthcare professionals but also non-profit organizations and for-profit organizations moving into this conversation and where that's coming from but also with respect to that what are some of the key considerations that you would really wanna see for the field as that's starting to grow? Well I mean I think Maslow talked about the socio-cultural determinants, it's been here for a long, long time but I think one of the key turning points has really been data analytics. Murray did a fascinating paper that showed there were eight Americas and by using data analytics to see that you didn't have to go to the developing world to see these huge gaps in life expectancy but here in America there was a 30 year life expectancy differential by your zip code so that a Native American man living on a reservation in North Dakota has an average life expectancy of 58 where an Asian American woman living in Bergen County in New Jersey lives to be 88. And so I think that sort of those precision tools helped us to really see what are the differences? What are the factors that could be contributing to this? And I think some of the hotspotting techniques that we have now to kind of zoom in on where there are problems because you can be in one state and there could be huge differentials between communities and I think that that has really helped us to pinpoint the importance of socioeconomic cultural factors. I think there's another shocking statistic that the three wealthiest men in the United States of America Bezos, Gates, and Buffett have the same wealth as the bottom 50% of all Americans. These income inequalities I think are really hitting home in terms of the role of poverty. One of the initiatives that we're working on here at New America is called the 53% initiative. Consider this statistic, 53% of all infants born in America are enrolled in the WIC program, the Women Infants Children Supplemental Food Assistance Program. 53% of all infants, 25% of all toddlers in America. But by the time that infant becomes a five year old when they age out of the program, there's a 54% attrition rate. Why? And I think that also brings up these issues of how do we create in the digital age more high tech, high touch programs that incorporate an understanding of what the needs are of people and how they can best access the programs in the federal government and in the private sector that are available. Those attrition rates show that we haven't been doing the kind of job we need to be doing in order to maximize the health and well being of our citizens. Yeah, I think particularly your point about income inequality really resonates because I'm sure many of us in the room have worked on issues of identifying perhaps that a patient or a client has let's say a food insecurity need, right? And then thinking about how to get them access to a resource that might actually address that need. But I think the real question is why does food insecurity exist in the first place and how do we think about the connections between the policies and the interventions and the sort of direct front line care that's being provided and then some of those broader questions as well. And so it's a point really well taken. I'd love to talk a little bit about, given that so many folks in the room I think are sort of deeply invested in this idea of health and human services coming together and are engaged in all kinds of different innovative models across the country that are focused on what that question might look like. And are here today because they particularly want to shape a community that's thinking about where technology fits into that or doesn't. I'm wondering if you could talk a little bit about the work that you're now doing at New America, what you hope to achieve with this health innovations lab, why it is that the question of technology and healthcare and how they intersect really appeals to you and what are some of the goals that you would have for the healthcare professionals, the technologists, the community organizations that would be brought together under the lab's purview. Thank you. Well, we're interested in doing a number of things with the health innovations lab. We want to curate innovations that have occurred and spread them because just as we've all worked in silos, there's often not a lot of opportunity to crosswalk fields and to learn about what other people's work is. We want to use data analytic tools to really identify some of the areas for innovation and we want to kind of help to create a seamless system of care. Talking about when people leave the hospital, how can they live more productively in the communities? How can we bring innovations and technology such as remote monitoring using apps where you communicate with your physician and other healthcare providers when they can signal that a problem is happening and then follow up with care? I think that there's just a lot of work that's going on and that could be going on to bring this into this 21st century. I built the first website in the government for health. Think about this in 1993, there was no website in federal government for health and NIH and CDC didn't want to give their brochures to put online because their public affairs budget was based on how many brochures that were distributed. So we had to go to the Department of Defense to build this innovation and about a year and a half later when people understood the power of the internet, we moved it back to the Department of Health and Human Services. But it was one stop shopping for women's healthcare. Since that time, there's been a proliferation of websites. Now it's almost hard to differentiate between them because where do you get the most trustworthy information but it just shows how something, an idea can be sparked, an innovation can happen, there can be resistance because again, institutions don't like to change. There can be resistance but then you see acceleration of progress and I think that's sort of what the lab is about is really identifying and helping to incubate some of these innovations that can create a more seamless system of care, a culture of health now and in the years ahead. Thank you for that. It's really interesting I think that increasingly when it comes to talking about the role of technology in healthcare, you find that there's often two camps. One camp thinks that technology could be a panacea and solve a lot of the challenges that we have in terms of healthcare disparities or healthcare communications or being able to link together some of these sectors that haven't been so good about coordinating with each other in the past. Whereas others I think look at something like technology which is multifaceted and say whoa, this could pose a lot of new risks, unintended harms that we haven't been thinking about in the past and need to be intentional about going forward. And so I was wondering if you could talk a little bit about I know you had named a couple of different opportunities but how do you think about those pros and cons and what are some of the challenges as we move forward with really integrating technology into our workflows within health? I think it's a very important question. I mean, if Charles Dickens were framing it he'd probably say it's the best of wires and the worst of wires because the technology can connect us, inform us but it can also debase and it can take away privacy. And I think we've seen this recently with Facebook issues. I think hacking medical records has become a business where healthcare practices are taken hostage for money to be paid over otherwise they're going to exploit medical records. And I think we've seen this with new genealogy websites and some of the genetic testing websites where people are being reconnected to people they didn't know. Parents are finding they had children had been given up for adoption and with infertility banks and so forth people are gonna find that they were parents when their children find them through these mechanisms. I think there are also a big study that's just been launched by the NIH. It's called All of Us and its aim is to recruit one million people to take blood samples, to do genetic screening as well as asking about lifestyle and environmental factors. And I think it's really going to explode the field of epigenetics which is to look at how environmental factors interact with our genes and cause them to misspell or what interventions we can do to promote health in the years ahead and also look kind of helping to create this field of precision medicine because as we have lots of people participating it's kind of the modern day Framingham study that will be able to target new medicines more precisely to the signature of that person's disease. But it also opens up a kind of a Pandora's box of potential privacy issues. Again, we've seen the DOD be hacked and the CIA be hacked. I mean, we have to make sure that cybersecurity is at the forefront of health and that there really is a partnership between technologists and health professionals that protect the most private of people's data as we move forward in the years ahead. I think again, this kind of working in an interdisciplinary fashion is the hallmark of health in the 21st century. I'll give you another example of work that I did in women's health, but at the beginning of the healthcare debate for health reform in the 90s, we were looking at what age people should start preventive interventions and there was a lot of, as there is today, debate about when do you start mammograms and the research was saying 50, but women had been educated to begin at age 40 for their mammograms. So when you delve deeper, there's three out of four lesions that mammograms find are benign and it misses 15 to 20% of cancer. So I thought if we can see the surface of Mars with the Hubble telescope and with DOD, we can track missiles 15,000 miles away in outer space. Why can't we apply those technologies to find small breast cancer lesions right here on Earth? So I called up the director of the CIA and the head of NASA and the general who runs the research command at DOD and they wanted to work with us to apply their expertise. So we brought in technologies from other areas and we were successful. It was the beginning of digital mammography and computer assisted diagnosis and we got a peace dividend from our national investment in defense and intelligence and space work. And I think that kind of model, fast forward to today, where we bring the expertise of economists, sociologists, housing experts to work together on health problems. I think that all of you have been really incubating innovative solutions and we were very heartened to see that CMS has put $157 million over five years into developing accountable health communities. You're incubating these ideas and then our challenge will be to scale up what works. Yeah, there are two things that you mentioned that I wanted to follow up on, one being the idea of patients' privacy and confidentiality potentially being at risk as we introduce new technologies and new innovations into the healthcare space and we've had a couple of conversations that I've really appreciated about thinking through what it looks like to really intentionally design for dignity with patients and think about, particularly with large government programs or even with the healthcare system itself, what it might actually sort of look like from a vision perspective to place the idea of dignity at the center of a lot of our workflows, which is certainly not the way I think many of us interface with some of these big systems. And so I'm wondering if you could expound a little bit on that and talk about what you think some of the key principles are there. Well, I think it's a really important question because I think, again, it's about technology and the public interest. There's been a lot of stigma associated, I think for many low-income Americans who are involved in federal food assistance programs. Our project, and I want to acknowledge Emily Yang, who's been program coordinator, she's just getting her master's from Johns Hopkins University with me today. But I think that one of our goals for the 53% initiative dealing with WIC is to really bring dignity into this process because the way the program works now, a mother will get a paper voucher for her food benefit. And that paper voucher can only be used once. So when she goes in, she has to buy all the milk and the vegetables, and they're not gonna last for that month. She also is giving the paper voucher in the grocery shopping line and other people can see and sometimes she forgets to get something and she has a toddler in hand, has to run back and forth and it's very demoralizing and stigmatizing. So the idea of our initiative, and we worked with, we had a conference at MIT with the Harvard School of Public Health and we brought together these unlikely partners, technologists, futurists, and public health practitioners, who more and more in the digital age are the partners that need to be at the table. And so many of you here today represent that new paradigm. But what we're trying to do is as the program moves to the delivery of food benefit by 2020 for an EBT card, why shouldn't that EBT card become a smart card paired with a mobile app that would scan the product, tell you what's eligible, provide nutrition education about what the content of that program is or that product is, provide child education tips in terms of helping parents to boost their child's learning and development, collect data so that you as public health researchers can understand the trajectory of the program, its outcomes, health outcomes as well. And I think that again, this kind of transformation from a 20th century program, a paper-based program to a technology program, yet keeping the human service aspect of it. We so want people to meet with clinic staff and to have the benefit of that interpersonal relationship, but why not widen it to also use social media so that you can connect with nutritionists and healthcare providers, but also with your peers in the program to get tips about nutrition and child development as well and to find each other to do cooking sessions or have potlucks. And I think that's sort of the transformational possibilities of technology that here at New America we're trying to achieve. Thanks for that. The other story that I always really enjoy whenever I hear it is when you do speak about demanding that if we're able to have a Hubble telescope, we should be able to find imaging technology that works for women's health. And building upon that, you've talked about the DOD actually in a couple of different areas. I wanted to get your sense of what are those unlikely partners or those unconventional stakeholders that may not see themselves as health professionals or in the healthcare space that you think are important to bring into these conversations that we're having about what the intersection of health and human services really looks like? Well, I think to your previous point, I mean, we brought into this conference also design experts, because I think we don't, and again, I remember from the work in women's health, we wondered why are women not in clinical trials? Well, one of the things was that we didn't ask them to be in clinical trials, but once it was open to clinical trials, we didn't think about all the barriers, the transportation, childcare, and other things. So I think designing, looking at the design and the architecture of the experience, what are the barriers to participation? What are the barriers when people go home from getting their healthcare that prevents them from getting their medication filled from having healthy food at the table, from having the housing that they need from making those tough choices between do they fill their diabetes, they get their insulin medicine, or do they put food on the table? To look at the pathway, the journey of a person in the community or a patient, and understand what the barriers to healthier lives are and what the opportunities are. And I think so design experts, I think technologists are really important. We need to have really all sectors of society at the table. We need businesses. We need media because, again, so many of the messages that people get come from media. And oftentimes they're the wrong messages. I mean, when you think about how much we spend, 1% of the SNAP program is nutrition education, and you compare that to the billions of dollars that are spent on health marketing of unhealthy foods, or not health marketing, marketing of unhealthy foods. So I think it's trying to bring in some of these unlikely partners. And I think whether it's the VA or the military, they have solutions too, because they're more integrated programming, and they may have ideas that could be put on the table. And so I think it's really looking through communities and through federal government, I think everyone has a role to play. And I'm reminded of the 2007 time cover that said it had a computer on the front, and that was the person of the year. And why? Because in the information age, each one of us brings a unique perspective. Each one of us has the ability to connect and to be an influencer. And I think we just have to think creatively about how to marshal those resources. Yeah, I appreciate that. It's a little scary that they put a computer up there as a person of the year, but maybe that's where we're going. The computer with us behind it, I think. But now, I mean, I think the AI issues are such that we're now looking at how does this technology maybe replace humans, and that's a whole new set of issues that I think we'll all be addressing. Yeah, and actually just to build on that for a second, given where we're going, you have been an educator yourself. You've seen lots of people come through health professions of all types, whether it's medicine or public health. And as you think about the skill sets that will be necessary in order to use technology in a way where form really follows function, right? So we're not allowing technology to dictate what it is that we're doing, but rather really thinking about what the true kind of problems are and how we might solve them and then deploying technology against that. What do you see as some of the areas for learning or areas competencies, if you will, that folks in this room, folks outside of this room, those who are just getting started in their careers will really need to hone in on. Well, I think the technology is only as good and as effective as the human values that animate it. So I think, again, we need to think in our society about civic education, about ethics, about the legal issues. I think that technology cannot replace human services, and I think it's a way of creating a new configuration of it in the 21st century. I think young people do, though, need to learn data analytic skills. I think they're very important in solving problems. I mean, as we talked about that zip code approach and the hotspotting that has given us new insights into where there are problems in communities and to delve deeper and to address those issues. I think that our education systems really need to change to address that, and yet, I know in medical education, we often stay the same, and I think there really needs to be a look at the kinds of tool kits that you're talking about that need to be included in the training of healthcare professionals and others as we move forward in this intersection of health and human services and technology in the 21st century. Great, thank you. So just to close this section, and then we'll open up to the audience for Q&A. We'd love to hear, you know, we've touched on a number of different topics, and this is clearly something that you are personally passionate about and invested in, and just curious what reflections or advice you'd have for those of us in the room who are either doing the work of directly supporting patients and clients or who are supporting those that do. Well, I do think that, you know, many of us were trained in that silo in terms of, you know, medicine or, you know, technology, and I think it's really reaching out and finding those partners as you're doing today. Sonia, I want to commend you really for bringing together all the partners that are in this room because that is the way forward in the 21st century, this, you know, accountable health communities where we bring the skills and the values of multiple fields together, and I think you'll find in those unlikely partners that there's a lot of excitement about being involved in a health problem. I know when we opened up the CIA to work on breast cancer, they were so excited because one, their activity had been covert, but two, to be able to work on an issue that could affect the health of womankind meant the world to them, and so I think that there are relationships and bridges to be built, and that's been something that has been of great value to me in my career, and I see all of you here today are doing just that, so I commend you. Thank you. We will open it up for questions. My name is Desiree Delatorre, and I'm with Children's National here in D.C. It's the Children's Hospital here. Thank you so much for both of your comments today. I'm really interested, coming from a Children's Hospital, the interconnection between health and education, and being in the Children's Hospital, we see such an opportunity to work with the school system. Can you talk about some of the incubation that you have had with innovation on the technology side, the health side, and the education side, if any? Well, I think, again, education is such a powerful predictor and is so important, both in terms of developing campaigns so that the general public is aware of issues. Think about, for example, tobacco prevention. If you don't begin smoking by your 19th birthday, you probably never will, and yet, still, 18% of Americans are smoking, and I've looked at, I don't know if you've seen some of the viral videos of the Truth Campaign, which got the money from the Attorney General Settlement against the tobacco companies, but they use cat videos, and they're really appealing to young people. But prevention, education campaigns are critical, but they really need to involve the people themselves and target. One of the things that we learned was, for example, when we knew that lung cancer affected men and that men were dying from lung cancer because they smoked, all of the tobacco prevention ads were targeted to men to get them stop smoking, but the education campaigns by tobacco companies targeted women to start smoking. It was against the law for women to smoke in the 30s and in New York City, and so they targeted women. Women didn't get lung cancer in America in the 30s. They didn't get emphysema chronic lung disease, but they were targeted by the wrong kind of advertising, the wrong kind of education, and their lung cancer rates have gone up, so then in 1987, lung cancer surpassed breast cancer as the number one cancer killer of women, and four times as many women died of lung cancer than breast cancer today. So I think education is a cornerstone. I'm thinking about the opioid epidemic, for example, and we've seen this problem just escalate in our communities around the country. 113 people die every day in America from an opioid overdose. How has this happened? Well, again, the wrong kind of education. The pharmaceutical companies targeted doctors to prescribe opioids. They sequestered the science and so didn't show that these were addictive drugs. Educated the public, there was a pain campaign that people shouldn't have pain, and it became the fifth vital sign. So patients were asked about their pain level and were given opioids. So we also have found that in America, life expectancy for the first time since the 60s has declined by two years over the past two years. We haven't seen this before for 60, 70 years, and that's because of these diseases of despair, and it's hitting people with lower education, high school education or less, in some of the communities around the country that we've been hearing about recently, and again, showing the power of education to make a difference in our health, and it begins with children. Children are 20% of our nation's population, but they are 100% of our country's future, and education is critical, and we know that it makes a difference in terms of disease and disability. And I guess one other thing I would say is, there's now all kinds of educational campaigns, not just campaigns, but messages and courses and training online so that whether it's Corsair or edX, you can participate in courses. Through telehealth and telemedicine, you can share best practices, you can train people in remote settings, you can interact with patients, you can put lesson plans online. And for the WIC program, we're looking at the way of doing education, Christian education services online. And so I think it just has opened up a vast arena of ways to provide education and interaction in the digital age. Actually, just one thing that I will add onto that question, because I think it's really interesting. In addition to sort of high level education, I was also thinking Desiree, in terms of interaction between the education sector and the health sector and what that might look like with respect to technology innovations. I was curious, to me it seems like one of the things that really stands out when you're talking about integration of any kind is not just the work of putting different systems together, but thinking through what incentives exist for that integration to actually happen. And I was wondering if you could talk a little bit about what you see as some of the positive incentives in the policy arena or else wise for different sectors to come together and potentially braid funding or at least braid the work that they're doing. Because without that, it seems like we may all have great intentions but no resources or ability to actually enable that work. Well, I mean, I think Hopkins has been at the forefront of that with the American Health Initiative. I think Robert Wood Johnson, some of the foundations are looking at new models to promote a culture of health. And ultimately that requires this kind of cross-sectoral cooperation. I again am very pleased that CMS has put money into it. It's a little bit of money. We hope that it will grow, but at least it's bringing people together across sectors to do pilot projects and that hopefully can be scaled up in communities. And I'm hopeful that there will be more and more of this kind of work that goes on. But oftentimes looking at innovative solutions means you have to be a change agent and you have to kind of press forward in new frontiers. But I think it's the obligation of all of us to really work with government, the private sector and NGO organizations to try to create that kind of cross-communication and to provide the funding that's necessary that provides incentives for this kind of work and that it be really rewarded in the institutions. Just as science is becoming much more interdisciplinary, it has to be much more interdisciplinary between the social sector and the medical sector. Thanks. Hi, thank you for those great comments. I'm Dylan Rosine. I'm with the Cybersecurity Initiative here at New America. And I'm really struck by in recent years the accumulation of health data in partnership with a lot of social services groups as well. But this sort of dissonance when we talk about the patient dignity centered paradigm in contrast with the fact that healthcare is the largest breached sector in the United States when it comes to data breaches. So when we have the most protected health information, private information of our lives in contrast with that simple fact, I'm wondering how we continue to deliver on a patient dignity centered paradigm given all of these new risks that emerging technologies can introduce. So if you can speak a little bit to the balance that can be struck between the positive health outcomes that can come with emerging technologies and innovations and also the flip side in securing that new data that's being collected through those innovations. Well, I'm so glad that's why you've got a program here at New America to really address these solutions. But as we said earlier, I mean, we're embarking on these huge, a million, all of us, you know, initiative. And yet, as you mentioned, and I think I discussed as well the hacking of information is everywhere, and particularly in the health sector. And so again, we really need a partnership between the cybersecurity experts and health to put up walls. I spoke with the inventor of the World Wide Web, Sir Tim Bernice Lee, about this very issue. You know, did he foresee that this wonderful invention that connected us in this seamless way would in fact open up the possibility for all the hacking that's occurred across our government agencies, large corporations in the health sector. And he said, well, it's porous, so it was possible. But that was not his, you know, vision for an interconnected world. But it certainly has become a clear and present danger today. And I think, again, we really have to work vigorously and accelerate progress to protect health information as we move forward with technology initiatives in the years ahead. One thing I would just add to that is as someone who is not a technologist, I think there's still such a huge space out there for just general awareness and education. So when I first joined the public interest technology team, one of the things that I had no idea about was data breaches in general. I would hear about them in the news like anyone would if they were reading articles or if they were getting the latest scare headline. But to really understand at a deep level, and I think particularly within healthcare, we've talked a little bit about this before, but the different types of literacy that come with different types of sectors and if you're deep within a healthcare system, not necessarily having the prior knowledge or education around what it might look like to design a safe and secure technology system. I think this is just a reality of kind of where people are coming from and what they've been trained in. And so I think too, even to think about within different sectors, what is the ongoing education about security and what might that look like in ways that are accessible to people and less technical. That's something that's really resonated with me as I think about if I'm gonna be talking about this world and this topic, how do I also be able to accurately represent what the security threats are within that universe? Other questions? Well, I will throw out one more because we had a number of questions that were submitted by people online. And this one I thought was really interesting because it sort of speaks to a little bit of what we were talking about around the human experience versus the experience that might come with technological advancement. And the question was basically around how we might think about the role of qualitative data. So things like storytelling and as you were talking about walking through the actual experience of a client and where is there room for that, for those very kind of human ways of relating to the work that we do and understanding the world that we live in in conjunction with technology? Is there capability for those two things to come together or do you think that something will get lost as we move forward? I hope not because I think ultimately the reason why we are looking for these solutions is because of the human value and the human connection. And so I think our goal should be to create high touch, high tech programs so that the service delivery part is always the cornerstone. And that's my feeling about that issue. Because caring for people has to be, is really what brings us to the table. What brings us here today is how to improve the lives, how to build a culture of health. And so while technology can link us and connect us and sync best practices across town and across the country and across the globe, we never can forget that human person that's there, that's at the center of our quest for a healthier future. You know, there's an ancient proverb that says he that's also make that she who has health has hope and she who has hope has everything. And I think Sonia, that's what your work in accountable health communities and all of your work is about providing hope for a healthier future, that's really embedded in a culture of health where we bridge health and human services now and in the years ahead. Thank you for giving me this opportunity to talk today. Thank you. Thank you. I've really enjoyed speaking with Dr. Blumenthal about is just understanding context and history when it comes to our healthcare sector and how we've come to the spaces that we are. I think it's very easy to say, ah, we're not doing enough. We haven't gone far enough. There's all of these things that need to be improved but I think there's also something that comes with perspective and being able to see what it was like when there was no website for health at all. And now of course we have a whole different set of problems that comes from having too many websites, too much technology, et cetera. So we are about to transition into the sort of practice-based application side of the event. And I just wanted to talk a little bit about what we hope the goals will be for the day. As I mentioned, the idea here is that we're collecting ideas, best practices, questions that all of you have about this work. And specifically we wanted today to result in two things. So one is being able to highlight what are some of the challenges that you all are facing as you're actively engaging with partners, patients, other stakeholders around this question of how to move between the healthcare and social services sectors. But the other thing we wanted to do too, and this will be something that comes out of the event, is put together a starter of a guide or a toolkit that would be available to other practitioners that are also in this space. So some of you, if you're familiar with New America's work, may know that the organization puts out a number of briefs and reports and toolkits. But one thing that they do in particular that I really love is something that they call their in-depth playbook. And this is used by a number of teams across the organization, basically to highlight different case studies of great organizations and coalitions that are doing work in a particular field. It also delves into some of the lessons learned. It will provide an area for different resources that are now out there around this type of work that different people can access. And so that's what we're hoping some of the content from today will help to really generate and fill in that document and that report, and then it will be available to all of you as well as all of your networks to be able to share. So just wanted to put that out there as well. So we will shortly transition into our next panel. I'll ask the speakers for that panel to just come up close to the stage. But before we do that, I know it's right after lunch and it's easy to get sleepy. So if we could just ask folks to stand up and we're gonna do a really quick ice breaker, name organization, and in less than 10 words, the thing you're most looking forward to this weekend. And then after that, folks can go out, get more food, and we'll come back in for the panel. This is like, oh, there you go. I don't know. Elise? Yeah, I want to talk to you. Okay, yeah. All right, are you guys ready for the ice breaker? I know it's really cold in here too. I've asked them to put the temperature up a little bit, so if that should be. Yeah, no, we're gonna go around the whole room. It's not that big of a room. So I think that way everyone can get to know each other. I'll pass the mic around. We'll skip over our speakers, so Greg, maybe. My name is Greg Bloom. I lead the Open Referral Initiative. We'll have a breakout session after this. I'm just in town for the weekend. I'm super excited about the funk parade, which is tomorrow. Funk parade? Yeah, it's the thing. I'm Julie Wang. I'm with Health Leads. And for this weekend, I'm just excited to enjoy the weather now that it's finally summer or something like that. Hi everybody, my name's Elise. I also work at Health Leads. And I'm going to a beer fest tomorrow in Hyatt'sville. Hi, my name's Natalie Craver. I work for the Housing Opportunities Commission of Montgomery County, which is the public housing agency. And L'Oreal Plaza was my answer. Hi, I'm Amanda Lizarra. I'm an assistant professor at the University of Maryland in College Park. And what I'm most excited for is also the weather. Hi, I'm Brittany Diles with Kaiser Permanente in our community health department. And I'm looking forward to the drive home to visit my parents for Mother's Day. I'm Hannah Passon. I'm with New America's National Network. And I am also excited for the drive to visit my parents for Mother's Day. Hi, I'm Anya. I'm a master's student at Hopkins, getting my master's public health. And I'm excited to present my capstone tomorrow and have that over with. Hi, I'm Letitia. I'm the health innovation officer at Fearless. And I am excited to see a friend that I haven't seen in a long time. Hi, I'm Megan Butler. I also work with Fearless. I am excited to sleep in this weekend. Hi, I'm Kelsey Croc designer at Fearless. And I'm excited for Mother's Day this weekend. Hello, everyone. I'm Pamela Parham with the American Heart Association. And I'm most excited about also celebrating Mother's Day with my mom and just taking her to our rooftop branch in Baltimore. Hi, my name is Menever. I'm a visiting scholar from Europe at Georgetown slash ILI. And I'm looking forward for the graduation of a friend of mine at the weekend. Hello, Andrew Simmons with resilience.io, a UK NGO. I'm mostly looking forward to actually going to New York because my brother and his wife will be delivering. Tonight, unfortunately missing the happy hour this afternoon, but I don't understand it. Hey, I'm Dylan Rosine. I'm with New America Cyber Security Initiative. I'm also going to be in New York this weekend, not with anything quite as exciting as that, but I'm going to the Egg Museum, which I haven't heard much about, but I'm excited to check it out. I literally know nothing about it other than the name. Good afternoon. My name is Desiree Dillatorra. I'm with the Children's National Health System. And I'm excited about Mother's Day, but unfortunately my mom's in California. So in the absence of that, I'm looking forward to visiting the embassies this weekend. I am Jack Kropansky, a semi-retired former software developer. I do a lot of writing and things like AI, and I'll spend a lot of my time on the weekend either outside walking in the weather or writing, lots of writing. Hi, my name's Julissa Powell. I'm with the American Heart Association and I am really excited to take my dog to the dog beach this weekend. Hi, my name is Sumi Eniles and I am with the Innovation Center at CMS and I am looking forward to sleeping in similarly. Hi everyone. I'm Buki Alungan. I'm from the Maryland Department of Health and I'm excited about Mother's Day. I have a day there and a day tonight, so I want to get out of here. Hi, nice to meet you. I'm Heejee Kim. I'm working at Atlantic Council and I'm looking forward to volunteer at EU Open House tomorrow. Nice to meet you. Hi, my name's Stacy Johnson. I'm a social worker at Bread for the City and I am looking forward to hopefully being surprised by the Mother's Day gift that I sent my husband, the Amazon link too. That's awesome. Thank you guys for indulging me and can I have my venerable speakers please come to the stage. There's even little stickers. Little stickers so that you don't sit in the wrong spot. That's fancy. You don't have your name on your chair, but we go. Not everyone. You're not in the wrong place. Clearly. So I'm really excited about this panel mostly because I know all of these people and I really like them a lot and so I'm excited for you to hear from them as well. I'm a big believer that panels should just be full of all of your friends. But in all honesty, the reason I'm so excited about this particular panel is because I think these folks here all have direct lines of sight into what it looks like to think about health and social services integration at kind of a true application level, right? So we have a lot of different stakeholders represented and people who have been in this space for a long time and have seen different angles of this question and we're hoping today to just illuminate some of the lessons learned that they've collected along the way and also maybe to kind of pose some provoking comments back to you all for you guys to be thinking about in your work. What we're gonna do actually is in light of trying our best to not make this just like your standard panel presentation where there's a moderator and I ask all of them questions and they all take turns answering and it takes us like 25 minutes to answer one question and one person talks way more than the others, Mike. We are gonna try something a little bit different where it's gonna be what's called a chain reaction panel where each of us are gonna pose questions to each other and our hope is that it makes it a little bit more conversational. It also gives us the opportunity to like do gotcha I think with each other. No, I'm kidding. They will all be very kind to each other and we will not ask any controversial questions but we're just gonna start off with, I'll ask each of you to just do a quick like one minute introduction and maybe just for folks in the room since there's a lot of investment here, share what draws you to this particular type of work. So, Mike, we'll start with you. Hi, I'm Mike, never worn a microphone before. Hey, I'm Mike Freed. I'm the CIO with the Baltimore City Health Department. I've been there for about three years. My first time working in city government. I'm responsible for the internal operational technology of the department as well as some of our strategic technology initiatives included in those is we are awardee of the CMS Accountable Health Communities Grant. So, thank you, Simeon. And we are extremely excited about that. Our model is we applied on behalf of Baltimore City and got signed MOUs with every hospital system in Baltimore which there are 13 in Baltimore City on a population of 620,000 or so people with, as you heard earlier, some of the worst health outcomes in the nation which kind of tells you the traditional model's not working. So, we're very excited to kind of take a city approach to this and really look at how we can do things differently. Hi, I'm Maisha Davis and I am the director of case management with Chase Brexton Healthcare. Chase Brexton is a federally qualified healthcare center located in Baltimore. Founded about 40 years ago this year really initially starting as a gay man's health clinic at the very beginning of the HIV crisis. And over the years has expanded its services and to not only serve that population but the LGBTQ community and vulnerable populations throughout our region. As we all know, Baltimore City as Mike kind of mentioned has some pretty significantly poor health outcomes. We have one of the highest HIV rates, new infections and so our work is very much centered around supporting our patients and helping them to achieve access to healthcare so that they can fully engage in their healthcare and meet those outcomes that they want for themselves, for their lives, for their families. My background is I'm social worker and I've been with Chase, I guess, for going on two years now. So, medical, social work, healthcare is a new field for me. My background is in child welfare but my passion for the work is very much rooted in supporting, being a resource and being available to vulnerable populations in my city. I'm native of Baltimore and so it's really important to me that any work that I do or participate in is designed to not only help improve the outcomes for the families and the individuals in my community but to also help them reach a place of self-sufficiency so that they are able to fully engage in their, in an equality life that they want to achieve for themselves and so that's why I'm excited to participate on the H.C. grant through the CDC with the Baltimore City Health Department and get the opportunity to meet with so many wonderful colleagues who have that same heart and that same mission for the patients we serve. So, good afternoon. My name is Thomas Kujo. I'm a house call physician in Baltimore, a researcher and excited to be here today. I would say I've engaged with the uptake of technology as it relates to the care of patients often through interactions throughout my career with the deployment of technologies, oftentimes EHRs where physicians document and so but I've been very interested in recently in regards to how we best utilize technology to connect people with resources and excited to be here for this discussion. I'm Kristen Topel. I'm the program director for the health leads program in Baltimore. It currently oversees three programs like Sonia worked at at Johns Hopkins Hospital. We have a student workforce model where we train students up to sort of serve as case managers where we screen our patients universally in each of those clinics and connect them to community resources. Why I'm most interested in continuing this conversation is we're really curious and exploring how do we continue to keep that patient voice at the center of our technological solutions here that some of the best practices we've learned in the 10 years or so we've been at Hopkins. We're curious to scale these solutions and how do we not lose that patient voice. I'm really curious, interesting continuing that conversation here today. Great, thank you all. We'll get the chain reaction started in just a little bit which sounds terrifying but before we do that I wanted to take a second to just point out that we've talked a little bit today about the different approaches that could be taken towards the integration of health and social services and you've heard a little bit about models that are out there like the accountable health communities model that's been put out through CMMI. But I also, what I appreciate about the work that a lot of these folks have done is it's not just about the sort of large scale formal initiatives, it's also about the ways in which we look at and identify where social needs could be addressed across multiple clinical settings and across multiple types of scenarios as well. And so just wanted to put that out there because I know different people are in all kinds of institutions thinking through what resources and capacity they might have to tackle some of this work and we wanted to be able to highlight solutions that are taking place at lots of different levels. So just to kick us off, my first question is for Maisha. So as an FQHC, as a federally qualified health center for folks who are not healthcare jargon-y like I am, Chase Brexton considers addressing patients' social needs really as a key part of the organizational mission. It's a mandate for federally qualified health centers to think about the whole patient to provide those wraparound services and I was curious as you think about the ways in which this work manifests, both inside of your organization but also in sort of larger conversations, what are some of the biggest challenges you face in trying to implement these types of solutions and how specifically do you use technology to potentially address some of those barriers? Sure. So I'm gonna try not to yell. I feel like, this is my thing is so weird and I talk loud anyway, so let me just, so to talk about like what are our challenges in addressing social determinants of health. I think the biggest piece that we see is centered around access. And access not just in terms of like getting to the resource, right? But really resource identification, what is it, what's out there and how is that thing going to best support families and individuals to meet their needs, right? And then also access as it relates to how did you pay for it? So many people don't bother to walk into the door because they don't have the resources, they don't have coverage or the coverage is too expensive, they can't afford the medications. So they don't engage because they're scared they'll end up with even more debt or more bills or be denied, right? Care because they can't pay. So my team spends a lot of time completing financial assessment and really trying to understand what the patient needs are and then linking them to whether it's insurance or enrolling them in insurance or helping them access Medicaid or Medicare, whatever they're eligible for, v-scaling them to the degree that we can so we cover those costs thankfully through being a FQHC. We do have some leeway, so to speak, to be able to eat some costs, right? So that folks can come in and get care when they don't have those resources. So we spend a lot of time really trying to make it possible for folks to know that they can come in the door and we'll do our best to make those resources available to them. That said, so much of our work is so focused on that piece and just the financial end and where are the resources and where are the things that people need immediately, right? So address those, usually those social determinants that are happening now, things that are impacting their ability to move around or to access or engage in their care right now, right? Oftentimes that stuff is crisis-driven. We can do those things. We can do that in-house and we do it externally. But at the end of the day, we kind of function in this Band-Aid model where we're temporarily providing relief. We're addressing the situation in the moment but seldom do we really engage with patients enough to help them create some level of behavior change, right? That's going to support them in not being in this situation again so that they can come in and really ask the right questions with their providers and their medical care teams and really understand what their outcome needs to look like and how they need to behave and perform and engage, right? So that they can really kind of recover and hopefully thrive moving forward and be fully engaged. And so, how does technology engage with that for us? Technology, if we're just easy, just be easy, right? Be easy for our patients. Be easy for our staff. Easy in terms of, you know, user-friendly is the term we always talk about but I don't even need to just be user-friendly. I need it to be at a literacy level that folks can understand. I need very few buttons, you know, just push and go and get what you need, right? So when we talk about things like enrolling in ACA or completing Medicaid applications, it's just, it's impossible for the average person to really understand how to maneuver all of that and without us, so many people would not be able to do that yet we exhaust so many man hours and resources, human resources, right? To get patients to get through just those simple processes to even get closer, you know, a half a step closer to access. So systems that can kind of break that stuff down and just make it so, not even just user-friendly but quick with the input, quick with the output. And then in real-time, real-time communication amongst the care team, right? I can't speak for other systems but at Chase-Barkston, we have a variety of systems that we function in to serve patients. So there's the EMR, then there's a population health tool and then they don't talk so there's another thing that we got to put information in and then there's just all these disconnected systems that don't talk and don't create, that don't allow us to create the integration that we're looking for so that the entire care team as well as billing, right, can, you know and everybody else can kind of talk to each other and we can communicate with Chris for example or the health departments or whatever in a way that's easy and doesn't require so much time and energy that takes away from the real work that we wanna do, right, with folks. So that's kind of my take on it and all these systems are important and they're all really growing and everybody's thinking about these things and working on it but man, the time and the investment that it takes to get us to that is just more time wasted on really providing a care that we need to provide to the patients that we serve. Yeah and before we jump into the next question I think one of the things that jumps out to me from what you're saying is I think oftentimes we don't really even stop to ask like why tech at all, right. Like what is the hypothesis around why we're deploying technology in certain instances and it almost seems silly because you're like well of course we have to use technology, it's part of our social fabric, et cetera but I think there are key hypotheses about why technology exists that oftentimes don't actually manifest in reality, right. So one of those is that technology makes life easier, right. It makes things more efficient and enables you to move faster. Like it's just another sort of interface beyond what being a general human would allow you to do. In theory. Right, in theory, right. So I think this is the question, right. It's like if we're implementing technology in a way that's not actually resulting in that hypothesis being true then it just adds yet another layer of stuff to the system and I think yeah that's a really, that's something that I hadn't thought about before it's really interesting. I don't know if other people have thoughts on that as well. I agree, sometimes the low tech solution is the solution that is best for people who are engaged in some of these problems and I think having technology that helps us identify hey, are these the appropriate solutions for these problems or are there other solutions that we need to develop and so I think as was alluded to in the previous session the role of artificial intelligence to help us to understand how can we can best address problems and not just put in new solutions that don't actually address the problems. What I also think the other part of it is it's not just like technology yes or no, it's like technology as part of like I think this is where design is so important because you have to have, I don't think there's much success with throwing technology in a process that's never existed anywhere else. You can't, it's very hard to have a process that is organically technology based. Technology is the most sticky and most useful where you've got people working together already or at least some desire to work together. A lot of the things that we'll do is just start by people sharing paper. There's literally start by just saying forget developing, forget doing anything. Are you guys willing to do this on paper? Can you move a post-it note from one side to the other? And if you are, then we've solved a lot of the barriers and then we can layer technology in an intelligent way on top of that to make that better and look at what those dimensions of quality are. Oh, it's my turn. Okay, great. All right, so Mike. Hi. Hi. Funny seeing you here. Yeah, isn't that interesting. So as a professional with the Baltimore City Health Department, I use that word lately. What's your point of view on how the local government agency can support organizations like mine, specifically as it relates to the technology piece and integration for the benefit of our patient population. And then is there a difference for you between implementing technology solutions at a city or community or government level versus like an individualized organization? And what does that look like for you guys? Yeah, you're welcome. Take whatever you want of that. Yeah, there's a lot there, right? I think that a lot of what we struggle with is what is the appropriate role of government? What's the appropriate role of local government in these places? I think that traditionally we look at building upon roles like we have of convening and in the public health sense, surveillance and guiding interventions and those sorts of things like about how can we rally resources and technology to improve those sorts of things. So like that conceptually is where we go to but also like how can we do the concepts earlier I thought were really great brought up around like dignity and making technology people focus because inherently government is set up and government procurement is set up to like build technology to extend institutions rather than empower people with technology. And I think some of that language becomes really evident even in the conversations earlier around like cybersecurity because I do think that cybersecurity and privacy and I'll conflate them for the purposes here because I think it's pretty much becoming the same thing or it's at least the same thing in a lot of people's minds, right? But one interesting take on that I think is that the risk of hack and breach is certainly high and is something we should take seriously and we should fortify the hell out of all these things. But the other one that I'm really interested in that we don't talk about a lot is as we're munging data together and as we're doing more of these cross sector data sharing things what does informed consent actually look like, right? Like I would argue that informed consent's really BS even as it's used now for most people I can't tell you what I'm signing away let alone someone where English isn't their first language they're not digitally literate and we just told them to click a box and we all feel good because we did our job and the HIPAA police won't come for us but like really under how can we look at new models for empowering people with understanding how their information is shared across these systems and I think that becomes a very interesting role for government. Again, looking at, we're spending a lot of time and because it's things like it's usually grant driven, right? So we've got this countable health community grant so we're spending a lot of time trying to figure out what is our appropriate role? Like how do we, people talk a lot about integration and the integration of health with social services but the reality of social services is that their systems are a mess, right? Like on the best end they've got some overpriced case management system that doesn't really have any sort of open data model and they say they have an API but it doesn't really work and it won't actually integrate with anything and on the worst end they've got a million spreadsheets in no time and so just layering, to your point earlier just layering technology on that does nothing. So being a little bit intentional around how can we support the plumbing at scale and the infrastructure at scale to support these data flows between anchor institutions and community based institutions as well as individuals, right? I mean the promise of meaningful use wasn't that two large university hospitals for example could share your medical record for a research study it was that you were able to control who saw your information and where it went and so how can we kind of build things that empower that? I don't know if I answered any of that question at all but. Yeah, what else? I'm curious to push further in that regard because in other nations there are instances where people's health data is, you know the government owns it in a sense and it's used to better health and so is that, what are your thoughts on in terms of how privacy and cybersecurity potentially is a barrier for progress and innovation? That's a loaded question. Yeah, I mean on the one hand again I go to like I don't think I have all the answers I don't think many people have all the answers I think that we tend to, our default position is to bring people together and be open and try and have conversations around those things because there's dimensions to it that we hadn't thought about. So I think a lot of people come into the world of data sharing at least some of the things that we saw was that people came into our conversations around like when we started having conversations around the accountable health community and saying we want to link social services information with medical information everybody was like time and again I hear people say yes the dream is that I can see everything in one place and then someone raised their hand and was like we have in Baltimore issue as most communities do with intimate partner violence and so it is not in necessarily the best interest of a person to have that little dot on the map of this is where they are and then they're going to see this person and they're going to see like there are actual real severe repercussions for that. That said I think that a lot of time I think there's a couple things to that one is like a lot of times and a lot of our folks is also are we extracting the full value out of the investment that exists today, right? So like one example is Maryland is fortunate enough to have a pretty ubiquitous health information exchange and it's very robust and it works reasonably well and it's everywhere and so we're looking at like how can we just take the data that's there and use it for things like public health surveillance so like we had a project to look at ED visits and hospital admissions among older adults for falls and create a surveillance dashboard for that that gives us information that's updated weekly or monthly that used to be a two year lag in information, right? So it's like just using that for just and again my lens is very gonna be practice based rather than research based necessarily but I think having those conversations really kind of leads to that I think also there'd be really interesting to see some of the work around profiling is a really loaded word, right? But like you take data and you can now apply technologies to make an anonymized profile of a population and look at interventions that way and so maybe one way around some of these things is instead of obsessing about for research purposes how much can we share Mike Freed's information versus layering AI on top of that to say here's a profile of this community that is representative of this community without actually being this person in there. What do you think? I agree. But I agree with you. It's a chain reaction. I got him. I agree with your thoughts but I guess as I increasingly think about how I provide patient care and the need for information and the need to exchange information in an easy way amidst an environment where there's so much information that you know is there but sometimes you can't access. Is it my turn for chain reaction now? I had something written down but now I'm curious about this. I guess my question is can you talk a little more about that like what do you practically, I think you probably have a really interesting perspective because you're in a research role but you're also out in people's homes and visiting them and seeing them. Can you see people maybe reflect a little bit on like what are those barriers? Like what are you seeing? What's that ideal state then in your mind? How does that look? Well, I think not having a whole lot of time reflecting on it and I wouldn't say that this is something that I think about every day in and out but one of the things is like does, oftentimes as I said, I care for older adults in their homes and sometimes there's needs that exist and knowing that I can tell this one patient, okay, this is the entity that can actually provide you with these resources based on their insurance status, where they are located in the city and so being able to provide quality information on the spot based on the needs that I see on the ground, there's barriers to that and maybe all it takes is chatting with the social worker who works with us but many providers don't have the access to those resources be it a social work or technological infrastructure to actually do that and so I think that we have a great ways to go and there's great opportunity for connecting those people who are practicing and actually in the space of seeing patients with the information that they need to optimize the care and health of the people who they're serving. And that actually might be a good segue into your question for Kristen. Hi, Kristen. Yeah, now I'm gonna shift my question a little for Kristen too, which is. What's she prepared for? Yeah, I know but I left my notes on the train, so here we are. So you guys have been practicing in Baltimore for a while, health leads has great reputation in this area. One of the things that we have seen is lots of vendors come into this space with different solutions to social needs. So is it solved yet is my question but I guess what I'm really interested in actually is that which is like kind of similar question about Chase but really which is like as you're working this as you're in the trenches, what are these barriers? Is it technology? How are we using technology to solve that? Like how does the actual tactical work inform the technological approach? Sure, I can go ahead and do it. No, we're also really excited with the interest that we've seen like someone was saying yesterday like $40 million in the last two years have really come into this space and that's been really exciting for us and we have had some interesting lessons over the last 10 years, particularly from the lens of like a resource database development, historically health leads, with Sonia starting at Harriet Lane thought we can put more resources in here and that'll be better, right? So we can have this huge resource database and that'll help people meet their resource needs, right? And then referring to what we were speaking about earlier this afternoon, we did some quick data analytics and found there was something like 1% of the resources in our database were responsible for about 50% of those successful resource connections. So that's when we really made that important shift that like we need to be connecting with our patients and our families and figuring out what is it that they want and what is it that they need? Which is, I was at a conference earlier this week with Dr. Arvin Garg who is sharing something I thought was, it really has been rolling around here for me quite a bit about the utilization of a validated screening tool, right? So everybody wants that validated tool. They want to screen our patients and know that what we're screening them for is what we're receiving on the other end. And he was sharing that they had done some research where you can have a population that screens positive for some food insecurity or transportation issues. And then if you shift the questions a little bit and ask if they would like resources for food or resources for transportation and housing that those groups weren't necessarily overlapping. Which was really interesting for me and I don't quite have the answer there but I'm also thinking like gosh, when we drive so much into this tech space and this validated space, are we answering the wrong question? So that's one thing that I'm thinking about. Another lesson that we have from Health Leads around that, bringing the patient voice into what do they want to be connected to? What do our families want to see is that are we capturing their feedback around the referrals that we're making? So there's one thing to create a resource database and make a referral. It's a totally other beast to capture was it successful? We made a referral to a food pantry, did they actually get food? And what allowing, using a software system right now at Health Leads that allows us to attract that has really opened up some really interesting movements for us. So we're able to either see, gosh, this resource is incredibly successful. And this is really leading us to create and closer partnerships. That's sort of what you were saying earlier, Mike, about can we then provide post-its and referrals back and forth. Sometimes using this tech solutions has allowed us to kind of take a step backwards and okay, it's actually easier for you to receive a fax referral or it's easier for us to give you a phone call before we send our patient over. We're using our tech to then use, partner with the community-based organization in the way that works the best for them. Additionally, it's allowed us for, when we're capturing this, how it comes to very quickly see trends. So either you're on the ground and you have a hunch around something that's happening. Is there a spike in food insecurity? Is there, in our case, in a few hospitals, there's a lot of issues with redetermination regarding medical assistance. What is going on here? And sometimes we can then very quickly, at the touch of a button, then see, oh gosh, there is a spike happening here or there, which then allows us to support maybe some policy development that I think is really what we need to use our tech to support, right? We need to support our community-based organizations and these solutions that are out there. So can we create tech that is going to really bolster the solutions that we truly need for our community and for the city of Baltimore? So making sure that the tech solutions that we're creating are not sort of driving us off into the space that's away from our families and is allowing us to really support what needs to happen, which I think everyone in this room knows, we need to support the community services a little bit more strongly than we are now. Yeah, I think it's really interesting too, just kind of anytime a new market opens up, right? Typically what happens is that new entrants into the market tend to go based off of the baseline that was established a little while ago, right? Like they're not gonna start at the same place as an organization that has been doing this work for a while and I think that's where the piece about community organizations really resonates too because something I've been thinking a lot about is again, similar to the patients who are like, well, social determinants of health aren't new to us, like maybe it's new to the healthcare system, but this is just my life. Similarly, I think a lot of community-based organizations have been in the work of, what does it really look like? Not just to get a referral in, but to get a patient fully enrolled in a service and then think about how that news resonates throughout their community, their neighborhood, et cetera. And so what are some of the, yeah, what's the like wisdom that already exists that we don't need to be recreating? I don't know if anyone else is talking. I was just gonna, as you were speaking, it made me think about some of these initiatives that are happening with regards to the text, specifically what we're trying to create in Baltimore, and I do think it's important. And hearing you makes me want to kind of go back to the table and say, hold up, we need to think about this a little because what I'm observing happening in kind of real-time at Chase Braxton and then with our partners in different counties that we're in, we're using the tech, we're trying to engage in the tech as it's designed to do all these amazing things, but at the end of the day, the food pantry at the church that's only open on Wednesdays, it's never gonna engage in that system and it is counterintuitive and counterproductive to try to force feed that process, right? Square, peg, round hole, and we spend more time trying to figure out how to fix that than we do actually, listen, here's the sticky width to go to the pantry, you know what I mean? So I like the idea of really thinking more closely about alignment with these systems and how to engage tech in organizations across the board, not just our medical centers and is it aligning with what patients actually need or versus what we need to prove, to demonstrate outcomes. So that's, yeah, I thought that was pretty profound. Dr. Kujo, as a clinician, you see what it looks like when your patient's social needs aren't being addressed in how it may hinder their healthcare, whether utilizing, you spoke about the EMR earlier, screening tools or resource directories, what is it that you actually find most useful on a day-to-day basis as a practitioner and what concerns do you have about the emergence of these technological tools in addressing your patient's social needs? Yeah, so I guess I think about it in this way and it's how I think about even my career as a physician and how I engage with patients in terms of proximity. One of the reasons I decided to go into geriatric medicine and do house causes because it allowed me to be proximal to the people and I think when health is proximal to people and we develop solutions that are proximal to people, we position ourselves for the most success. And all the work that I think we do in this space, I think we need to be thinking and meeting people where they are and be proximal to them. And I think when solutions that come up when we're proximal to people, we can move things forward. And so as I think about how technology interfaces with that is I think about how can the technology that we have and that we're employing bring us proximal to the information that can bring people more proximal to the solutions that will create change for them. And so the things that we employ in my practice is oftentimes we come together as a team and having systems in place and if it be a technology that's supporting that are not in your institution or not, but enable to access information in the easy means be it a dashboard, et cetera, where you can easily grasp what's going on in a simple way. Of course, there's a lot of complexity that goes on in people's lives but being able to appreciate what's going on in a global way for what someone's need. If this person is housing or food insecure and you have a green or red dot to designate what's going on, when we employ those systems to do those things in our work, I think we can be most successful. Additionally, as I think more broadly in terms of the power of technology and actual health care, I think about efficiency and synchrony of where opportunities exist and how we can connect people to the resources that they need. In addition to that, we often talk about connecting people to resources but we fell to see that people oftentimes are the resource and so flipping that on its head, when I care for people in their homes, they're often being cared for in their homes by other people and so those other people are often a critical resource that we have to figure out how to basically optimize how they're caring for their loved ones and so I think as we continue our work, it's important to understand what resources people are bringing to the table and helping them figure out how to best utilize those resources and not just we are coming to you with these resources and you don't have any resources that you're actually bringing to us and so that reciprocity I think is critical in this work and developing technologies that help facilitate this is I think important as we look forward. Anyone that anything that anyone else wants to add to that? Yeah, wholeheartedly agree. Well and I think to the idea of bringing information to people and not respecting what people already have, I mean I think in general as we look at healthcare as an industry it's sort of built off of this premise that you as a physician are bringing in a certain set of subject matter expertise and skill set that the person that you're seeing doesn't have and yet we don't ask the question in the opposite direction and so what does that look like? Yeah, so my question for you Sonya is you and I have had conversations about equity and in different spaces. Sonya and I are involved in this Robert Johnson Foundation Culture of Health Leaders program and in that space we've talked about equity and so I'm curious to know your thoughts on as we think about health and services, how we integrate that with addressing inequities that exist? Yeah, I think there's really sort of two pieces that come up for me and has been echoed by this panel throughout that and one is within this vein of patients as experts and thinking about where the true expertise lies and having it whether it be in communities or whether it's in community based organizations. I think particularly I'm really fascinated by this question of how do we define health not just as beyond medical care but as literally what patients would define as health and how do you democratize processes both from a funding perspective, from a delivery system perspective so that communities themselves get to say we believe because the truth is when you go to a neighborhood association meeting in East Baltimore and you ask people what do you think about when you think about health? They say violence, chronic disease, opioids, they're not saying oh I think about my blood pressure levels or my HB A1C and what if then it wasn't just naming that but there was an opportunity to actually put real dollars behind that and think about what it would look like to invest in those services as the true health solutions themselves and so I think one of the things that all of us in this room can do as people that are engaged in the work of healthcare and live in communities and our patients ourselves but are also sort of working perhaps at the level of sharing best practices is how do we challenge ourselves to actually go and have real conversations with patients and real conversations with community members as they are themselves organizing around what health should look like in their communities and as they're advocating for programs like increased employment opportunities or better food ecosystems, not just a food pantry, not just enrollment and SNAP but legitimately access to food within their cities which can be solved by, for example, city government actually putting money into that or a hospital deciding that they're gonna invest their entire community benefits portfolio in addressing food insecurity through the development of local businesses and co-ops and things like that. So I think there's a sort of real question around like what does that process look like? If we were to build out workflow around that how would we do it and it's so different from our traditional kind of clinical lens which is predicated upon having answers that come from research and science? How do we sort of break that down and break it wide open a little bit? I think the second question is sort of to this point about where technology comes in. One of the things that I have been able to observe and that I find both fascinating but also concerning is at the end of the day technology is kind of whatever you want it to be. It can be a tool, it can be a concept, it can be a metaphor but it is also in the United States an industry. And so how do we think about the values and principles that then come with the industry of technology? And there's like little tea technology and big tea technology. So there's little tea in the sense of like we need some cool tools that will enable us to do our work better. But then there's like Silicon Valley and venture capitalism and all of these other forces that drive what technology could or should look like and who gets to say what it could and should look like. So that's something I think we have to keep in mind particularly from an equity perspective because then what happens is you have voices of folks that are not only not knowledgeable about healthcare but literally don't have the lived experience of the people that they're potentially designing products for. And as Mike was talking about like this is where design becomes essential, right? Because design can be the process through which you unlearn a lot of what you think you actually know. And so I think those are two big areas particularly from an equity standpoint where until we're real about those things, until we actually kind of like call them out and say well it's great that Google wants to become involved in the integration of health and social services but what does that really mean? Like what will that look like? Who are they building these tools for and then where will that data go? I think it can be an enormous space for potential but it requires like the active civic engagement of all of us as voters. You said something that made me think of something that someone, it wasn't a patient that I provided care for but it was a story that someone shared with me and it was around when CMS began increasingly concerned about readmissions there was a story that a friend told that basically the patient again when they came to him and said okay we wanna help you figure out housing or figure out X, Y, or Z. The patient asked the person what happened? Why are you interested now? Why are you curious about these things now? And when you dig deeper into that it goes to you're costing me. And so I think being mindful of our motivations is also critical for this work and when you engage with people that cost is not the thing that you're thinking about but you're really interested in improving their health and the health of their communities. I mean I think those are great points and I think also like just the idea, there's a concept now or it's like social entrepreneurship is a very exciting thing for a lot of people now but it also seems to be a way that companies can feel very good about doing things and that's fine but that's also not like a fundamental solution to some of these entrenched social problems and those companies get involved because there's a cost, there's an opportunity, there's a market and so that's why I was joking around with hopefully it's an unprofit about this, right? Because there's not, there are others in this space who are clearly there because they see market value and while that's fine and used intelligently can be somewhat of a sustainability model to address some things, it doesn't replace like core governmental or social services and I worry that I think that's kind of where we're going. Also what you said reminded me of a quote that I heard at a conference I was at a while ago which they said that tech mirrors those who build it and that's something that at least I've tried to very intentionally internalize and to say who are we partnering with when we want to make things or we want to bring solutions to the table and is that not just an inclusive design process from the community but then like is this community empowered to actually work on this and to help bring this forward? Yeah, well I think just to sort of wrap this up and then would love to hear last reflections from folks and open it up for Q and A I think just to take the housing example for a second as we were engaging in the accountable health communities work in Baltimore, the example we would use all the time is like look, we can have the most badass technology that's identifying all the social needs in the world, we can be making great referrals and we can have amazing physicians and amazing systems and all of this stuff but we just don't have affordable housing in Baltimore and we're not gonna get there unless there's an active advocacy and policy effort that is led not just by physicians and hospitals and people who have traditional power but community members have been fighting for affordable housing in Baltimore forever and how do we sort of pair these different sectors together and think about what the role is of existing organizing efforts in pushing the agenda on health? I think ultimately we're all sort of building up towards kind of a futile effort if that root cause solution isn't there and so it's another aspect to the work I think it's sort of separate or outside of the scope of what might be considered what an institution would be working on but certainly I think in conversations with community members that's what gets reflected back is like look, I'm glad that you wanna connect people to housing, I'm actually like every week in my neighborhood association meeting trying to get city leaders to listen to me about housing so I think about that as well. Last thoughts, reflections, closing. Yeah, I mean I think this is really interesting I really would love to follow up with everyone here and talk about it because I think that there's great stuff happening in this space I'm really, the people in this room seem to be doing really interesting work. I think there's a lot of opportunity to start rethinking we talked a little bit about earlier cyber security I think the other part to start rethinking is the concept of open source. What does open source look like in the terms of like community owned because I think that traditionally people in technology have said we're gonna open source this project we're gonna put it on GitHub and it's like but have you looked at digital literacy? I mean have you looked at like actual digital equity because then you've done nothing but enshrined it in another silo and probably made yourself even more secure and so what is a more intelligent way to think about community owned technology and how that can really be supported? Yeah I think for me I'm just enjoying the conversation and you know the things that are I'm continuously being reminded of is what is our motivation right? What are we really here for? What's the real end goal? You know what I mean? And so for me it's to continuously kind of keep the community keep families keep the individual at the forefront of this. Again we can build all the beautiful systems as we've all been saying that we want that are just perfectly awesome but if it's at the end of the day it doesn't serve the individual and it doesn't contribute to improving quality of life that we've missed the mark right? And so whether it's a piece of paper and a notepad or spreadsheet or like this super awesome one touch mega system if it doesn't reach the end years if it doesn't get that patient get that client get that family on better ground and better footing then it's kind of off or not. So I just like the idea of not solely looking at this through the context of the lens of tech but of community systems of all these other domains that impact our folks and how does that all need to kind of integrate and work together and whatever that needs to look like for folks. And yeah. Yeah I would just say that as I think about how we can substantiate the solutions that we develop is I think thinking about the data that we collect and how we, what questions we ask it to get to that data but I think having the data is critical because when you have the substantiation that X equals X leads to Y then you can really think about how you can disseminate programming and technology to impact more people. So I think as we think about solutions to problems that exist in our communities capturing what's truly the problem with the right questions and substantiating it with good data is critical for people to believe that your solutions are actually will work. Hard to go last, echo what everyone else has said and speaking to that housing that you were mentioning earlier Sonya and the importance of having the families and our patients and users are part of this very early on. I'm reminded of sort of an embarrassing moment at Health Leads but I think it's good to be open to that and to learn from that where we had families reviewing a screening tool and I think I can't remember if it was the first or second question was about housing and very astutely was like, do you have somewhere for me to live? And we're like, well no, but so why were we asking the question and why is it the second question that we're asking so I think really going back to what those motivations are but then I feel like there's a lot of responsibility in this space too if we're gathering this data for seeing trends, if we're seeing gaps, if we're seeing opportunities, I'm thinking about a clinic that we worked with that was saying, gosh, we're having the hardest time connecting our families to employment opportunities. Maybe this is an opportunity for us to embed one of our really strong community based organizations into our clinic. So utilize the technology to adjust the system that we're working in and not just continue to capture the data and to lose it but how do we use that data to inform what we're doing in our communities in an important way and I think just ending on saying like I, you know I've been in this space for a few years but already it feels like year after year the energy is growing and I'm just, I'm feeling more and more hopeful about the solutions that are out there. It's no longer a space where we're having to convince anyone that social determinants of health is something that we should address. Everyone knows that and it feels really exciting to be in the how and how do we utilize this technology to really address it in an important way and it just feels like an important moment and an exciting moment right now. Thank you guys so much. I'm gonna open it up to questions. Thank you, I've really enjoyed this discussion. I wanted to pick your brains a little bit more about the data sharing and being transparent with patients or clients, however you refer to them about what that looks like. So I worked for a care coordination agency who utilized CRISP to find out when their folks were jumping in and out of hospitals but having that conversation with the clients to explain to them, most of them had no idea what CRISP is that there is sort of in their words like a big brother who can tell you as they're hopping around from hospital, hospital, from the care coordination agency's perspective like for program outcomes we wanna know if we lose you where you ended up so we can go and find you. So from the one side wanting to get the outcomes for the program and the clients but then also trying to explain to the clients your data is being shared whether you know about it or not. So I'll start because we're literally facing this right now, right? As you were talking to Mike about informed consent we, you know, everybody kind of has feedback on what that should look like and when other entities have outcomes of getting it done it's like, oh, just tell them, just read it, it's all there, right? And, you know, when you're real time sitting with a patient, with a client, you're not, it's not just that simple, right? You just can't, oh, just read this, it's all the same as we're gonna collect your data and we're gonna, and then check the box, right? Or give us your signature. So my social workers are really struggling with how to communicate this in a real way so people understand I want you to participate but I need you to be clear. I need you to be clear what this means and while I wanna be able to tell you your information is protected, know that these number of entities could have access to it and can see that and it might not mean anything today and one day it could come up and you might wonder, how did you get that? Well, this is one of those avenues that they could receive some of this information and it's not to scare them but to just to be 100% transparent because we want people to go in understand it to the best of their capability and to the best of our ability to explain it what this means for your information to be out there, you know what I mean, to be in the system, whatever that means, right? So it's, and my, you know, my social workers are so ethical and they constantly are like, what it, you know, what this is, we have to be ethically sound in this and how we help patients and clients understand what this really, really means. Not just for themselves, for their families, for their caretakers, for whomever, so it's a constant conversation and we really, for nothing, to be as transparent and improve the literacy around it and the understanding for our clients around that. Yeah, I think the other thing, like one of the things that strikes me about it is it just always pulls my mind that it's a box of text, like why don't we draw this, right? Like, so one of the things we're trying to do is see if we can work with some local designers for us to figure out, like, can we make simple, consumable visualizations of how data is collected and shared, at least for the folks that we work with. I think an extension of that is, like, some dynamic system where it's very clear, like, you can go in and see, right, and now that has digital literacy implications, but like, but it's at least the goal, right, is at least holds the institution accountable to say, like, here's someone at any moment in time can look at how their information is being used and I think that that's where some of the, so there's been, like, great work around, like, things like Blue Button and Data Liberation and all that kind of stuff, but it has to be more than just like, these aren't, I don't think it's a binary choice if you just want, like, I don't want you to have any of my data, I want you to have all of my data and give it to everybody, like, come on, that's not reasonable, right? Like, people should be able to make informed decisions about where their data is shared with, who collects it and then how they, in turn, share it with other people and there's just these, like, webs of legal agreements that just bypass all of it, right, and we're guilty of it as every institution is and so how do you just change that and I think really empower people to make those decisions, to your point, like, where they are? Because I'll bet the social workers don't even understand. They don't, yeah, absolutely. Okay, so I wanted to start it, I wanted to start on my, it's gonna be brief, but I wanted to start from where you stopped, Kristin, where you talked about the fact that if you collect data, then it becomes important for you to be able to do something with it, which is what I say with people, which is where the technology line comes in. So, right, I work with the Office of Minority Health and there are times that we do community conversations, our grantees do that, and then I come up, I'm like, so what if they find things out? What exactly speaks to asking the question of why is ours on the second question? If we're ready to ask the questions, if we're ready to disseminate those tools, then we have to have the resources or at least be able to navigate them to where it's needed. And I wish Dr. Warren Jones, she was here, was here right now speaking to what you talked about, Marsha, the fact that we deal with things on the spur of the moment, there's an immediate need and that's what you attend to. So, Bonsika's Hospital, and I cannot speak well to that, but you could find out more about it as the Bonsika's community works. And they're the side of them that does things like getting people GED trained, CNA, because you have to be able to empower people beyond what you do for them there and then. So there are, so I think, and I think that's what elderly does as well, being able to have that part that doesn't just attend to their immediate need and is able to empower them to be able to sustain themselves. Basically, I think that is important. And I was surprised when you talked about the fact that in the other conversation you had recently, they talked about a tool that assess the need of people and then when they found out if they were willing to accept those resources, they said no. I'm wondering if it's possible. I don't know if that has been done to take that even a step further. Are these people minorities? Are they bothered about immigration issues? Are there things about the fact that I would get a bill if I go there? Because if you say you need something, then you should want it. So if they're not wanting it, why is the question, why? So I'm not sure if that has been expanded to that level and if not, I think that would be something interesting to find out. And finally, the question I really have for you, which is not totally related to this. Because in Maryland, there was the health enterprise zone. I'm not sure if you were aware about that and that has closed out. And then the conversations at the end, I was part of the team. The conversations at the end where money was saved, but who saved the money? You talked about the fact that 40 million were saved at some point. Where does, is that liquid money? People talk about this money and it's just something like flutes and somewhere. But you get what I mean? Where does that go? Thank you. So a few things. I think speaking about the screening tool, I think there was another piece to that too. And that the tool, the, when we would ask the questions around if they were food insecure or housing insecure, it would identify those people sort of correctly. But if you pulled it back a little bit and asked if they would, if there were other individuals that would be interested in resources for food or housing, we were capturing people, they were capturing people prior to when they would be identified by the validated screening tool. So I think there was both happening there from what I understand that some people who were identified were not interested in connecting resources. And I wonder if they also asked to, goes to Thomas's point in that families are resources and individuals are resources and perhaps they are food insecure and they know how to navigate that effectively. And there are families who are maybe not going to be identified but are curious in preventing that from happening, I think. And so I think that's what was sort of being highlighted there. And then in the piece around the investment in the sort of tech sphere, my understanding there is that there's been, that's about how much money has been invested in creating these different types of solutions. So this influx of software systems that Mike was speaking about are solutions have sort of entered into this space and that's about how much has, yeah. I was gonna also add that I think in the absence of resources to solve problems does not mean that we should not query if a need exists. I think sometimes solutions may not have been developed or resources may not exist at the time but that doesn't mean we should not ask and so I think that goes to being important stewards of people's data and if we don't have the resources to address them that we feed back to them the information that we identify that there is some need and maybe you can help us figure out a solution to solve this problem or, and so having people's data but also sharing the data with them I think is critical, it's critical also. I'll say to your question about what might be the motivators behind someone saying I do have a need but I'm not interested in accessing a resource. I've learned a lot from New America on this topic because they do a lot of work in social policy looking at welfare programs, public assistance and what are actually public attitudes towards being enrolled in some of those services, right? And as you can imagine humans vary so there's lots of different perspectives, right? Some people are like, yes, sign me up. Other people may have concerns like the ones you were raising which is, oh, will this put me into a system where I can be identified? What if I'm undocumented? What are some of the challenges? But I think too there's also a really core question to be asked about in general like how do we as a society view those programs and how do we then allocate our sort of talent and services and innovation towards those programs? Dr. Blumenthal was talking a little bit about SNAP and WIC innovations and I think oftentimes with these government programs because there's been a national narrative around, well, their entitlement programs and this is just the government providing, not a narrative I think most people in this room buy into but it's certainly a narrative that exists because of that you have this sort of like almost like de-innovationizing if that's not a real word but of those types of services and similarly you have customers who say, well, I'm not interested in going and like waiting at DSS for five hours, I've done that before, this isn't something that I wanna pursue I've got other things going on in my life and so I think too there's this sort of multiple layers of individual perception of these services and how that ties into societal and American perspective of those services as well. And I think that goes back to the incentive point as well which is like there's just this obsession with saving cost or driving efficiency and like the, sure, so that's where like private sector will come up with something in app to make, you know, you wanna have to stand in line at WIC, right? But like what the private sector has continuously proved is that the models that we have set up do not serve vulnerable populations well and not in any real inclusive way and so like we just have to change that, the narrative I think around that to say like, you know, I mean, I don't know, maybe if we look at the total cost of healthcare and this and that, but I actually just firmly believe that we need to like heavily invest in the social services sector and I believe a lot in like technology maturity curves so I think that just starting, like there's value in getting these sectors to start doing some sort of digitization and then, you know, what can you build on that and then how can you have open standards and those sorts of things but I just think we have to change the narrative around like this is gonna be a cost savings activity or else we'll just efficient size or self into a hole. Ooh, I made up a word too. Thank you. I enjoyed listening to the panel and I've been working, I'm a physician, I've been working in the social determinants of health for years and I always find it very interesting that these kinds of things that you guys are doing and talking about especially, you know, Maisha when you mentioned what you do at Chase Braxton, you know, I have the same distinct feeling that I have had for the past 16 years which is when we admit patients and eventually send them out to go out we reach out for the social worker to come in and kind of give them little resources to go to places like Chase Braxton for those patients who may be living in the fringes of society and we don't know what happens and they just kind of go away and then two months later, Mr. Jones comes back and he has the same issue and we wonder why Mr. Jones keeps coming back. We have completely siloed out that part of healthcare, the healthcare that happens outside of the premises of our care to small people, small numbers of people that are engaged in doing it. So I feel like medical schools should be sweating this. Educational systems should be sweating this. Sitting down and thinking about how do we train our trainees so that they're actually part and parcel of the kinds of thing that you guys are doing out there so that we're aware. So when patients come back instead of calling them non-adherent, that's actually a better word than what we used to call them. We have a little bit of an understanding the kinds of things that you're running into, the kinds of things that a patient's running into and the other thing I wanna say quickly is with health leads and the work that you guys are doing, the thing that keeps coming back is the power of the community and these individual efforts can only go so far but when we organize people around communities, there is actually a power and a momentum that allows people to support one another in culture of health that there were Johnson Foundation has championed a few years ago. So there's several layers to what we're talking about but I think at the end of the day, there's gotta be that holistic approach that includes institutions that train healthcare workers in order for this to make a difference. Yeah, my name is Alisa. I work at Health Leads as well you made me think of a lot of questions and I appreciate everybody up here and I'd be curious, Thomas and you as well, one of the things Health Leads is increasingly thinking about is how do we connect hospital systems to the communities more effectively? What does it mean for a doctor where you work to talk directly to the woman that works at Chase Brexon whose name I forgot, yeah. And I'm just curious, like what do you think is a realistic way to start? Like how do we start connecting physicians and healthcare providers to community services? And to the point you said, the systems that are in place at Chase Brexon may be like a completely different language than the systems that are at place at Johns Hopkins or your institution. And so I'm just curious what feels like a realistic first step from your all's perspective? I think some of this is in terms of working in teams and interdisciplinary care is exist and is occurring on the fringes. I think it's pervasive in the VA, of course. But one of the things that got me interested in the care of older adults is because oftentimes you do think about the care as a team, we work closely with social workers and occupational therapists and pharmacists, et cetera. And so but that model in training is, I think there's a desire for it, but aligning different curricula and figuring out best practices is something that is in this nascent phase. And I think when it does occur, I think we will be in a better state with pedagogy and also care for people. So in terms of how you, yeah, I'll stop there. I don't know if that gets at what you're mentioning. Just in full disclosure, I work for Hopkins as well. But since 2014, I'll tell you my own personal experience is I've been holding a small group at the Red Emma's Cafe. I don't know if you guys from Baltimore know Red Emma's, but it's a little small cafe I do too. So I have been holding a class. So Red Emma's has a group that it's a co-op for those of you who may not know it. And it's called, it's Baltimore Free School. So anybody who wants to teach anything can teach. You can teach about how to arrange a room or whatever. So I teach a class, Your Health in Baltimore. And in that class, I essentially just go out and solicit people who sit around the Red Emma's Cafe area. And a lot of them, people know that area very well in the Grim Mount area. There are a lot of people who are socially challenged. And attendance is variable, but we sit down and I have the students, volunteers who come with me. Sometimes I have practitioners who come with me. And we sit around the table, kind of like what we do when we just ask about what is it like for you to live out here? What does it mean for you to be healthy? Somebody was asking that question earlier. And what are the barriers? And if you were to design healthcare, I think Mike was mentioning about design. How would you design it? And it's been an incredible learning experience hearing people telling us how they would design it if they were allowed to design healthcare services. So these are tiny small efforts, but we are learning a little bit from being around people, real people, away from our white coats and our fancy buildings. So any other questions? All right, thank you guys so much. This was an awesome panel. I really appreciate it. Thank you for the good questions as well. We are gonna take a break. I know you guys are probably ready for one. There's coffee and refreshments in the back. It's 2.50 now. I just asked that we come back at three o'clock and we're gonna have three work sessions available. One focused on patient privacy and security, a little bit of what we were talking about. Dylan, who's right over here, is gonna be leading that session. Greg Bloom from Open Referral is gonna be leading a session on data sharing across sectors and thinking about how to put together some of these multi-stakeholder coalitions and actually make that work. And then we're gonna have fearless solutions which will stay in this room actually. And they're gonna be leading a session on designing for and actually with end users. So go get your snacks, come back, and then the work group sessions will go from, let's do three to 4.15, and then we'll shorten the closeout a little bit. So thank you guys.