Every fall since 2016, the Palo Alto Medical Foundation’s Grants and Disbursements Program has awarded philanthropic funds to key projects, programs, technologies and studies proposed by PAMF innovators. Physicians, nurses, program managers, researchers and executives across the organization pitch their ideas for improving patient care to the PAMF Community Board of Trustees, which then selects which initiatives to support with unrestricted gifts from the community.
In 2019, the trustees granted 14 clinical teams and all four area CEOs $1.5 million total, bringing the program’s four-year tally to $5 million. Read about some of these incredible projects.
- Simple Medical Devices Save Lives
- Palo Alto Outpatient Palliative Care Expands Across Sutter Health
- Improving Colonoscopies to Cut Cancer Risk
- Gathering Patient-Centered Data to Guide Care Decisions
- Acupuncture for Anxiety and Depression
- Congestive Heart Failure Care Continuum
- Oncology Telegenetics Best Practices Study
- Rapid CT Program
- Savi Scout Wire-Free Radar Breast Localization
- VersaVision Digital Specimen Radiography System
- Transcranial Magnetic Stimulation Clinical Program
Improving Colonoscopies to Cut Cancer Risk
Despite declining mortality rates, colon cancer remains the second most deadly form of the disease. About 90% of cases arise from polyps, precancerous growths in the lining of the colon that can take years to develop into cancer. Therefore, early detection and removal of polyps with routine colonoscopies is the best way to prevent colon cancer, slashing the risk by up to 80%.
However, with one in 23 men and one in 25 women still developing the disease, 80% is not good enough. This has prompted physicians and researchers worldwide to try to learn even more about colon cancer and find ways to improve early detection.
One recent learning is that sessile serrated adenomas (SSAs), a type of polyp previously not considered risky, is in fact linked to the development of colon cancer. “SSAs can be difficult to identify and remove completely,” says Sanjay Ramrakhiani, M.D., gastroenterologist at PAMF’s Mountain View Center. “They are flat against the lining of the intestinal tract whereas regular polyps are often like mushrooms with bulbous heads.”
Although PAMF’s gastrointestinal clinician group finds and removes hard-to-see SSAs much more often than the national average, there is some variation within their detection rates, potentially impacting patients’ risk of colon cancer.
To learn what’s causing the variation, the PAMF GI department launched a study using Sutter Health’s electronic health record data and clinician-logged information about colonoscopies performed. “If we can identify the factors underlying varying SSA detection rates, then we can act upon them to increase detection and hopefully decrease the risk of colon cancer,” Dr. Ramrakhiani says.
He and co-investigator Su-Ying Liang, Ph.D., a research economist at the Palo Alto Medical Foundation Research Institute, are looking at three sets of potential causes: patient-related factors that may promote polyp development, such as gender, body-mass index and smoking; endoscopist qualifications such as training and detection rates for other kinds of polyps; and procedure-related factors such as time spent examining the colon, types of instruments and cameras used, and clinician patient volume.
As a community-based organization, PAMF is uniquely qualified to conduct this research. According to Dr. Ramrakhiani, university settings typically don’t have enough patient volume of routine procedures while most small group practices lack the expertise in data collection and analysis.
“We are fortunate to have a huge database of 80,000 to 100,000 procedures, whereas previous published studies have had much smaller numbers,” he says. “That makes the power of our study so much greater.” Dr. Ramrakhiani also commends “our cohesive, engaged physicians who put time and effort into entering information into the electronic health record, allowing us to retrieve quality data.”
To support this research, he and Liang presented their project to the PAMF Community Board of Trustees and received a $26,000 grant. “We’ve wanted to do this work for a while, but we wouldn’t be able to get it off the ground without philanthropy,” Dr. Ramrakhiani says. “The time and resources of team members need to be supported, and with philanthropy funding, we got that support.”
Although the study is ongoing, the group has already published an early finding that the use of distal attachment devices, which splay open the folds in the large intestine, does make a difference. Colonoscopies performed with these instruments had a 7% to 8% higher SSA detection rate than baseline.“
Ultimately, our endpoint isn’t just finding polyps but reducing cancer,” Dr. Ramrakhiani says. “In further research, we may compare our data with the California registry and see how each of the procedure, physician and patient variables we identify impacts the risk of colon cancer, both in our patients and statewide. If not for philanthropy, we couldn’t achieve this.”
Gathering Patient-Centered Data to Guide Care Decisions
When facing a serious health condition that requires treatment, such as a chronic joint issue or prostate cancer, patients have plenty of questions. Thanks to digital technology enabling the collection of complex medical data for large groups of patients, Palo Alto Medical Foundation practitioners can offer them a general idea of how well a particular treatment works and what they can expect.
But what many patients really want to know is what have others similar to them — same age, gender, risk factors, etc. — experienced? How will this treatment impact their quality of life over time? Which surgeon should they see? And following treatment, is their recovery on track with that of other PAMF patients like them?
“Even if patients don’t ask these questions, they’re usually thinking them, and nobody is answering with patient-centered data,” says John Cooper, M.D., a Palo Alto Foundation Medical Group anesthesiologist and associate medical director of the PAMF Outcomes Information Program. “We can cite studies of people who’ve had the same treatment elsewhere, but every hospital is different, every provider is different and every healthcare system produces different outcomes for each patient.”
A few years back, PAMF began collecting patient-centered data to share with patients when making important treatment decisions. To do this, they administered scientifically validated handwritten surveys called patient-reported outcome measures (PROMs), which inquire about symptoms, functioning and quality of life before and after treatment. But in order to amass impactful, easily sharable data, this process had to go digital.
In 2016, Dr. Cooper and colleagues at the Outcomes Information Program launched a pilot project to build an electronic PROMs (ePROMs) for total hip replacement. “We wanted to learn what was needed to make the system automated, efficient and scalable to all parts of PAMF,” he says. “We pitched the pilot in the Grants and Disbursements Program and received the full amount we asked for.”With the help of Sutter Health’s Research, Development and Dissemination group, Dr. Cooper’s team built the software while capturing information from almost 2,000 hip replacement patients in the Palo Alto Division. Patients completed a survey preoperatively and every three months for two years, generating aggregated outcomes of all PAMF patients.
According to Dr. Cooper, this information can be useful for patients, caregivers and providers at multiple points along the patient journey, including for shared decision-making during care visits. “Patients can go into a PAMF clinic, take the survey with their doctor, look at the outcomes together and decide whether they are typical of a good hip replacement candidate,” he explains.
Then, if they opt for surgery, the data can help both the patient and care team better manage recovery. “We can click on their outcomes within the electronic health record and see their progress,” Dr. Cooper says. “If their recovery is lagging behind what is typical, the provider can reach out preemptively and ask them to come in.” Patients can also use this information to track their own progress and stay aligned with recovery regimens between visits.
Eventually, patients will even be able to access these data when shopping around for care, Dr. Cooper adds, via a public website that will present easily digestible information on the experiences of PAMF patients.
Developing the software program for the hip replacement project took a year and a half and used up most of the Grants and Disbursements money. “These funds helped us build such an efficient, stable, scalable platform that we can now build projects for other procedures and treatments for just $10,000 instead of $220,000 each,” Dr. Cooper says.
The refined process allowed the team to apply a Sutter President’s Award worth $25,000 toward creating solutions for carpal tunnel surgery and all spine surgeries. Right now, they are working with nine PAMF orthopedic specialists and gathering data on about 1,600 cases a year. The ultimate vision is to scale out ePROMS to all PAMF patients, covering heart disease, heart failure, prostate cancer and other conditions that require important treatment choices.
“Once we have these data, we can share them transparently with patients—both the good and the bad so they can make more informed decisions,” Dr. Cooper says. “I believe patient-centered data collected and presented in a clear, easy-to-understand format is what patients need to receive quality care that fits them. Once they have that, the relationship between patients and the health system will change for the better.”
To help the team continue building upon their work and offer this data for more conditions and treatments, PAMF has launched a fundraising campaign with a target of $1.85 million. The goal is to create the Institute for Patient-Centered Outcomes, which would absorb the Outcomes Information Program. To learn how you can help with this campaign, please contact Shannon Brady at firstname.lastname@example.org or (831) 458-6930.
Acupuncture for Anxiety and Depression
A second new project will also benefit patients with depression and anxiety. Along with their TMS funding, Drs. Nguyen and Rogosin secured a $42,000 grant to offer auricular acupuncture via shared medical appointments at the Mountain View Center, part of PAMF’s Camino Division.
Strong evidence shows that auricular acupuncture, which involves inserting thin needles into particular points around the ears, is helpful for anxiety and depression.
“Many individuals, when having emotional problems, look for non-medication options first,” Dr. Nguyen says. “PAMF offers auricular acupuncture in the Alameda Division and it is very popular, with patients reporting improvements in their mental health.”
Because of its effectiveness, Drs. Nguyen and Rogosin wanted to expose more patients to this therapy without referring them outside of PAMF. About five years ago, a Fremont practitioner started an auricular acupuncture group that was very successful, but when she left PAMF, the service was not continued. “We are so excited to add back auricular acupuncture because we know it works and we know patients love it, and this will dramatically improve access to behavioral health services within PAMF,” Dr. Rogosin says.
Congestive Heart Failure Care Continuum
When administering an echocardiogram, physicians use the ejection fraction (EF) measure—the fraction of blood pumping out of the heart with each beat—to diagnose congestive heart failure. EF also reveals the severity of the condition, informing treatment decisions. Physicians then monitor this number over time to gauge how well patients respond to interventions.
The problem is that EF is not easily accessible in the electronic health record (EHR). The system doesn’t give it a distinct data field, so clinicians must dictate the number within an unstandardized text report in the EHR. Then, when the next clinician pulls up a patient’s chart, unless they know to look for EF, they may not see that the person has congestive heart failure.
A PAMF physician raised this issue last year while caring for a patient with a health concern that could be confused with congestive heart failure. Only after she combed the entire EHR did she discover the test result signaling the condition, allowing her to avoid recommending an unsuitable treatment.
“The other issue is that, since EF is not in a structured field, we can’t accurately track congestive heart failure patients and determine the best treatment for them,” says Wendi Knapp, M.D., hospitalist at PAMF Santa Cruz and clinical lead for PAMF’s Data Science Working Group. “If we had a miracle medication for anyone with an EF below 40%, to find candidates, we’d have to read through all the records manually.”
To remedy this issue, the Data Science team designed an algorithm that extracts EF, puts it in a structured field and gives it prominent placement in the EHR. But beyond creating the code, “every algorithm must be validated and measured scientifically to make sure it’s extracting the right data and reporting it out properly,” Dr. Knapp says.
Although the algorithm has been highly accurate so far, it must be evaluated further and aligned with prescribing guidelines before it can be deployed across Sutter Health, requiring additional hardware, trained clinicians and a statistician. Now equipped with these resources thanks to $366,240 from philanthropy, the team hopes to roll out the change systemwide in 2021.
“Developing these types of programs is often not a funding priority,” Dr. Knapp says. “Therefore, philanthropy helps us implement practical programs that impact patient care directly and immediately—which is Sutter Health’s goal.”
Oncology Telegenetics Best Practices Study
Since its inception in 2014, the Cancer Genetics and Prevention Program, part of PAMF’s oncology department, has seen skyrocketing demand for genetic counseling, which aids in early identification and management of hereditary cancer risks. CGPP went from serving 772 patients the first year to 3,126 patients in 2019, 75% of whom pursue additional services or procedures to address their cancer risk.
With interest in this service rising sharply, there is a nationwide shortage of genetic counselors. CGPP is fortunate to have six, but demand for their services dwarfs their capacity. As a solution, CGPP piloted telehealth—or telegenetics—at Sutter Pacific Medical Foundation in Santa Rosa in 2018, extending genetic counseling to 427 SPMF patients who wouldn’t otherwise have access.
Feedback from referring physicians and patients was overwhelmingly positive, as telegenetics eliminates cost, transportation and time-constraint barriers to access. And as the COVID-19 pandemic has shown, telehealth in general offers convenience and safety for all patients. Also, starting in 2021, California law will require health insurers to reimburse for telehealth services to the same extent they would in-person care. Anticipating even greater demand in the coming years, CGPP is working toward expanding telegenetics across Sutter Health while also adding an interactive video component.
“We look forward to livestreaming because we believe patients’ visual cues will really help us interpret their readiness for these sessions,” says Sharon Chan, clinical genetics program manager.
To inform the video model’s design and systemwide expansion, CGPP has teamed with Dorothy Hung, Ph.D., from the Palo Alto Medical Foundation Research Institute to study best practices for telegenetic counseling. Funded by the PAMF Grants and Disbursements Program, Hung is assessing the socio-technical processes that are essential to successful implementation of digital platforms.
“Understanding and outlining best practices for integrating telehealth prepares us for a rapidly evolving landscape that necessitates its integration into clinical practice,” she says.
Additionally, as the COVID-19 crisis has forced rapid and widespread adoption of telehealth, “our identification of effective implementation strategies will serve primary care, urgent care, geriatrics, orthopedics and other areas that have begun developing or expanding their digital capabilities due to the pandemic,” Hung adds.
Chan believes telegenetics is uniquely well positioned to be on the forefront of telehealth. “We are one of very few services in which the counseling portion is very important to patient outcomes, and it’s a not a high-touch service—there is no patient exam,” she says.
Rapid CT Program
Typically, when patients experiencing acute chest pain arrive at PAMF urgent care or primary care, they receive an initial electrocardiogram (EKG) and a blood test for troponin levels. Because the latter assessment checks for heart attack but can’t yet rule it out, patients are sent first to an emergency department and then to a hospital’s chest pain unit. There, they repeat EKG and troponin every four to six hours and have a cardiac stress test the next day. If all tests are negative for heart attack, they are discharged home. All told, patients often spend 18 to 24 hours at the hospital.
“For over 95% of these cases, there ends up being no heart attack,” says Cheena Ramrakhiani, M.D., a cardiologist at PAMF’s Palo Alto Center. “This patient flow is expensive, leads to unnecessary hospital admissions, wastes patients’ time and delays definitive diagnosis and subsequent care.”
To ease these inefficiencies and rule out heart attack much sooner, the Palo Alto cardiology department proposed using its recently acquired 512-slice cardiac CT scanner. This state-of-the- art technology evaluates coronary arteries in just 10 seconds, with an extremely low radiation dose, significantly reducing time to diagnosis. Ideally, if a patient’s urgent care evaluation deems them low to intermediate risk, they could be directed to cardiology instead of an emergency department outside of PAMF.
“They get a coronary CT scan, expedited diagnosis and consultation with a cardiologist, and they are done,” Dr. Ramrakhiani says. “We have done this for several patients, and the time from when they hit urgent care to diagnosis is under three hours.”
While some hospital emergency departments have begun deploying rapid CT scanning, it has not been done in an outpatient setting. Therefore, before PAMF adopts it as standard protocol, more data must be collected on patient outcomes and financial metrics. To facilitate this research, Dr. Ramrakhiani’s team received $50,000 from philanthropy, allowing PAMFRI to help gather and analyze data. The grant will also go toward building required resources in the department.
“If successful, this program will improve care by reducing time
to diagnosis, total cost and unnecessary hospital admissions,” Dr. Ramrakhiani says. “It will also declutter the emergency department by keeping low-risk patients with chest pain out of the hospital.”
Savi Scout Wire-Free Radar Breast Localization
Whenever a woman’s mammogram detects a tumor or other suspicious abnormality in her breast, it can incite an anxious and scary time for her and her family. There are often multiple clinic visits and procedures to follow, and the fear of cancer and how that diagnosis will impact the patient’s life can be quite unsettling. Knowing this, PAMF aims to provide the very best care for each woman in this situation and make her journey as seamless as possible.
But in order to deliver on these goals, it is important that PAMF clinics possess the latest surgical technologies for breast cancer treatment. Now, thanks to funding from the Grants and Disbursements Program, the Camino Division has joined the Palo Alto Division in using Savi Scout Wire-Free Radar Breast Localization, a top-of-the-line tool that streamlines procedures and keeps more aspects of cancer care in-house. With high-tech mammography locating smaller and smaller suspicious tumors, surgeons need assistance finding the exact tissue to excise. Before PAMF acquired Savi Scout, patients underwent a procedure called localization during which a radiologist inserted a six-inch wire into the breast on the day of the surgery. This wire then guided the surgeon to the tumor’s approximate location.
Although this system worked, it presented several issues. “Great care must be taken to avoid the wire being dislodged from the lump until, eventually, surgery is performed,” says Lou Gaspard, surgery manager at PAMF “This means no mobility for the patient and a whole day must be blocked out to place the wire and conduct the surgery.”
But with Savi Scout, a nonradioactive, electromagnetic wave technology, there is no need to implant a cumbersome wire. Instead, a physician or radiologist makes a small incision to insert a tiny infrared reflector the size of a grain of rice into the tumor cavity. Then, on the day of the actual tissue removal, the surgeon runs a handheld probe over the breast that emits a soundwave picked up by the reflector, telling the doctor exactly where to operate.
“Savi Scout is the first technological improvement in this area in at least the 30 years that I have been performing breast surgeries,” says Seth Strichartz, M.D., a surgeon at PAMF’s Mountain View Center. “With the old technology, we had to put in the wire on the same day because we couldn’t have a woman walking around with a wire sticking out. This made scheduling difficult because we had to line up the availability of a radiologist, an operating room and the breast surgeon to make it all work. But because the reflector can be put in well in advance of the surgery, this system uncouples the placement of the localization device from the surgery.”
Along with easing personnel shortages and space constraints, Savi Scout also improves surgical precision. “The wire was not always put as close to the tumor as I would have liked or in the most cosmetically advantageous place,” Dr. Strichartz says. “With Savi Scout, the surgeon decides where to make the incision, and we can almost always put it closer to the tumor.”
This advancement in care also lessens patients’ anxiety and the amount time they must spend at the clinic. And for the small number of women who have a lump that is very likely cancerous, Savi Scout allows them to undergo one less procedure. “If it is obvious to the radiologist that it is cancer, a woman can have Savi Scout put in at the time of her biopsy,” Dr. Strichartz says. “Then when the biopsy comes back cancerous as the radiologist suspected, she does not need to return for a separate appointment to have the reflector implanted.”
When PAMF general surgeons came to Gaspard requesting this technology, he felt philanthropy was the right avenue to pursue. “We knew Savi Scout was the best way to treat our patients, but the technology is expensive—$83,830—and we just don’t have that kind of money laying around,” he says. “It was suggested that we attempt to obtain funding from PAMF’s Grants and Disbursements Program, and after submitting the application and making our presentation, we were granted the money to purchase Savi Scout.”
Acquiring this technology brings the Camino Division up to date with Stanford and local competitor El Camino Hospital. “Because we didn’t have Savi Scout, there was a period where I had to take cases that I traditionally handled at the PAMF surgery center in my building over to El Camino,” Dr. Strichartz says. Now he can keep those cases at PAMF, simplifying the patient journey and further easing stress.
“Our surgery care is at a higher level as a result of this technology,” Gaspard says. “I like the fact that after coming into radiology and having the chip placed, patients can go about their business—picking up clothes from the cleaners, taking kids to soccer games and enjoying dinner out. Then on the day of the surgery, the patient shows up, has the chip and lump removed and is on her way home.”
VersaVision Digital Specimen Radiography System
It often makes news when PAMF acquires cutting-edge patient-facing technologies, such as robotic surgical equipment or lifesaving cardiology tools. Yet there are many behind-the-scenes innovations that, while maybe not as buzzworthy, also make a tremendous impact on patient care. A prime example is the VersaVision Digital Specimen Radiography System, which PAMF’s pathology department now uses to assess suspicious breast lesions. The Palo Alto–based department acquired this technology with a $116,000 grant from the Grants and Disbursements Program.
VersaVision takes highly detailed images of breast specimens such as core biopsies, mastectomies and lumpectomies, enabling pathology staff to quickly locate lesions and make diagnoses. This state-of-the-art technology marks a major improvement in patient care, as it can significantly shorten a woman’s wait time between undergoing a biopsy or operation and learning whether or not she has cancer.
Upon detecting an abnormality, a radiologist conducts a biopsy and places a 2-millimeter metal clip inside the woman’s breast to indicate the lesion’s location. Next, a pathologist reviews the specimen and determines whether the lesion must be removed completely; if it does, the radiologist and breast surgeon discuss the best way to excise it. Once the surgeon removes the tissue, it goes to the pathologist, who then must find the lesion within the specimen in order to analyze it and offer a diagnosis.
However, locating a lesion and nearby clip within extracted breast tissue can be difficult, especially when the abnormality cannot be seen by the naked eye. Traditionally, pathologists had to make their best guess as to where it was located—and sometimes this required multiple samplings of the tissue, each time delaying diagnosis by one day.
With VersaVision, however, the pathology staff places the tissue directly into the machine, which displays a high-resolution X-ray of the specimen and reveals the exact location of the clip. According to Jorge Rodriguez, M.D., Ph.D., medical director of the pathology laboratory at PAMF, this significantly increases the pathologist’s odds of locating the correct tissue the first time and making the proper assessment.
“The biggest impact for patients is that we can find lesions more quickly and with a lot more accuracy, reducing the wait time for a final diagnosis,” Dr. Rodriguez says. “It also represents a significant reduction in superfluous work that the pathology team must do, because instead of hunting around in the tissue looking for the lesion, we can immediately find and focus on it.”
Along with saving the pathology staff time, VersaVision also slashes costs. “The materials used to cut tissues and make slides for review—the blocks, the wax, the labels, the slides themselves—all cost money,” says Christine Alvares, pathology department manager. “By reducing the materials required for each case, we save money for our department and for Sutter Health.”
Alvares applied to the Grants and Disbursements Program in hopes of acquiring VersaVision as quickly as possible. “Getting approval for medical equipment is challenging because we are competing against other departments that have just as important and necessary items on their wish lists,” she explains. “Because VersaVision is expensive, and because pathology is more behind the scenes than cardiology or surgery, for instance, we knew it would be difficult to receive capital. And even if we did, it could still take another year before we actually got the technology.”
When the pathology team learned they had secured a grant and could purchase VersaVision immediately, they were thrilled. “Some of our staff had worked with this machine in the past and knew how much time it saves and how much it improves patient care,” Alvares says. “Overall, it has been such a blessing for our department to acquire VersaVision—and so quickly, which would not have been possible without philanthropy.”
Transcranial Magnetic Stimulation Clinical Program
Major depressive disorder affects 17 percent of adults in the U.S., many of whom struggle to find relief. While there is an array of antidepressants available, only 33 percent of patients who take one recover, and their odds of success decrease with each successive drug trial. Plus, these medications often carry unwanted side effects that deter patients from staying on them.
“Traditionally, we’ve had very limited ways to manage treatment- resistant depression,” Dr. Rogosin says. “Complicated medication regimens and more invasive treatment modalities such as electroconvulsive therapy are not as well tolerated.”
Now, however, there is hope. Thanks to a $150,000 grant from the Grants and Disbursements Program, PAMF will pilot transcranial magnetic stimulation (TMS) at the San Carlos Center this fall. This Food and Drug Administration–approved noninvasive intervention for treatment-resistant depression and obsessive-compulsive disorder involves placing a magnetic coil over a patient’s scalp to stimulate specific brain regions linked to depression.
“TMS is thought to use magnetic fields to stimulate nerve cells in the brain to improve symptoms,” says Tam Nguyen, Ph.D., psychologist, director of behavioral health across PAMF’s Camino, Peninsula and South Bay divisions and operations lead for this project.
Though it typically involves 36 treatments, TMS is painless, has very minimal if any side effects and is usually covered by insurance. It is also very effective. Following a six-week course, 50 percent of patients report significant improvements in depressive symptoms, while one-third recover fully—including those who’ve failed multiple medication trials.
The project leaders aim to implement TMS by September, once they’ve purchased the equipment and designed the workflow and patients have been deemed eligible through insurance.
“It’s very exciting to add another treatment option, allowing for the continuation of care in-house instead of referring patients out like we had been,” Dr. Nguyen says. “We anticipate that patients will appreciate this service, and from there we’ll look at the data to see if it makes sense for other PAMF locations. Because of the high costs of purchasing the machine and setting up the infrastructure, we wouldn’t be able to do this without philanthropy.”