Download - Medical grand rounds 9.22.2011
![Page 1: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/1.jpg)
Utilizing three important screens to improve health: the computer, cell phone
and televisionJames Kahn MD
Professor of Medicine, UCSF
AHRQ HS017784; NIH grants RR024369 and MH088341 and DA032057
![Page 2: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/2.jpg)
Overview
• Provide a framework for mHealth and internet based research
• Review active research projects• Discuss new models that develop from the
research projects• Conclusions • A glimpse into the future
![Page 3: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/3.jpg)
Conclusions
• New tools are necessary to improve health care• Personal Health Records (PHRs) are intended to
improve self management• We deployed a PHR integrated into our EMR for
patients receiving care at the HIV/AIDS clinic at SFGH and were surprised by the ready acceptance of the technology and its dissemination
• Text messaging is another important tool to deliver health care
• mHealth applications have local, national and international implications
![Page 4: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/4.jpg)
Three themes for our work
1. Improve health and reduce the digital divide through technology development, adoption and utilization
2. Empower patients through innovative use of technology
3. Provide a platform for research that emphasizes operational excellence and implementation science
![Page 5: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/5.jpg)
IOM How to Improve Care
“Improvements in care cannot be achieved by further stressing current systems of care. The current systems cannot do the job. Trying harder will not work.”
IOM 2001: Crossing the Quality Chasm
![Page 6: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/6.jpg)
The Case for Improvement
Hip FractureAtrial Fibrillation
Community Acquired PneumoniaUrinary Tract Infection
DiabetesColorectal Cancer
Congestive Heart FailureHypertension
Coronary Artery Disease
22.8%24.7%39.6%48.7%45.6%53.5%63.9%64.7%68.8%
McGlynn, et al. NEJM 2003 348:2635-2645
Outpatients receive only 55 % of recommended care
![Page 7: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/7.jpg)
Do vs. know
Transformative technology
Do
Know
Real world
Incentives for the process
Hypothetical growth with knowledge and resources
Pay for results
Empower Consumers
![Page 8: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/8.jpg)
Sources used to find information
![Page 9: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/9.jpg)
The future is already here, it's just not evenly distributed
William GibsonThe Economist 2003
![Page 10: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/10.jpg)
Information Systems
Financial InformationDemographics
Notes, ImmunizationsLabs, Medications
ImagesConsults, Reports
Important Documents
Financial InformationDemographics
Diagnosis, ImmunizationsLabs, Medications
ImagesConsults, Reports
Important Documents
EMRs populated withdata from “reliable” sources
PHRs populated withdata from patient sources
Systems owned Patient owned
![Page 11: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/11.jpg)
Definition--Personal Health Record
A longitudinal record of individual healthThe PHR can be accessed and populated, from
electronic sources, patients or devices Information in the PHR is owned or at the least
shared by the patientThe PHR is meant to move along with the
patient no matter where they are located or their connection to a specific health plan or organization
![Page 12: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/12.jpg)
Self management support vs. shared decision-making: a new dynamic
• Shared decision-making is the process for involving patients in decision making and planning
• Self-management support is the broader process of engaging and activating patients to more fully participate in care
![Page 13: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/13.jpg)
Patient Self-Management
“Patients with chronic conditions self-manage their illness. This fact is inescapable. Each day, patients decide what they are going to eat, whether they will exercise, and to what extent they will consume prescribed medications.”
Tom Bodenheimer, et al 2002 JAMA 288(19); 2470
![Page 14: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/14.jpg)
Why Develop a PHR?
• Promotes self management by providing information that is up-to-date and understandable
• Reduce the Digital Divide through more egalitarian access to information
• Improve the experience of care• Improve the health of populations• Reduce per capita costs of health care
Health literacy is vital to understand the information to create an action plan based on the information
Berwick, D. M et al. (2008). Health Aff 2008: 27: 759-769
![Page 15: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/15.jpg)
HIV is a chronic diseases • Dangerous chronic illness with available,
effective treatment
• Treatment is difficult and lasts over years and decades
• Treatment requires sustained behavior change on part of patient
• Gap between knowledge and outcomes
These statements apply to HIV and apply to:
Hypertension
Diabetes
Congestive Heart Failure
Asthma / COPD
Obesity
The data elements change, but the strategy and the tools for improved outcomes is consistent and includes: patient education, behavior change, monitoring, medication adherence and engagement with an extended health community
![Page 16: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/16.jpg)
Architecture for myHERO at SFGH
![Page 17: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/17.jpg)
Total number of PHR users
Kahn J S et al. JAMIA 2010;17:224-228
©2010 by BMJ Publishing Group Ltd
![Page 18: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/18.jpg)
Number of sessions /user / time
Kahn J S et al. JAMIA 2010;17:224-228
©2010 by BMJ Publishing Group Ltd
![Page 19: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/19.jpg)
Goal of the project-AHRQ
Our central hypothesis is that a secure PHR that combines meaningful information, web-based tools for support and reminders for patients will provide a substantial opportunity to promote self-management and will lead to improved health outcomes
To test our hypothesis we are performing a randomized controlled study to evaluate the biologic outcomes between persons randomly assigned to full use PHR compared with persons assigned to deferred access.
![Page 20: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/20.jpg)
Study Design
Screen all clinic patients to participate
Obtain consent from all willing participants
Control group—deferred myHERO access but with internet training, free email address
Experimental group –immediate myHERO access with internet training, free email address
Provide access to all participants
Randomize
12-months
12-months
Investigators: Joan HiltonUrmimala SarkarDean SchillingerDavid ThomRicardo MunozNeda Ratanawongsa
![Page 21: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/21.jpg)
![Page 22: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/22.jpg)
![Page 23: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/23.jpg)
Mental Health Diagnoses
![Page 24: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/24.jpg)
Substance use Diagnoses
![Page 25: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/25.jpg)
Observations from Recruitment
• Patients who are “full” users are very excited about seeing their personal health information. – “This is the coolest thing I have ever seen”– “This is truly amazing”
• Deferred users are not thrilled with their assignment but there is no differential drop-out rates
![Page 26: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/26.jpg)
Accessibility Issues• Font Size—we made the Font Bigger• Radio Button Size—increased the size• Mouse Use• “Next Page” vs. “Submit”—now “DONE”• User names and passwords
– Patients now write these down– New tool to reset passwords online
![Page 27: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/27.jpg)
What worked and what did not
• Patients will use the PHR survey system.• Patients want accurate data• Patients are receiving appropriate care
especially related to ART.• Good anti-HIV responses are common with
available medications
![Page 28: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/28.jpg)
Technology Skill Acquisition• We provided 50% with their
first email account. • We taught 85% of patients
how to use the internet. • Terms:
– cursor, – field, – user name, – password, – address bar, – enter, – scroll and – link.
A series of “How to”1) Make a capital letter; 2) Use numbers and letters;3) Locate a cursor; 4) Copy something; 5) Paste something; 6) Scroll down or around on the
page;7) Make the @ sign; 8) Enter something; 9) Go to a website
![Page 29: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/29.jpg)
Information Sheet
Visit this website to take your surveys: myhero.sfdph.org• Your myHERO username: _______________• Your myHERO password: ___________________• Your email website: __________________________• Your email username: ______________________• Your email password: _________________________• Please keep this in a safe place & don’t share your
usernames or passwords with anyone. • For free computer classes, please go to the main San Francisco public library on Tues’ 5:30 PM-7:30 PM,
Wed’s 5:30 PM-7:30 PM, Thurs’ 5:30 PM-7:30 PM, and Saturdays 10:00-1:00 PM with Project Read.
![Page 30: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/30.jpg)
Bridging technology
Not all patients have equal access to the internet but nearly everyone has a cell phone and these devices are becoming more common, less expensive and more powerful with a growing number of applications– Help drive patients to the internet when there is new
information of value– Alerts and reminders– Inform patients of new information and disasters– Improve management for health and wellness– International implications for health care
![Page 31: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/31.jpg)
All Whites (75%)
All Blacks (59%)
English-Speaking Hispanics (80%)
73%* of the population reports using the internet or email. Here is a breakdown of use among different online groups.(shown as a percentage of population online)
18-29 Years Old (90%)
30-49 Years Old (85%)
50-64 Years Old (70%)
65+ Years Old (35%)
No High School Degree (44%)
College Graduates
(91%)
<$30K Income (53%)
>$75K Income (95%)
Men (73%)Women (73%)
*Source: Pew Internet & American Life Survey, May 2008. http://www.pewinternet.org
** This statistic comes from the Pew Internet Project’s Latinos Online data, collected June-October, 2006.
High School Graduates (63%)
Urban (74%)
Rural (63%)
Suburban (77%)
Spanish-Dominant Hispanics (32%)**
12-17 Years Old (94%)
![Page 32: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/32.jpg)
55%* of the population reports using a high-speed connection (e.g., DSL, cable, wireless) when accessing the internet from home. Here is a breakdown of use among different online groups.(shown as a percentage of population using a high-speed connection from home)
Whites (56%)
Blacks (41%)
English-Speaking Hispanics (55%)
18-29 Years Old (69%)
30-49 Years Old (68%)
50-64 Years Old (49%)
65+ Years Old (19%)
No High School Degree (29%)
College Graduates (78%)
<$30K Income (31%)
>$75K Income (82%)
Men (57%)
Women (52%)
High School Graduates (39%)
Urban (56%)
Suburban (59%)
Rural (38%)
*Source: Pew Internet & American Life Survey, May 2008.http://www.pewinternet.org
12-17 Years Old (66%)
![Page 33: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/33.jpg)
Whites (79%)
Blacks (73%)
English-Speaking Hispanics (80%)
78%* of the population reports owning a cell phone. Here is a breakdown of use among different online groups.(shown as a percentage of population owning a cell phone) 18-29 Years Old (86%)
30-49 Years Old (87%)
50-64 Years Old (77%)
65+ Years Old (55%)
No High School Degree (59%)
College Graduates (89%)
<$30K Income (63%)
>$75K Income (92%)
Men (78%)Women (78%)
High School Graduates (73%)
Urban (75%)
Suburban (81%)
Rural (73%)
*Source: Pew Internet & American Life Survey, may 2008.http://www.pewinternet.org
12-17 Years Old (71%)
![Page 34: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/34.jpg)
Mobile Phones
In 2007, worldwide mobile telephone subscriptions reached 3.3 billion -- equivalent to half the global population 26 years after the first cellular network was launched
100% mobile phone penetration in the US by 2013
![Page 35: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/35.jpg)
Specific SMS FunctionsReminders to patients
ImmunizationsAppointmentsPap smearsMammogramsMedication Adherence
Notifications for patientsLab results are available for viewingClinician follow-up is expectedMedication Refills should be requestedTargeted behavioral interventions for: Depression
intervention, Tobacco Abatement, Anxiety control
![Page 36: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/36.jpg)
Study Design
Screen all clinic patients to participate
Obtain consent from all willing participants
Control group—No SMS messages
SMS messages for medication adherence and lifestyle
Randomize
Run in SMS texting check
Investigators: Joan Hilton, Monica GandhiTeam members: Tracy NunneryLindsay Halperin, Kelly Bryant
![Page 37: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/37.jpg)
Automating SMS --closing the loop
![Page 38: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/38.jpg)
It is complex…
![Page 39: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/39.jpg)
Total Screened = 476
Enrolled = 99 patients (20.8%)
Types of Phones33 Smartphone
8 iphone4 blackberry21 other full keyboard,web enabled phones
62 Standard Phone
Phone Providers 48 Metro PCS (48%)14 AT&T 12 T Mobile6 Sprint 8 Verizon Wireless 4 Virgin Mobile2 Boost Mobile
![Page 40: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/40.jpg)
Ineligible patients
487 ineligible screening events (69 twice)127 Undetectable VL 76 Not on ARV meds 60 Patient reports adherence support not needed 62 No cell phone (11% of all screened patients)154 Other (Do not text/Not interested /Language)
“The most exciting experiments are the ones that do not go as expected”
![Page 41: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/41.jpg)
Cell and Computer Use
“How often do you use your cell phone for text messaging?”Always/Often 84%Sometimes 9%Rarely/Never 6%
Number with an e-mail accounts 88% (N=87)Number with a myHERO (PHR) account 40% (N=39)
![Page 42: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/42.jpg)
SMS messaging for medications
9,957 messages for medications adherence and conditions were assigned by the system and 9719 (98%) were sent. Errors occurred during unexpected system maintenance.We studied a “closed-loop” response system and more than 57% of the messages had a message reply. 94% of the messages that had a successful reply also generated a positive response i.e. “Did this help you? Reply Yes or No”
![Page 43: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/43.jpg)
SMS messaging for medications
70% remained at daily reminders20% opted for messages 3 times a week10% opted for messages once a week
![Page 44: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/44.jpg)
New model of workManaging a clinic population
Patients who can use technology to help manage their care
Patients who need human navigators to help with technology and care
Patients who need human navigators to help with care and are not ready for technology
Patients who totally self manage their care
Patients who need more assistancePatients who need assistance
Patients who need human navigators to help with care and are not ready for technology
![Page 45: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/45.jpg)
Push or Pull Information
Is it better to push information to patients and hope there is uptake?Is it better to let patients pull information when they are ready and for its uptake?Does it matter?Why not do both?
Technology makes thisa viable approach
![Page 46: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/46.jpg)
Utilizing three important screens to improve health: the
computer, cell phone and television
![Page 47: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/47.jpg)
Conceptual approach
Systems pushing information to patients and clinicians (Ex: PHRs and lab results)Patients pushing information to systems and others (Ex: Bluetooth devices, social networks)Systems pulling information from patients (Ex: GPS awareness; run on flu medications)Patients pulling information from systems (Ex: patients able to query databases)
![Page 48: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/48.jpg)
New horizons for SMS
Help
What would you like us to do?1.Make or change a visit?2.Refill meds or list my meds?3.Check labs?4.Receive advice now?5.Get a call back?
3. Check Labs
What labs?1.T-cells2.HIV Viral load3.Liver studies4.Cholesterol studies5.Diabetes labs
1. T-cells
Your last 3 T-cells were:
520 on September 24, 2010310 on March 15, 2010421 on November 1, 2009
Who are you? Will you send your ID?
JSK56789!
![Page 49: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/49.jpg)
Telehealth
Clinician perspective telehealth is already deployed for diagnostic and routine follow-up in Dermatology, Radiology, Psychiatry, Ophthalmology.
Clinician extenders and save patient expensesEncourage connection to the health systemInvolve a group of caregivers or care providers
efficiently---especially remote connections to areas of great expertise
![Page 50: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/50.jpg)
An example of merging technology
![Page 51: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/51.jpg)
Good ideas are not adopted automatically. They must be driven into practice with
courageous patience.
Admiral Rickover
![Page 52: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/52.jpg)
Conclusions
• New tools are necessary to improve health care• Personal Health Records (PHRs) are intended to
improve self management• We deployed a PHR integrated into our EMR for
patients receiving care at the HIV/AIDS clinic at SFGH and were surprised by the ready acceptance of technology its dissemination
• Text messaging is another important tool to deliver health care
• mHealth applications have local, national and international implications
![Page 53: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/53.jpg)
Partners for our work
• Commonwealth Foundation• Blue Shield Foundation• NIMH, AHRQ, NCRR• Microsoft• Avanade• Boomcomms• California Health Care Foundation
![Page 54: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/54.jpg)
Medical Informatics Team
04/12/23Supported by AHRQ HS017784; NIH: RR024369 and MH088341
NIDA R01DA032057 54
Jackie SoKelly BryantLindsey HalperinSkip LeasureMitch RobertsTracy NunneryOlivia ChangRaeni MillerRobert ThawleyJoan HiltonMonica GandhiAdam CarricoLeslie Wilson
![Page 55: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/55.jpg)
Research requires change
It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change
---Charles Darwin
![Page 56: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/56.jpg)
Thank you and Questions
Jim Kahn415-699-1118
[email protected]://profiles.ucsf.edu/ProfileDetails.aspx?Person=4999786
![Page 57: Medical grand rounds 9.22.2011](https://reader035.vdocuments.site/reader035/viewer/2022062307/5554da03b4c9051b6e8b4f16/html5/thumbnails/57.jpg)
Jerry Garcia
“Somebody has to do something, and it's just incredibly pathetic that it has to be us.”