Hi, everyone, and welcome to ACC Quality Summit 21. I'm Barb Christensen, and once again, I'm greeting you virtually and not in person, which I'd really hoped to do. However, I am able to welcome you live from Hart House in Washington, D.C. I really miss not seeing all of you sitting in a large hotel ballroom, and sincerely hope each of you is weathering our current challenges of COVID surges, and a special thanks to anyone attending from recent hurricane-hit areas. Our thoughts are with you and wish all a safe and quick recovery. As of today, we have over 3,300 attendees from 42 countries, which exceeds our attendance from last year. And again, just like last year, our faculty have put together an excellent program supporting our theme of lead, design, and achieve, which we know you'll find both timely and informative. Now I'd like to say a special thanks to Kim Marshall, who for eight years has served as the nurse planner for Quality Summit and the QII Learning Center. Thank you so much, Kim. We couldn't have done this without you. Now before we get started, just a few housekeeping items to make the most of your virtual Quality Summit experience. We want you to use the question and chat function to send comments or questions, as we'd love to hear from you. You can navigate your schedule through the app or on the homepage of the Quality Summit website. And if you haven't downloaded the app yet, you can find it in your app store under Quality Summit Virtual 2021. Now if you still happen to have last year's app, you can go to the menu on the upper right and select Other Event and choose Quality Summit 2021. We want you to check out the new Summit Showcase, which you'll find in the Exhibit Hall. Our top 20 abstract poster submissions, a theater showcasing our first, second, third place poster winners, and the three honorable mention abstract poster presentations. And new this year, an opportunity to check out the job board listings from participating health care systems. The presentations on demand sessions are now available for your viewing. However, the three-day conference sessions will be available on demand following the conclusion of the conference. For those of you who need education credits, you can claim those after 1.30 p.m. tomorrow, October 1st, through the URL link provided on the app or on the homepage by clicking the Claim Your Credits tile. You don't want to miss the posters to read and hear what your colleagues have been doing over the past year. And of course, we want you to vote for the people's choice. All the details can be found on the e-poster tile on the app and Quality Summit homepage. And for those of you on Twitter and social media, our hashtag this year is ACCQuality21. And finally, join the scavenger hunt throughout the summit showcase to be eligible for raffle prizes each day. And you can check that out on the homepage. Now I'd like to introduce the Quality Summit course director, Dr. Ty Gluckman. Ty is the medical director of the Center for Cardiovascular Analytics, Research, and Data Science at the Providence Heart Institute in Portland, Oregon. And he's been guiding us through the planning of this year's Quality Summit. So Ty, welcome and thank you. Thanks so much, Barb. I'm thrilled to be here meeting virtually with all of you today. Here we are another year later, still challenged by the COVID-19 pandemic. And yet, we have adapted, shifted, and found that the upside of a virtual Quality Summit is that it allows us the opportunity to show the world what a great job all of you do every day at your hospitals and practices. Our faculty this year are stellar, and I'd like to thank each of them for finding the time to prepare and deliver exceptional presentations. I'd also like to thank our co-chairs, Dr. David Winchester and Dr. Ralph Brindis, whose leadership and guidance has been invaluable. In addition to this, I'd like to thank ACC executive leadership, staff, and especially Maria Ortiz and Maddie Tappe for keeping all of us on track these past few months. Thank you all. To our exhibitors, your support is truly appreciated. Most of all, we thank you, our attendees, for joining us over these next two days. You are the reason we come together to learn and discover. You make a difference each day in the work that you do. It's now my sincere pleasure to introduce Dr. Dipti Ichipuria, president of the American College of Cardiology. Dr. Ichipuria is an interventional cardiologist, the Eric and Sheila Sampson Endowed Chair of Cardiovascular Health, and director of disease management for the Hoag Heart and Vascular Institute in Newport Beach, California. She's also an associate professor at the University of California, Irvine. Prior to becoming ACC president, Dr. Ichipuria has held many leadership positions within the college, including being a past member of the ACC's Board of Trustees, past chair of the Board of Governors, and past president of the California State Chapter of the ACC. Thank you, Dr. Ichipuria, for your ongoing support of the NCDR and accreditation services and for being here today. Greetings from California. I'm Dipti Ichipuria, president of the American College of Cardiology, and it's my pleasure and privilege to welcome you to the ACC Quality Summit. Thank you to each of you for taking time out of your very busy schedules to be part of this annual event. Over the next three days, we have a unique opportunity to not just hear from experts, but more importantly, engage in discussion and learn from each other about ways we can grow as a profession and use innovation, knowledge, and data to optimize patient care and outcomes. Much has changed, and quickly, over the past year and a half. We have all had to adjust our day-to-day personal and professional lives in ways we could not have possibly predicted, but what we have achieved together during toughest of times has made us a stronger community, challenged our creativity, and truly fostered innovation, collaboration, and teamwork. This year's summit will highlight some of the exciting opportunities we have to continue to move forward together and achieve our common goals. The joy of a virtual meeting is that you have time to explore all three tracks and deep dive into sessions on leadership, accreditation, quality improvement and action, and our suite of NCDR registries. In addition, don't miss 15 on-demand sessions and the more than 90 e-posters showcasing quality improvement efforts in hospitals, institutions, and practices across the country and around the world. On a broad scale, I think we will all come away inspired by Dr. Cheryl Pegas and her keynote on ways innovation can help make our jobs easier and the lives of our patients better. Those who know me know that I'm quite passionate about innovation. I love the quote by Peter Drucker that says, if you want something new, you have to stop doing something old. Several of my recent Jack Leadership pages and virtual Saturday coffees with the ACC department have addressed several facets of innovation and the role it can play in healthcare transformation. Whether it's leveraging new technologies, digital technologies to improve patient care and clinician wellbeing, or learning more about innovations taking place in the food and agriculture industry, like cellular agriculture, we can make tangible impacts on cardiovascular health and prevention. I'm also looking forward to hearing from past ACC president, Dr. Pam Douglas, about the ways that NCDR and accreditation continue to support our efforts to provide the highest quality cost-effective care for all of our patients. Data leads to knowledge and knowledge is power. By harnessing the power of the data at our fingertips, we can demonstrate in real time how new clinical guidelines are being used in patient care. We can also find opportunities to close gaps in health disparities and solve for health equity, a strategic priority for the ACC and a personal goal of my own. Thank you again for being part of the Quality Summit, and thank you for your continued demonstrated commitment to quality care. I continue to be inspired by the tenacity, innovative ideas, and leadership demonstrated by the NCDR and the accreditation community, and I look forward to learning and sharing with you over the next few days. Thank you very much. Hi, everybody. I'm David Winchester from the Malcolm Randall VA and the University of Florida here in Gainesville, Florida. And it's my pleasure today to introduce our keynote speaker, Dr. Cheryl Pegas. She received her bachelor degree from Brandeis University, her MD degree from Weill Cornell Medical College, and an MPH degree from Columbia University. After several years of working in private practice as a cardiologist and then in multiple industry jobs, she is currently Walmart's Executive Vice President of Health and Wellness. In addition to that, she sits on the board of the American Heart Association, she's the immediate past board chair for the Association of Black Cardiologists, and she is the founder of A New Beat, an organization dedicated to improving cardiovascular health and careers of women and underrepresented minorities. She's joining ACC Quality Summit today for our keynote talk about the current and future role of innovation in healthcare. Welcome, Dr. Pegas. Hello, everyone. Great to be with you today as we talk about innovation, a word that I think gets used quite a bit in many different industries, but really important for healthcare and the work that you all do. I want to start out by talking a little bit about the work that I'm currently doing. I'm at Walmart, I lead our health and wellness business at Walmart, and I want to talk a little bit about the scale of what that business looks like and what we do, because I do think it's important as we think about innovation and where the people we serve actually are. Walmart has about 150 million people who come through our stores every week. These are across all parts of the United States. 90% of Americans live within 10 minutes of a Walmart, 70% within five minutes. We and I know this is a statistic that many people may not be aware of, 4,000 of our stores are in HRSA-designated medically underserved area, 4,000 of our stores. We have over 5,100 pharmacies, including in Puerto Rico. We've got over 3,400 vision centers. We've got hearing centers, over 470. We have clinics. Interesting as you think of the care that someone receives within a healthcare center, these are not retail clinics, they are healthcare centers staffed by primary care physicians, nurse practitioners, care coordinators, community health workers. We also provide dental services within these clinics. We provide optical services within these clinics. We provide radiological services within these clinics. Just think about that. In sites where we have over 5,100 Walmarts, today, we have a place that someone comes to where they can not only get fresh food, and Walmart is the largest provider of fresh organic food in the country at the lowest prices, but there are services that they can receive, including pharmacy, optical, clinical care. We provide behavioral health within our clinics as well, and if it's the place that you go to in a medically underserved community, there are multiple services that you are able to receive on one visit. We also have the ability to provide immunizations, and I know many of you have seen and heard of the work that we've been doing during COVID-19. For what I just shared, about 4,000 of our stores are in medically underserved areas. So what do we know about the people that we serve? We know, if you ask them, that many of them do not seek healthcare because of cost. 43% of our shoppers do not get healthcare because of the cost. For many of them, it's not convenient. There have been a lot of studies that have been published that share someone has to take a day off of work for a physician's appointment, they end up simply not going. 27% of our shoppers say convenience for them is not available. Access to healthcare remains a priority, and many of them do not have access, particularly if you're in an MUA. It's really challenging to get access to healthcare. And then, of course, many people simply delay care because the convenient access that they may be looking for is not available to them. But they are not the only people in healthcare. Many of you are aware that decisions on how you seek healthcare are actually made by those who pay for healthcare. So let's talk a little bit about what the people who are purchasing healthcare for their employees or if it's managed Medicaid or CMS, the things that they're looking for as they get healthcare for their people. This is a survey that we actually did very recently, specifically asking payers and employers what are the things that are important to them as they purchase healthcare. They want people to have easy access to healthcare, even when they don't think they need it. People say they'll go to the doctor when they need to, but that need to never happens. We think the future is trying to get healthcare to people before they even realize they are sick. From a benefits manager, in healthcare, it comes down to accessibility. Whatever you can do to make it quick and easy, because health-related things are not something people necessarily want to do. I love the comment from one payer that we think of success as big gains, game-changing improvements. As long as our full vision comes through and is successful, even if it's only for a small amount of people, it's really important to understand how you're targeting and what's getting done. My last one, which I'll actually read in its completion, every payer in the country is working on keeping people well. We're trying to reach out to members and give them the tools to live their best lives. If a diabetic can't afford either insulin or food, we will cover their insulin or give them a Walmart card to pay for their food. We are trying to provide solutions. That's really, I think, what we all come back to. We are trying to provide solutions. Not one of us, any group, be it clinician, be it, I think, what you would consider people providing community services, not one of us can do it alone. If there's anything we've learned during COVID is that we need to work together with all of our assets across this wonderful country to improve healthcare access and healthcare outcomes. What does that mean? I'm going to shift to using a definition that, for me, has captured a lot of my work that I've been doing in healthcare for a very long time. Many, many years ago, early in my career, I got to meet Clay Christensen and his group. He and his team partnered with one of my previous employers to discuss how do you innovate and change within healthcare? Clay Christensen coined the term disruptive innovation. For him, disruptive innovation meant that a new entrant made an existing service less expensive and more accessible. I want to just repeat that. The definition of disruptive innovation, it's less expensive and it's more accessible. Based on what you've heard in my introduction, you can see why that resonated with me back in, I think, 2003. It really, I think, signifies what we are all trying to do in healthcare, make it more affordable, and make it more accessible. The other important points about disruptive innovation, and I recommend everyone read this book. It is truly, I think, something that helps in what we're all trying to do in healthcare. What he also talked about was what incumbents do, the people who are established, and in this case, in healthcare. They spend a lot of time improving their current products and services to meet the needs of their current customers. Not for those who do not have access today, not for those who can't afford it. Incumbents focus on their current customer base. They tweak their products a little bit to make it better for that customer base. There are huge customer bases who have unmet needs, and they're not being met. So the incumbents ignore the needs of these groups. And how do entrants then go ahead and sometimes not only match their incumbents and when they first target these overlooked segments, they bring them into the marketplace so they too, in this case, can receive care. They make it affordable, and then they spend the time, now that they've gotten cost and access correct, they spend time improving the quality. And once they've improved the quality and they have a better price point and they've scaled their offerings, they sometimes displace their incumbents. Really important theme for healthcare. And as I said, Clay Christensen has been teaching it and his team. He's no longer with us for a very, very long time. And so what does that mean when we think of the work that we all do? Let's think about innovation and healthcare and what's actually occurring. And it's occurring from the outside pushing in on healthcare. There are four main drivers that have been driving innovation, frankly, for the longest time. I think the last 18 months have made us all realize how important these drivers are. One, the people who pay for healthcare, be it government or employers, they're asking for changes. 90% of the 3.8 trillion healthcare industry comes from employers, CMS, and payers. The people who buy healthcare are asking for more. 55% of this 3.8 trillion is funded just purely by CMS and some state Medicaid programs. They are engaged in healthcare and they are key constituents. As we look at how we innovate, we must meet their needs. The second area that I'd like to just talk about is value-based care. And I know if you're a cardiologist, you think of bundled offerings. Same thing. But value-based care continues to grow. And value-based care really means that people want to measure the outcomes of what they're buying and paying and ensure that it's improving. There has been a five times increase, a 500% increase in VBCs over the last five years. I know many of you know this. We all expect it to grow. Telehealthism is something you hear about a lot. And it's interesting that it's a term that really says people who receive healthcare would like to receive it where they are comfortable and have access. They want to receive good quality care. They want to trust their care. Telehealth has a large component of that. I can't say that we physicians are the ones who've pushed telehealth. I think it is people who pay for healthcare and the actual users who have said, I really like the flexibility of being able to get care, be it on an evening or not having to take a day off from work to get care. And people want to receive care in a digital manner. And so we are adapting. We adapted, many of us, because of COVID-19. And hopefully we acknowledge and recognize the positives that have come from that and how we will continue to provide care. And lastly, kind of where I started with Clay Christensen's innovation theorems, which is that healthcare is not just what you get between a patient and a physician. 70% of health outcomes are actually based on social determinants of health and personal behaviors. And if you look at many of the outcomes, again, in all of the studies that have been published during COVID-19 pandemic, you will find that social determinants are the areas where we've seen the biggest gaps in healthcare and where many of us have known for a while it is the areas that we should focus on no matter what our specialty in healthcare. So the only thing COVID-19 has done is it's accelerated the drivers of innovation. It hasn't necessarily changed them. By the way, Clay Christensen's terms, I think, were developed long before I ever heard them. Disruptive innovation still remains something that we're working towards in healthcare. We have not yet achieved it. And so what does that mean for what we continue to do? Value-based care is really important. That shift that we're seeing in value-based care is here to stay. For underserved populations, for aging populations, this growth that you're seeing where managed Medicaid and Medicare Advantage continues to increase. These numbers that I have here, 121% increase in enrollment in managed Medicaid. Over a 200% growth in Medicare Advantage really, really speaks to the fact that people want to see improved care and they want it to be innovative. They want it to look at social determinants. They want us to think about how people can access care, not just nine to five, Monday through Friday. And most importantly, that they will measure it, they will look at the success, and they will see how we improve healthcare. This is a shift, and I know for many of us, we've been watching this shift, for me, probably from all sides, but it's a really important shift in how we improve healthcare. And many of the writings and thought leadership that you've seen in cardiology and other areas talk about the real importance of this shift to looking at outcomes and managing social determinants of health. The time, I think, for this leadership is now. And hopefully, everything we've learned in the last year and a half does not take away from the work that each of us can do at our own institutions. I want to talk about social determinants a little bit more. I've spent a lot of my career working on how do you improve social determinants. I will tell you, it is work that I love the fact that everyone's talking about it now, that everyone's talking about improving health equity. My hope is that it does not fade as the primary driver of improving health outcomes for all Americans. And frankly, across the globe, you see people understanding the needs of what you have to do in social determinants. We're starting in three areas. We're looking at food security and looking at how we launch programs to meet that need. We're also looking at maternal and infant health. And part of that is food security. You have to ensure that pregnant mothers or mothers thinking of becoming pregnant have access to fresh, healthy food. We are in their communities. It is a commitment of our organization and our company to ensure that we're providing fresh food and access. And of course, cardiometabolic. And some say it's because I'm a cardiologist that this is one of our priority areas. But it's actually because it's still the number one cause of death. It affects all communities. And the health disparities that exist in this area are things that we can all work on. We at Walmart think about the social determinants in the ways that I've just talked about. The social and economic factors, food, income, employment, education, housing, transportation. We partner to be successful in those. We help people with their health behaviors. It's one thing to tell someone you should go home and eat a healthy diet. It's another to tell them how you can afford to do it and explain what's in those diets. For us, we see that as a primary component of our work. And our community health workers spend a great deal of time doing this. Interestingly, we spend a lot of time, obviously, on clinical care in this country. It's only 20% of health. It drives a lot of where we spend our dollars. Just small shifts in addressing social determinants and personal behaviors could change how we look at health care in this country. One of the things we're committed to at Walmart is doing some of that work. And now you know my reason for joining Walmart. It's to focus on that 70%. I want to talk about how we're doing that. I've talked about community health workers quite a bit. I tell people all the time it should be 10 to 1, 10 community health workers to one doctor. And you need more nurses and you need more nurse practitioners than you do clinicians Because that team-based care that includes community health workers and pharmacists really get a lot of the work done that we may not see in that 15 or 20 minute visit that someone has with us. Because people are living their best healthy lives when they're not in doctor's offices. And so we've got to ensure that they are receiving care in their communities accessible and affordable. We do a lot of proactive outreach. We ensure that if we not only haven't seen you pick up your medicines, but if we know you were receiving food and we haven't seen you come in for that, has something occurred and what do we do? We will deliver it to you. We will sometimes have a community health worker go into the home to ensure that you're having your needs met. Now the only way you can do that is if you're right in the community, you have people who work in your business model for us at Walmart, who know the community and who are trusted. So I want to repeat those in the community, know the community, trust it. That's how innovation actually happens. Ask any new entrant how they're able to gain access. That's what works. If we believe in medically underserved areas, you do not have access to healthcare. You must provide telehealth. It shouldn't be you don't have access to healthcare and there's none in your community. It is our commitment to ensure that people have access to healthcare. Our telehealth company that we recently acquired provides acute care. It also provides primary care and it provides behavioral health across all 50 states. And as you recall me saying, we have 4,000 of our stores in medically underserved areas. The ability to get one stop shop, particularly if you're in a community that doesn't have access and you can get your teeth examined, get your eyes examined, get your child's teeth and eyes examined and be able to get behavioral health allows people to feel cared for in their own community by people they trust. It is a really, really important component of what we do. And we don't just go out and think we're doing great. We measure what we're doing. And I'm calling out the NPS score, which is a measure, net promoter score of how people who utilize your services feel. And we on average have an NPS score between 78 and 80. I truly believe it is because the people who are providing care are from the community that they're serving. They're culturally appropriate. They allow people to understand through great health literacy, communications, and they represent the people there. They understand the needs because it's their needs themselves. Walmart has over 1.6 million associates across the US and almost all of them serve and work in the communities that they grow up in. They start off knowing the needs and we, I lead a large organization, aren't the ones telling them what they are. We're actually saying to them, tell us what you need to allow us to provide care in these communities. And they're the ones who are shaping these offerings because they need it for themselves and for their families. We've done a lot of partnerships and I'm sharing a few examples here, but know that we've done probably 400 partnerships in the last eight months. Some to ensure access to COVID-19, some to ensure access to healthy food, some to make sure that we're meeting the needs, be it in maternal health or in cardiovascular health, where we've done some work and are continuing to partner with some organizations. We published a paper earlier this year with Humana in reaching underserved African-American populations in Montgomery, Alabama, where we had people who they trust, call them to let them know that they had vaccines available, answer any questions that they had, and then ensure that we provide a transportation for them so that they could get their immunizations. And by the way, pick up all the other needs that they have. It also gave Humana an opportunity to hear the other needs that their members have. And we were able to link them back to their primary care physicians in the community. Those are the types of partnerships, healthcare is local, that you have to do with each community. We partnered with Rush in Chicago, got a call from a number of the cardiologists at Rush that on the south side of Chicago, they knew it was challenging to get access to immunizations and care, but more importantly, that people wanted to go to a place that they trusted to be able to get their questions answered. We met actually on a Wednesday night with all the men, people from the mayor's office, people from the different healthcare systems. By that Friday, we were doing over 1,000 immunizations on that Friday alone. Again, partnerships, understanding how you play a role in the ecosystem, listening to others, and working together. I've mentioned cost and innovation and disruption and how you really provide greater access to healthcare. One of the things that some of you are aware of is that earlier this year, we, Walmart, launched our own insulin brand. It's called Rely On Analog Insulin. It is a short-acting insulin, and as I speak, we're probably introducing a mixed insulin, a 30-70 mix. The real importance of this launch is that it is 78% lower than current insulin on the market. I could probably share with you the emails and calls that we've received since that, but the most heartfelt ones have been from patients who now can afford insulin and don't feel like they're trying to stretch it. Disruptive innovation makes things available to people who today do not have access. Healthcare delivery has changed, and I think has changed for the better. People should be able to get care where they're able to get care, be it in person, virtual, or in-home, depending on the diagnostic needs or the personal needs. Our goal must be to address social determinants, help people with their personal behaviors, and yes, help them. If it was easy, none of us would be talking about elevated BMIs and the ways we're seeing increased diabetes. We have to help people engage in taking care of themselves, and we have to give them the tools or let them know where in their community they can access it. Healthcare is brick and mortar. It's absolutely where you will need hospitals. Absolutely, you need primary care and cardiology offices, but we also need telehealth. We need in-home, and we need others on the team, be it community health workers or pharmacists or care coordinators or nurses or nurse practitioners or dentists or opticians, audiologists, all connected and providing care. Our omni-channel model allows us to have all of our healthcare professionals on one singular platform, be they dental or pharmacy or clinical care, being able to communicate across our ecosystem to ensure that when we touch someone, we're able to provide their needs across our entire ecosystem, more importantly, allowing us to link with other healthcare professionals who they need to see. Many of the people, obviously, who we are caring for do not have primary care physicians. Why? Many of the communities I've just said are in medically underserved areas, so really ensuring that we are connecting them to sustained healthcare and that we're ensuring that the information is available to them and they understand their needs is a critical part of the work that we do every day, and work that I must say, as I look at the teams providing this care, I am humbled to be the physician on this team a lot of times because the care that they're providing are actually the services that people really need. I will end with this quote from Kenneth Blanchard, and I've used this not at an ACC meeting before, but maybe at TCT, because for me it's a really important quote. There's a difference between interest and commitment. When you're interested in something, you do it only when it's convenient. When you're committed to something, you accept no excuses, only results. Thank you very much for having me. Great to be with ACC, as always. Thank you very much, Dr. Pegas. It sounds like you have got an awful lot of work on your plate. I'm gonna quickly throw over to Brendan Mullen from ACC to introduce himself, and then we'll go to Q&A, if that's all right. That's great, thank you. Great, thanks, Dr. Winchester. Howdy, good to see you, Dr. Pegas. I'm Brendan Mullen. I'm Executive Vice President of the NCDR and Accreditation here at the ACC. One of my sort of mind-opening experiences, actually, in healthcare and medicine, was when some of your predecessors invited several of us down to Bentonville about 10 years ago, and explained the type of infrastructure that Walmart was building, both in terms of its bricks and mortar stores, and also the conception for the future of virtual retail space. It was remarkable at that point. And it really changed my thinking about how we could expand access by using resources outside of traditional healthcare medicine. So my first question for you is, I'm curious, as you've developed that strategy, you talked about retail healthcare in Walmart, you talked about the role of virtual telehealth. How then you're trying to connect those resources into more traditional medicine for when patients have higher acuity care that they need as potentially their disease progresses? Thank you for that question, because it is an important question. I'd start off by saying this has been occurring for many years, right? It is not new in how we ensure that there are connections in healthcare. Frankly, I think even when we're talking about practices, we wonder how will the information get from the primary care physician, the GI physician, and the cardiology physician to the patient or to the emergency room when they need it. And so there are ways and tools that we've utilized technology to enable that. One is by having a common electronic medical record. And we at Walmart are actually on an EMR platform and we connect to other health systems that have electronic medical records. So those connections exist. What's really important for us, however, is how easy is it for someone to be able to access their abilities to utilize these services? If you are in a community that does not have primary care physicians, rarely do you then have a cardiologist. And so the ability to be able to have your pharmacist connect you to virtual cardiology care or other specialty care is critical in how we provide care to many of these communities. These are sometimes underserved or rural communities that truly have no other access. Walmart fills that need quite greatly. As you heard me mention, the majority of our stores, 4,000, are in these types of communities. And that's how we're doing it, with lots of partnerships with health systems nationally in utilizing some of their telehealth services and in the ways we are developing some of our own to really impact cost overall. Thanks a lot for that. I had kind of a follow-up question I was gonna ask about healthcare records, interoperability, and specifically, how is your model built out to allow patients to access their own records and to understand what's going on with them? That's certainly something that we deal with a lot, both in my job at the VA and when I work on the university side. Yeah, and so we're all aware of the EMR platforms that we utilize and the patient portals available so that patients have access to their information. A key point here, though, is many of us are aware, even if someone is able to go in to the patient portal and see the information of their visit and know, do they have enough health literacy to understand it? And so we utilize community health workers quite significantly to ensure that we are making things, one, culturally appropriate, but two, health literate. So you have someone who's walking you through what you heard from the doctor. Do you understand what that means? Here is what the follow-ups may need to be. And because a lot of this is done digitally, one of the things I think you sometimes hear about, well, a lot of communities don't have broadband access, so they may not have a computer at home. Pew Research shows that 85% of people actually have a smartphone, be they African-American or in an underserved community. Many of you are aware that Medicaid actually covers those services. So we also make sure that our responses and our information are available mobily. And we also make sure that we've checked for health literacy, grade five and below. We ensure that we are communicating with someone who is like you in your community to explain the information. That NPS of 80 really reflects that. It's not because we've got great patient access on the portal and we're interoperable. It's that people still need a human-centered approach so that they feel as if someone is connecting to them and that they can trust them with their true healthcare questions earlier. That combination is what we're utilizing. To me, Dr. Pinkett, that raises a really interesting place where medicine and commercial retail come together. So one of the great disruptive innovations probably the last 10 or 15 years is being able to use consumer data, analyze it, and being able to target them to motivate certain behaviors. And it's benefited a lot of our lives in terms of our ability to consume things in retail. I'm curious, is Walmart thinking about combining that, of course, with the appropriate HIPAA protections and recognizing health data as differently? To think about different ways of reaching out to customers slash patients and communicating with them? So I would say the answer is always, more personal data helps you in being able to get longer-term engagement. But I wanna challenge something, and I say this as an avowed data geek who's spent most of my career evaluating data and what solutions can be. I sometimes think we all believe we need more data to provide accessible, affordable care. And that's actually rarely the case. I think we all know that if you write a prescription for someone and you yourself don't know the cost of that, having someone be shocked when they get to the pharmacy at the cost, that's an issue we can solve without having more data. Affordability is an issue in this country. We should be thinking about that. And our training as clinicians should be understanding the difference between generics, brands, and understanding what's on formulary for someone's insurance. And so yes, I could get more data to let me know that cost is important, or I can proactively begin to address that and make it part of our training. I think we also know that many people struggle to be able to get to appointments for healthcare. Yes, I could ask them more data of what are the times that are available, or I could set up my ecosystem so that there are evening and weekend hours. And so I think, yes, data can help, but there are some broad swipes that we in healthcare should be doing to improve access and affordability. It is definitely the starting point of what we do, and then ensuring that we look like the community we serve so that we can build trust, the third pillar. So yeah, we can always add more data. I love data. I love publishing data. In all of the years that I've been doing this, as many people have asked for more data, the simple changes that I just talked about would go much further. It'd be great to see a study that showed that we did those three simple changes, and here's what occurred. Thanks, I think that has bigger insights than you might realize for our National Cardiovascular Data Registry and how we think about improving quality with data. So thank you for that. I may be back to you for that then. Dr. Winchester? Yeah, yeah, I just wanted to briefly follow up on one of the points you brought up there about maybe that we don't, it's not necessarily that we need more data, it's that we need the right data at the right time. I've worked in a number of different institutions with a number of different EMRs, and I can't remember one that ever really gave me a good interface to say, a good interface to say, oh, this patient with this insurance can get this statin at this price, right? Now, I greatly appreciate the creation and the growth of the low-cost pharmacy generic lists that came about when I was in training. That was fantastic. We printed those out and put them up in my resident clinic, and everybody used those all the time, but that was like sort of one little carve-out of a solution, and I was wondering if you had any other thoughts about how systems can be better built to provide those sorts of solutions. I don't know how much it costs to get an echo. I don't know how much it costs to get an ECG, and maybe from time to time that would make a decision, help me make my decision as to whether or not to order yet another test. So, yeah, just your thoughts on how we do that better. It's so the right question, honestly. So, I went into medicine because in my community, and I grew up on East Flatbush, Brooklyn, you really couldn't afford healthcare, and you didn't have great access, and so it was always interesting from my perspective in what I knew in accessing care for myself, my family, and then when I got into healthcare, and you're looking at it, that the questions that were most relevant to us weren't the ones that the physicians I was training with really asked a lot of. I was fortunate, however, I was at Cornell. I had David Rogers and Tony Gatto as mentors, and there was nothing that we talked about that they didn't intuitively know there were issues to solve. What we didn't know is how do you solve it at scale, how do you ensure that you're making a difference at scale? EMRs, I think, give institutions an incredible opportunity to do that. You actually usually build upon your EMR the ways that you'd like to see care given. What if part of the requirement was we will update our system so that you can see formularies and cost of drugs? They're available. How do we know they're available? Every pharmacist has it. Not that hard. If that was what you felt was the important driver for improving the care of the communities you serve, you would make it a priority. There are health systems who we work with today at Walmart who've decided that access to fresh food is a priority. They're integrating it into their EMR. They're making sure the question is asked. They're ensuring that people understand how to get it affordable, how to teach someone what fresh food is. So I do think priorities matter. And when you look at improving quality and improving outcomes, there are some basics that I don't think we need to go retest. We actually know what they are. The will, it's my Kenneth Blanchard commitment statement, as you know, it is the will to do it. Are you committed to doing some of this work? It is not difficult work. It is not difficult to scale this work. I think I really, really like those questions. They're the ones that my entire career, I've been hoping to solve inside the traditional healthcare ecosystem, outside. And as you know, I jump back and forth in both because we're getting better. So that's the other thing, right? Gosh, would we ever have had this conversation 10 years ago? Just the fact that we're talking about it and we recognize the importance of it is change and improvement. And so I am not, never, never someone who is not incredibly optimistic about where we're going. This dilemma of solving problems at scale is probably no more acute than when we're trying to address health disparities. And I found that it's probably the most interesting and inspiring part of your talk. I'm wondering what advice you would give to physicians and clinicians that are operating in a healthcare system where they feel trapped, trapped by the RBUs, trapped by the 10 minutes of time that they have with their patients. How do they start to act on, I think, what is a deep internal commitment for many of them to start to address some of these disparities, but struggle with how to take that first step? What kind of advice would you offer for them? The first is acknowledging that it exists. And so, yes, there are different times when you don't need more data. This case, you do. Institutions actually need to know their data by race, ethnicity, gender. And they need to be humble enough to see if those disparities exist, to acknowledge them at all levels of the organization. Because that first sense of community, of being we are all trying to do our best work and we still are not succeeding, that means that there are other things we have to do. Just that base statement, and I've seen institutions around the country get to that point, it is a challenging place to get to, as you know, because everyone feels they get up every day and they treat every patient equally, and hence all of the outcomes are equal. That first acknowledgement that there are differences, the ACC has done a lot of work in this area, wouldn't it be great if every institution says, we know our data and we know where our differences lie. By the way, if that was the only thing that came out of me giving this talk, I would consider it an incredible success before we even start to think of what do we do next? Because you have people at different places, you have people like me who spent our entire careers on health equity work, and you have people who've never even thought about it. Just imagine the richness of those conversations and institutions where people care about just doing a good job and improving patient care. So that's where I would start, and I'd love to see that become something that we do a lot more of. So I think I've got just one more question that I wanted to ask in keeping with your theme of disruptive innovation, and that's to ask you, what do you think the rise of online retailers will do to the model that you've built out for the impact of these brick and mortar retail healthcare models? So I mentioned this a couple of times, trust is really important in healthcare. You trust people from your community and people who are like you. And so I always think of technology as a way to sometimes decrease the work effort of healthcare professionals. There aren't enough of us, there's way too much paperwork. Is there a way that we simplify that so you have easy access when you're seeing a patient to have all of their information available to you, that we've allowed people before the appointment to tell you a little bit about what's going on with them? Those capabilities ease the burden of providing care, of making it easy to access. It doesn't take away the fact that people still want to meet people and talk to people like them. And so I think the three-pronged area of, is it affordable? We can check that box because we can definitely improve affordability. Is it accessible? And not us define accessibility, but it be defined by the patient seeking it. I am disabled and I'd like to get it in home. I'd like to use it digitally because I'd like to do it on the move. I need to come in in person because I need a test or I need a blood test, I need to do other things. Our ability to let people know that omni-channel care is how we know they want to receive it and we will allow that to occur is really, really important. That's not going away. This third piece about human-centered care, however, is how online doesn't win by itself. And I think we all know that as clinicians and I think other businesses, even those who started online, are shifting to ensure they have brick and mortar because people need a place that they can also go to and they need a person who they can trust and talk to. You have to do all of them. If you were starting with just one, I'd start with getting trust of people in healthcare and people trust the people who are providing care to them, who they can see, touch, feel, or who are just like them. Well, I think that was all that I had. Brendan, did you want to ask anything else? Just want to thank you, Dr. Pekus, for joining us today. Your insights were very, very interesting, very, very enjoyable. And it's, as I said, it's just fascinating to see how much the Walmart experience has personally opened my mind to how we think about the next generation of healthcare in this country. And it's great to see that work continue. So thanks again for being with us. Dr. Winchester? Yeah, thank you so much. We really appreciate it. Some incredible insights. And stick around, everybody, for the rest of an exciting Quality Summit. Thank you for having me. Great to be with everyone today.

Cheryl Pegus

Walmart

Health and Wellness

Innovation in healthcare

Telehealth

Social determinants of health

Data and technology

Health disparities

Human connection