 Our first speaker is Stacey Lindow and Stacey is an associate professor of obstetrics gynecology and medicine geriatrics. She received her amenity degree from Brown, did a residency at Northwestern, and got a master's here at the Harris School of Public Policy Studies where she was also a Robert Wood Johnson clinical scholar. And Stacey is one of these rare people that is a national expert in two quite different areas. Initially she was an expert on the area of sexuality in older persons and really bringing to light a taboo subject where the quality of life of sexuality in older people is a big deal. And Stacey was one of the first to really describe what is the issues and the scripted statistics regarding this and how can we start trying to improve sexual quality of life among older people. And our next area which she'll talk about in this talk today really is thinking about how do you mobilize the assets of the community to improve community health. And really Richard Kohler and I were talking about this a little bit earlier that Stacey is really sort of at the front edge of a cutting wave where with the increased emphasis on population health and as funding improves for looking at population health what Stacey will talk about will really be sort of at the forefront. Stacey also is a favorite of my medical students here as a role model for someone who is an outstanding clinical investigator and someone who really thinks about how can we improve the care for some of our most vulnerable populations. Stacey will talk about community RX connecting health care to self care. It was a story because I can't help but remember when I see Mark I was two weeks postpartum with our third son and I got a call that I needed to come in to help Mark with a meeting with a donor. It was very important and I felt very special that I've been called to this task. So I stuffed myself literally into a dress and came to campus to have a conversation with a donor about why they might think about supporting not only the ethics center but something beyond that. And I looked at Mark and I said, you know, Mark Siegler is a firecracker. And when the firecracker goes off these sparkles land all over the globe in the form of these ethics fellows who then build new flames all over the earth. And then I think I almost started to cry and then I thought, well, you know, I've rest my case. I'm going to go home now and nurse the baby. But I think we were actually successful ultimately in that bid. And I'm continually inspired by you, Mark, and I know everyone in this room is. Thank you and Marshall, thank you for your mentorship and for that generous introduction. So I want to start by acknowledging a broad range of partners who have worked with me to develop this program called Community Rx. And I think this gets to the recent question, actually, which is how do we ensure that the citizenry understands the research we're doing? And I think one path to that is to engage with the citizenry and identifying the questions we're asking and shaping the ways we do the research in ensuring that the data we collect is good for the next New England Journal paper but also is useful to the people who are asking the questions and whose lives are touched. And the work this work Community Rx is very much an outgrowth. I think of a very concerted effort to work closely with a broad range of community stakeholders to solve, I think, a very basic but recalcitrant problem in health. You saw that first slide up there about, you know, don't copy this. And this work is funded by primarily a grant from the Centers for Medicare and Medicaid Services. I had to submit my slides for review. They're sort of very close collaboration with our funders around this work. And any ignorance is mine alone and not that of the federal government. The third bullet point actually also raises some interesting ethical issues that we could talk about maybe as part of the question and answer. But I am expected as part of this funding to create a sustainable business model for the innovation we've developed. And what this means is that a new entity has been founded, an LLC entity. I'm the founder and the manager. And whether or not it will become the sustainability solution for Community Rx remains to be seen. But it does present a potential actual or perceived conflict of interest in presenting the study findings. So intersectoral health is a mouthful and not a term that many of our stakeholders really resonate with, but it's an idea that the World Health Organization has been talking about for four or five decades and that the Institute of Medicine has recently signed on to. And the idea is that if we're going to move from a healthcare system to a system that promotes health or a health system, that there is this collective influence and responsibility that all sectors have for creating and sustaining the conditions necessary for health. And on the one hand this is an inclusive statement bringing in entities, community-based service providers, social service providers who maybe have been left out of the healthcare economy for forever. On the other hand, this could be seen as sort of distributing or redistributing responsibility for the health of the population. So we're going to move in this direction and the Robert Wood Johnson Foundation, for example, would call this a culture of health. We hear the phrase health in all policies. All of these ideas relate to this basic concept of multiple sectors coming together to take on responsibility for the health of the population. If we're going to realize this idea, we need to create some infrastructure to support it because right now the practice of medicine is largely a siloed from the practice of all the other things that happen in the community, in education, in housing, in the justice system. Those systems are largely disconnected day to day from our operations of clinical care. So here's the ethical problem as I see it. And the caption says it's the only treatment option that we'll say she has under her current health plan. And so I'm a gynecologist and I'm the cave lady up there standing on the cliff sort of looking like what just happened. And my patient actually came to me on solid ground. She came, she made it to my clinic where I treat sexual disorders for women with cancer. And I've been able to diagnose her problem and I've been able to give her a prescription, let's say, for vaginal dilators, which my patients who've had pelvic radiation need to recover their sexual function. And then I say to her, based on our conversation, there are some other things you might need. Taking care of your weight is important for survivorship after cancer. Eating healthy, exercise. Maybe swimming would be good because it's a low intensity physical exercise. Where is she going to go to get these services? I really have no idea. My patients come from all over. I can't possibly manage all the information about all those other things that she needs to keep herself healthy as a cancer survivor. And in fact, just a sort of a funny anecdote of the problem that comes from this, we do prescribe these dilators and they are medical grade, there's a medical grade option for these dilators that costs about $150 and I have to write a prescription for it. The alternative would be for the patient to go to a local shop like the Pleasure Chest, which unfortunately when I mentioned this to a patient I called it the lion's den and then we both realized that was actually a strip club. So I mean, this is the problem with not having good quality information about where are the resources of the community. She looked at me, she was sort of like, I know what you mean, but I think that's a strip club. And at the same time I'm like, oh my God, don't go to lion's den for that. But, you know, why do we tolerate such poor quality and really the absence, the total absence of reliable information about all those other resources we need to take care of our health to manage with disease, to take care of a loved one every day. And so to me the ethical problem we're talking about here is that throwing people off the cliff. They're gripping on to that prescription for their anti-hypertensive or for their dilators. And we're yelling after them, but there are all these other things you need to do and I have no idea where you can go and I don't know if you can afford it or if you're eligible for that service. And so this is the problem we're trying to address. I think it's largely a justice problem, but there's not much beneficence or even autonomy in this picture either. So the Robert Wood Johnson Foundation did a survey of 1,000 primary care physicians and learned that physicians wish they could write prescriptions to help patients with their social needs. They learned that four in five physicians say their patient's social needs are as important as their medical conditions. And they learned that four in five physicians are not confident in their capacity to address their patient's social needs. So let's just look for a minute at electronic prescribing of drugs. This is the trend. What technology has been adopted this quickly? And we know that electronic prescribing of drugs in many ways has been part of the incentive to adopt electronic medical records, which has been challenging at best. But e-prescribing of drugs went from zero to 20% to ubiquitous in the last six years. E-prescribing of drugs makes it really easy to connect our patients to the medications they need. It requires good quality information about the medicine and all the doses and all the various formulation. And all of that information is built right into our workflow. What if the same quality information were available for the resources the community people need to take care of themselves? And we could inject the doctor-patient encounter, the nurse-patient encounter, with that information real time so that it was as easy to prescribe a drug as it was to not prescribe the lion's den or to prescribe swimming or a cancer wellness support center. This is what the architecture looks like for e-prescribing of drugs. It's complicated. And I think the most important point for this slide is to ask how do we know if the patient ever took the drug? We ask them the next time they came back. And the same would be true if we had as elegant an architecture and an underlying information system to connect people to the resources of the community. So the Health Care Innovation Award from the Centers for Medicare and Medicaid became available as an opportunity in 2012. There were 900 million taxpayer dollars appropriated to the Centers for Medicare and Medicaid for this new innovation center. And 107 of these were awarded in the first couple of rounds nationally. They were looking for innovations that would improve health, improve healthcare, reduce costs, promote the workforce of the future. The recession was hitting hard around the country at this point. And that would define and test a clear pathway to sustainability. That's not typical for NIH funding. It's becoming more common, I think, that taxpayers are looking for return on their investment even for grant-type funding. So we created an idea called HealthyRx, the connection between healthcare and self-care, or what I would say to people who understand e-prescribing, e-prescribing of everything else. What we had when we applied for this funding was a program called MAPS Core. This program grew out of relationships with community members that had been cultivated over several years. And when I say community, I mean anyone who cared about health and vitality on the south side of Chicago and who heard about what we were doing and came to the table. That's the definition of community. And community members said if we're going to work together with you researchers at the University of Chicago on issues related to health or urban health, we have three stipulations. One is figure out a way to engage youth, employ youth, give the youth of our communities a reason to come to the University of Chicago, expose them to science. Another was take a broad definition of health. It's not just the absence of disease or infirmity, it's all the things we do as a society to be healthy and its economic vitality. And third it was we better collect data that we can use and you better be able to deliver it to us fast. One of the core questions we were all struggling with are what are the assets of our community that we can build toward better health? There wasn't a good answer to that. And so we started employing youth to walk up and down every block of every street with smart phones and start cataloging all the resources of the community. And over time we just completed our sixth year with this. This became known as MAPS Core and it became a data engine for this e-prescribing system. So when we applied to CMS, this is what we had. We had a really unique workforce solution. I don't think anyone else applied with a youth-based workforce in the future and we had data about the resources of our community. And the idea was that we would connect up this resource database that the kids are creating to the electronic medical record workflows in clinical practices in our communities. So these are the communities. This is the city of Chicago, O'Hare. For those of you who have been stuck there, it's all the way up here. Over the last six years we've mapped all of this geography. It's about 90 square miles. And we have resources, thousands of community resources identified. Why did we have to do that? Well, the best available data, the data behind Google, the data behind Yellow Pages, the data behind Yelp is not good enough to be able to refer a patient to a place for services. It would be the equivalent of, here's a prescription for an antihypertensive. I'm not sure which one the pharmacist is going to give you. Or here's a prescription for your antihypertensive and I'm only 60% sure the pharmacy is actually there. Okay, so that's not tolerable. In the health, human services sectors had the poorest quality information in these mainstream data sets. And our hypothesis is that the poorer the community, the more invisible are the resources of the community. In connecting up the community resource database to the electronic medical record workflows, we needed to create logic so they could talk to each other and we call these ontologies. The ontologies are driven from fields in the electronic medical record that the doctor or nurse has to populate and we know the age, the gender of the patient, what language the patient speaks hopefully, we know what problems the patient has today, we know the address of the patient. Those are data that power this system. And the software pulls on those data fields that we have to populate anyhow and when we close the chart to move on to the next patient, sends a signal to this database that began with the youth data collection and sends back what we call a healthy RX prescription. I'll show you the prescription in a minute but over the demonstration period, this is the geography where we're deployed. Our first site was the Komet Holman Health Center, a really innovative, federally qualified health center of the Near North Health Services Corporation located at 43rd and Berkeley here on the south side of Chicago. And we've now spread to 21 sites across five healthcare organizations and integrated the technology with three electronic medical record platforms. It's been hard work but honestly, it's not that hard to solve this problem. It's just that we hadn't thought we really hadn't taken ownership of the problem before. This is what a healthy prescription looks like. It prints out with the after-visit summary for those of you who practice medical care. This is a summary that has to be printed in order there's an incentive around printing this summary in order to meet certain kinds of regulatory requirements that Medicare and Medicaid require. So a sample healthy RX prints out and what it does is connect a patient to a specialized type of community health worker. It has the lady Pamela sayings at the top of the page, and then provides in different categories the two closest programs and services to the patient's home address that are designed to address the problems in her problem list. This isn't all the information she could use. She's directed to the community health worker if she wants more information, if she wants to give feedback about her experience, et cetera. There's a public website so that even if a patient isn't coming to a clinical site where we're operational, their own healthy RX are created for somebody they care about. Now, the only resources that are in this database are the ones now in the 16 zip code area where we're conducting our work. And since April of last year, we've generated more than 125,000 of these healthy prescriptions and served close to 60,000 unique individuals. So you saw those data from the very beginning about provider confidence in their ability to meet their patient's unmet needs. These are preliminary data. We're monitoring ourselves, and we're also being evaluated by an external evaluator for our productivity and our performance on this project. These are serial cross-sectional surveys of providers who've been using the healthy RX system in a whole variety of sites over time. So at time three, we had 43 providers who had been using the system for at least 18 months. And what we see, this is just one of many metrics, is a much higher proportion of providers that are saying they feel confident or very confident in their ability to meet their patients unmet social needs. Is that because we're injecting every single patient visit with this information, this colorful information about the resources of the patient's community? We don't know cause and effect, but this is a promising sign. I want to end with a quote. These are pictures of our MAPS Core Mappers at the upper picture, is a picture of them at the Scientific Symposium at the end of the summer, where they collected about the assets of the community and presented back to community stakeholders, family members, and others. And C.K. Prahalad, who was a business professor at the University of Michigan. Unfortunately, I read his book for the first time a few weeks after I understand he passed away because I had intended to drive to Ann Arbor to meet him. He said, if we stop thinking of the poor as victims or as a burden and start recognizing them as resilient and creative entrepreneurs and value conscious consumers, a whole new world of opportunity can open up. Now, I don't entirely agree maybe with the diction of how he presented his idea. I tend not to call people the poor. But I think his point was, again, salient to some of the earlier questions we've had today. And that is, if we work with the people who have been resilient in solving their problems, if we work with the businesses and organizations who have been resilient in sustaining themselves even under very difficult conditions and we combine the talents and skills of scientists and physicians with the talents and skills of community practitioners and residents that we can find creative and I believe sustainable solutions to very basic problems. Thank you very much. I'm Joe Katva from Elkhart, Indiana. And I don't know if I have a question or just an observation. I'm incredibly excited about this. I didn't know about it at all and you just made my entire day worthwhile. I'm a little struck by your cartoon where you suggested that this is a justice issue. And you made the offhand comment that I don't think there's much autonomy here. I think the difference, though, is that you're actually conceiving of autonomy differently than most of the presentations in the earlier part of the day. We have a tendency, I think, to think of autonomy as isolated individuals. So whether I as myself have, you know, all these powers and rights. But when your model actually understands autonomy as a collective endeavor, right? So when you talk about these community assets and using youth to discover what the community assets are, you're talking about empowering autonomy but it's a social endeavor to do that. At least it seems to me. My offhand comment didn't contemplate your perspective and I'm very grateful that you shared it. I'll use it next time. And what I meant was that something, I think, more simple-minded, which is without basic information, patients, neither patients nor their healthcare providers can make an informed decision. And so that was my simple comment. I really like this idea of sort of collective autonomy or collective enablement of autonomy. Thank you. I'm really inspired by your work, too. I just had two quick questions. You didn't show any data about utilization or uptake on the patient's side. Yes. And second, what do you do with the one quarter of all patients who are probably functionally illiterate? Thank you. On the first point, we're early in understanding whether patients actually go to the places listed on the HealthyRx. What we were funded to do was to implement a call-in survey. So every one of those HealthyRx prescriptions, all 125,000 has in the upper right-hand corner, call in for $25. You can help us make HealthyRx better. It's more market research than I'm used to but this is what we were funded to do. And we've had hundreds of people call in. In fact, every month more people call than we can afford to pay to participate. And what we see now is that 15%, one-five of the people who call in, report going to at least one place listed on the HealthyRx that was a place they had never been to before. In my mind, that's a fairly optimistic view of things. Even more interesting, I think, is that 50% of the people who call in, it's a convenient sample, but 50% tell us they've told somebody else about the HealthyRx information. And 100%, which you have to be skeptical of in science, 100% say they said something positive. And then people go on to tell us what they told the other person. So we now have funding for a gold standard study, an NIH-funded R01, you know, Prospective Randomized Trial, where we will follow people, very meticulously, intervention in a controlled group to see what they do with this information, how it flows and spreads. That'll take five years. So that's my best answer. With respect to literacy, I'm concerned about that, and it's actually my interest in research started in part with studying health literacy. At this stage, even low literacy people can see a person's face and can read a phone number. And in the very brief training we're giving to providers, and we've trained more than 1,000 providers to do this, we're asking them to focus on Ms. Sayings, the community health worker, and her phone number. And most people with low literacy are able to make that connection. Thank you. Very quick question, quick answer. Okay, yes. Beautiful work. Congratulations. Thank you. Do you think people who are participating in this are looking at themselves rather than having an illness now thinking about health and healthy lifestyle in a much more transformative and positive way? Gosh, I hope so. Do you feel that way from hearing what I've talked about? Yeah, I feel like they're owning health. They're owning, you know, a life change. They don't have hypertension. They have a strategy of dealing with a condition that actually may go away if they lose weight, exercise, change. Yes. I mean, it's a completely different way of looking at what you have versus how you manage it in a... Yes. You know, the most common ontology that drives the Health Air X is wellness. So if you don't have one of those conditions, you default to a wellness Health Air X. And we have them tailored to different age groups and genders. But I think one of the... This is anecdotal. But one of the anecdotal experiences is both for patients and providers is the revelation of how much is actually here. And this other idea that we can bring the... raise the economy up by bringing local businesses and organizations into the fold of health and wellness. Thank you. Thank you.