An interview with Vishal Kinkhabwala, MD, MPH, HIV Prevention Activities Coordinator, HIV Prevention Unit, Michigan Department of Health and Human Services. The overarching goal of the HIV Prevention Unit is to expand access to PrEP for patients throughout the state of Michigan.
by Anna Morgan, MPH, RN, PMP, NaRCAD Program Manager
Anna: We’re so happy to be catching up with you today, Vishal! Can you tell us a little bit about yourself and how you got into the work of academic detailing?
Vishal: My background is in both public health and medicine. After finishing medical school, I realized that as much as I loved the clinical aspect, I wanted something that combined both my passions of public health and clinical medicine. My first job after graduating was in New York where I linked newly-diagnosed HIV patients into care. About a year later, I found an opportunity at the Michigan Department of Health and Human Services that fit with what I ultimately wanted to do, HIV prevention.
My current work is focused on ending the HIV epidemic in Wayne County. One of my favorite parts of my job is detailing, which I do part-time. Our program officially began detailing in September of 2019. We’re in the process of making the jump to e-Detailing, but we’re still in the planning stages.
Anna: Before we chat about how you and your team have been preparing for e-Detailing, let’s talk about how clinicians in Michigan have received your messages around PrEP. Were clinicians receptive to your detailing efforts when you were conducting in-person visits?
Vishal: Most clinicians that we detailed were either already familiar with PrEP or had that enthusiasm to learn about it. Many of the clinicians were excited about helping with MDHHS’s overall goal of increasing patient access to PrEP and talking about the associated HIV prevention counseling.
Clinicians were typically familiar with PrEP but weren’t aware of the nitty-gritty details of how to prescribe and manage it. A big part of what we discussed during our detailing visits was identifying which patients are candidates for PrEP. Our program’s purpose is to increase access, even if it’s just for one or two patients.
Anna: It’s wonderful that the clinicians you’ve detailed have been supportive of your program’s goals. Transitioning to e-Detailing will certainly be easier knowing that you have support from clinicians. What have you learned so far from planning for e-Detailing?
Vishal: It’s been fun prepping for e-Detailing with our team. The big thing I’ve learned through networking with detailers from other jurisdictions is to be flexible and be prepared for any situation, especially in the virtual environment. You might have one idea of how your session will go, and it could go in the opposite direction, which is part of the charm of detailing. It’s about forming a connection and tailoring your methods to what the clinicians' and practices' needs are. I’m a relationship-oriented person, and I feel like that’s one of the most rewarding parts of doing this.
One of the things that also excites me about virtual education is the access to information right at your fingertips. For example, I was detailing a clinician about PrEP and HIV prevention last year who asked me, "Well, I have this issue with a lot of patients with STDs. Can you talk to me about STD treatments?" It was an in-person visit, so I only had the materials that I had brought with me, which were all focused on HIV.
The beauty of doing e-Detailing is that you can have resources pulled up and can get the information for the clinician almost instantaneously. As I said earlier, detailing is all about having that relationship, meeting the clinician where they're at, and serving their needs. Virtual education gives you another tool to be able to do just that.
Anna: What a positive spin on e-Detailing! Speaking of sustainability, that’s the theme for our upcoming conference. You attended our conference last year in Boston and will be presenting at our virtual conference this year. What were some key takeaways from last year’s conference that you were able to bring back to your program and implement?
Vishal: Last year’s conference was my first exposure to NaRCAD and the world of detailing- it was honestly one of the coolest experiences I’ve ever had. It was great to be exposed to e-Detailing through the virtual detailing panel before it was even brought to the forefront during COVID.
Because I was hired a few months prior to the conference, I had not attended a training yet. I joined the “AD 101” breakout group, which was supremely helpful. When I got home, I did mock detailing sessions with my colleague and reviewed all the resources on the NaRCAD website. I also practiced detailing on the stress balls I have in my office!
Anna: It’s so nice to hear how impactful the conference was for you as a new detailer. We strive to include a diverse audience of new and veteran detailers each year. What are you looking forward to most about this year’s conference?
Vishal: There are so many absolute rock stars in the field of detailing. I’m looking forward to getting to see familiar faces and meet new faces over the virtual platform. I’m excited for the exchange of ideas, programs, and concepts. So many people have given me ideas for our program in Michigan.
It’s such a good feeling when I can say that not only have I received help from others, but that I’m able to inspire other people. It’s also comforting to know that this is such a passionate group of people that no matter the adverse situation, the work continues getting done. I’m counting down the days until the conference in November!
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Biography. Vishal has been working with the Michigan Department of Health and Human Services since August 2019 as the HIV Prevention Activities Coordinator. His work focus is on program planning and implementation for the Ending the HIV Epidemic Initiative, focused on southeastern Michigan. As part of this initiative, he works as a part-time Academic Detailer with a focus on HIV Prevention with the overarching goal of increasing access to PrEP throughout the state of Michigan. He completed his Master of Public Health degree from Benedictine University in Lisle, IL in August 2013 and his Doctor of Medicine degree from Avalon University School of Medicine in Willemstad, Curacao in June 2018. Prior to working for the State of Michigan, Vishal worked for the New York State Department of Health as a Disease Intervention Specialist, working on a pilot HIV Molecular Clusters initiative. Vishal is particularly looking forward to moving the Michigan Department of Health and Human Services PrEP Detailing program forward into the realm of virtual “eDetailing.”
The pandemic has changed everything about our lives and our work. Some occupations have been able to adapt to the new abnormal, such as programmers and financial traders. Others have found it harder to do their jobs as before, like brain surgeons and academic detailers. For the latter, in a socially-distant, avoid-human-contact world, how can we pursue an activity that has as its very definition in-person, interactive communication?
Academic detailing programs around the country and the world have been grappling with this challenge. And unlike our colleagues the brain surgeons, we have been able to come up with some plausible solutions, even if nothing is quite the same as being up close and personal. We’ve been learning about the virtues and limits of Zoom/Skype/WebEx. If we’re paying attention, using them can bring into sharp focus the central aspect of interactivity, on steroids. It’s a little like becoming a better runner by strapping weights on your ankles (or so my athletic friends tell me). A non-adept academic detailer can mis-use a Zoom encounter even worse than a face-to-face one: “Sit still for 20 minutes while I do this presentation at you.” That will fail on a platform even more calamitously than it does in person. (One clue is when the prescriber mutes their video to read their e-mail.) But if we’re open to it, the e-encounter can focus our attention even more on whether we’re learning where the clinician is coming from, getting feedback, actively asking what sub-topics they most want us to cover.
The artificiality and forced intimacy of a screen-to-screen encounter, and the reason we currently have to do our work like this, can also focus us even more on another key aspect of academic detailing, empathy. “How are you holding up?” or “I bet COVID has really changed your practice” are opening statements that can address the 800-pound virus in the (virtual) room, acknowledging the obvious strangeness and discomfort that afflict so many conversations in these awful times.
On a more concrete level, pandemic-style education is also forcing us to come up with new ways to use our educational materials. What to do when you can’t focus a practitioner’s attention on a particular graph or table you’re showing them because they’re dozens of miles away? Displaying a PDF of a document and whizzing around your cursor is one easy, but primitive solution. What about presenting a list of topics hot-linked to a detailed display for each? Or completely re-formatting our materials (stop moaning) for better adaptability to a computer screen?
Those of us who also used to teach in classrooms have learned that with a little work (ok, a lot of work) coronaeducation can even be better than what we’ve been used to doing: using links to video clips or animations, real-time interactive polling, techniques that maybe we could have been using in the classroom, but weren’t.
Another key advantage of academic e-Detailing, if we can figure out how to make it work well, is the prospect of having a virtual visit with a clinician without the sunk time of getting to their office – a major enhancement in working with practitioners who may be an hour’s drive or more from the educator’s base. The benefit for our field in productivity and cost-effectiveness could be considerable.
Contrary to naïve beliefs that “Soon everyone will be protected by the vaccine and we can get back to normal,” this virus probably won’t let us return fully to the old ways any time soon. Instead, it will force us to mutate our work to cope with it. And in the process, not only will we be able to continue our work, we may even discover better ways of doing it.
Be strong and stay safe.
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Jerry Avorn, MD, Co-Director, NaRCAD
Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief Emeritus of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist, geriatrician, and drug epidemiologist, he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use, particularly in the elderly. Read More.
An interview with Debra Rowett, BPharm, Adv Prac Pharm, FPS, the Director of the Drug and Therapeutics Information Service (DATIS) in Adelaide, Australia. Debra joins Winnie Ho, NaRCAD Program Coordinator in a two-part conversation about a 30-year career of pioneering academic detailing in Australia and reflects on the past, the present, and the future of the field. In Part Two, we discuss the evolution of academic detailing as the world of healthcare changes. You can read Part One here.
Winnie: You wear so many hats when it comes to AD. How have those roles changed over your time with DATIS?
Debra: Before I was Director of DATIS, my role was primarily around developing our detailing materials, and evaluating the evidence and our program. I was always interested in the synthesis of evidence and turning that into value for clinicians. I was a clinical pharmacist who was working with people across many disciplines, and there was a growing body of evidence, but translating that into practice was always a challenge.
W: I think you touch on a fundamental aspect of AD – that we turn evidence into value, and that we translate all this research into action. It’s very critical that AD continues to provide that independent, trusted, unbiased source of information to ensure evidence is disseminated responsibly and utilized properly.
D: I would agree with that, very much. We live in an information-dense era and much of the information is synthesized and aggregated at the population-level, but clinicians are responsible for decisions at the individual patient level. I think AD is about bringing evidence to the point at which clinical decision making is made.
W: I’m curious about your experience with evaluating evidence for AD materials. It’s clearly a difficult, but super important aspect of AD. You have all these clinicians who are trying their best to make the best possible decision for their patient – and AD comes in, and in many ways, helps share in that responsibility.
D: Evaluating evidence is also about recognizing what we don’t know in the evidence. When reviewing the evidence for an AD program, we look for where there are gaps in the evidence, where there’s controversies, and differences in opinion about the evidence. No matter how well done, you make choices along that entire process about what to include, what to exclude – and even with the synthesized evidence, there is still human judgement about how to use it.
W: Right, and that human judgement also needs to focus on how that evidence came to be and how it was produced.
D: Absolutely. As we know evidence-based medicine is not just about the randomized controlled trials and published evidence, it’s about the intersection of published evidence, clinical judgement, and the patient’s specific needs, goals, and circumstances. The real opportunity for AD is that you can personalize this information for the provider to work with.
W: It’s extraordinarily rewarding work, and it’s a constant process in grappling with the things we don’t know. As someone who has been in this work for a long time and has had to adapt a long-standing AD program to changing guidelines and medical evidence, you’ve likely seen some big shifts in the medical consensus. Take opioids for example – the consensus around the safety of its use has had a dramatic change over the years. How have you adapted when the evidence base can sometimes change quickly within a few years?
D: It’s important that we come to providers with a balanced view, and that we acknowledge with them that there is uncertainty, that there is complexity, and that it isn’t easy to make these decisions with their patients. There’s a lot of things that we don’t know. If you come with too much certainty, you lose credibility because translating evidence into routine clinical practice is complex. Every time a medicine is prescribed for and used by a patient, we’re forecasting how the future will proceed - the exact benefits and harms that a patient will experience are uncertain.
People are living longer and with multimorbidity which presents new medical challenges. We’re seeing more people living with issues like musculoskeletal problems, hypertension, diabetes, renal problems, atrial fibrillation, and surviving their myocardial infarctions. The number of medications that patients take now compared to 30 years ago have increased. There are individual guidelines for each condition, that don’t necessarily take the other comorbidities into account.
The drugs used to treat one issue may lead to treatment conflicts for another condition and needs to be taken into consideration. It’s not just in one area of practice that has changed too, or just our demographics – we’re seeing fewer solo General Practitioners and more team-based practice in Australia. AD needs to take all of that into account when considering how to detail, and also who to detail.
W: Can you explain what you mean by “who to detail”?
D: It’s important to understand who the decision-maker is and what the decision you’re trying to address is – for some of our AD programs it might involve other health professionals; it’s not always the doctor.
W: Right, and this whole of office approach looks at all the players involved in the continuum of care, and acknowledges that they may play a role in how clinical decisions are ultimately made.
D: Yes, and I think this is why AD is even more important now than it was when we first started. It allows us to bridge individual condition silos, and helps providers navigate multimorbidity. Healthcare is never a one-size fits all, even for an individual. Their circumstances and treatment goals can change over the course of their lives. AD can personalize the information and tailor it to the needs of the clinician. AD can also be the conduit between population level evidence and its translation into clinical decision making - that is one of its greatest strengths.
W: NaRCAD has been lucky to see overarching growth of AD programs everywhere, along with all of its exciting new innovations and evolutions. Any final thoughts on AD before we hear from you at our upcoming conference?
D: One of the things I try and impart when teaching the method of AD is to value the knowledge of the person you are detailing. There is a lot of listening that occurs in successful AD if you are truly to meet the needs of the provider you are visiting. If you keep at the very heart of what you do, respect for learning together and hold true to the principles of academic detailing, you will meet incredible people everywhere you go. It makes for a wonderful career.
(Part Two of Two)
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Debra Rowett, BPharm, Adv Prac Pharm, FPS, has led an academic detailing team for over 20 years and is a member of the team which designed, developed and delivered the “Best Practice in Educational Visiting” training for academic detailers in Australia. Debra has worked closely with NPS Medicinewise since their inception and has provided consultancies to other national and international academic detailing programmes. Debra is an experienced academic detailer with expertise in designing, developing, training, implementing and evaluating academic detailing programmes. Debra has served as the President of the Australian Pharmacy Council and is currently the Vice President of the Council of Pharmacy Schools. Debra has worked extensively in the area of quality use of medicines, inter-professional practice, policy and health workforce development in Australia. Debra is a member of the national Drug Utilisation Sub-Committee of the Australian Pharmaceutical Benefits Advisory Committee (PBAC).
‘At the Heart of our Program is Service’: Reflections on 30 years of AD in South Australia (Part One)
An interview with Debra Rowett, BPharm, Adv Prac Pharm, FPS, the Director of the Drug and Therapeutics Information Service (DATIS) in Adelaide, Australia.
Debra joins Winnie Ho, NaRCAD Program Coordinator in a two-part conversation about a 30-year career of pioneering academic detailing in Australia and reflects on the past, the present, and the future of the field. In Part One, we introduce you to DATIS and academic detailing in the Australian context. Stay tuned for Part Two!
Winnie: We’re so glad to have a chance to chat with you about your long career in AD, Debra!
Debra: This is a great part of the job, talking to other people in the AD community. It really is a great privilege to be working with academic detailing organizations in different countries. I’ve loved getting to meet and learn from so many different people.
W: I would agree! I’m sure you have some great stories of what it’s like to work internationally in this field.
D: One of the things that it has really highlighted is the nuance of language. At a training workshop in the U.S early in my career, I was saying how we would meet with doctors in their "surgery", and how important it was to meet them in their surgeries close to where they make decisions. The workshop participants really politely said to me, but isn’t surgery a really bad time to detail? Oh! Surgery – I meant their office.
W: We really would have quite a different communication model if we had detailers visiting providers mid-surgical operation! This does gives us a good starting point into discussing how Australian AD is unique. Besides the context of the word "surgery", what else would our non-Australian colleagues need to know about Australia to understand the context of what you do with the Drug and Therapeutics Information Service (DATIS)?
D: I have been involved with DATIS since its formation in 1991. I was a clinical pharmacist at the Repatriation General Hospital, a teaching hospital, when Jerry Avorn’s paper was published. His work on how AD could influence clinical decision making really resonated with us in Adelaide. One of the big things to know about Australia is that we have a National Medicines Policy, which aims to improve positive health outcomes for all Australians through access to and quality use of medicines. DATIS was one of the first programs funded through the Quality Use of Medicines initiative, and in 1998 NPS MedicineWise (formerly the National Prescribing Service) was funded.
W: Australia is enormous - it must be a challenge to cover. What is the geographical coverage of your AD program?
D: South Australia has a population of about 1.4 million people and a vast geographic reach – the furthest of my AD visits is about 800km (500 miles) away from where we are! We work to provide AD to over 85% of all family physicians in South Australia, so about 1,300 General Practitioners (GPs) each year. We provide AD services to aged care, primary care and hospital providers. We also work in partnership with NPS MedicineWise who have implemented AD at the national level.
W: That’s certainly an enormous coverage zone, especially for those core 12 people! How has this work manifested in South Australia?
D: At the heart of our program is service, and we build our program to emphasize that. There are three aspects of DATIS: service delivery of detailing visits, training of detailers, and research. We have a core team of 12 people who carry this work out alongside our colleagues who join us for various projects. Because of our multiple different contracts, the clinicians we provide services to can see us for multiple reasons in a year.
Between visits, providers will ring us with clinical questions about therapeutic issues that have arisen in their practice. We have also developed interprofessional communication training to support interprofessional practice with a focus on pharmacists and physicians. Our AD programs usually seek to address a therapeutic area or clinical issue however a recent AD program we developed with our hospital pharmacy colleagues was to support pharmacist preceptors implement a performance outcome framework based on entrustable professional activities for interns and undergraduate pharmacy students.
W: It's incredible that DATIS has such a focus on this three-pronged approach, because it continues to help push our understanding of best practices in AD through implementation, study, and training others to carry on the work. Can you tell us a little more about the foundation that DATIS is built upon?
D: Behavior change theory and implementation science has informed our work from the outset in 1991, including the development of the training program which was designed in collaboration with psychologists and experienced GP medical educators. Social marketing frameworks, an adult learning approach, the concept of cognitive biases, clinical reasoning all recognize the many interacting and complex influences on behavior. We try to learn from these and apply to the design and implementation of AD.
We also use pharmacopidemiology methods to understand evidence to practice gaps and for evaluation. As AD evolves and changes, something I really emphasize is staying true to the principles of AD – this is a rigorous process.
W: We’re seeing innovations all over the world and across so many clinical topics. Are there any unique innovations that you feel differentiates Australia AD from other AD programs?
D: One innovation that we're exploring is applying the principles of AD to patient behavior change interventions. As part of person-centered care, it is important for patients to understand their medicines, and to be involved and empowered in shared decision making. We haven’t called this work AD, but have applied the principles of AD in this research.
Complex clinical decisions need to be made each and every day by providers, and it's a privilege to be able to bring providers the best available evidence through academic detailing services, part of the power of AD is the adaptability and personalization to providers along the continuum of care. We are seeing the world of healthcare change, and we have so much to learn as it does.
(Part One of Two)
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You can head on over to our Discussion Forum to continue the conversation!
Debra Rowett,BPharm, Adv Prac Pharm, FPS, has led an academic detailing team for over 20 years and is a member of the team which designed, developed and delivered the “Best Practice in Educational Visiting” training for academic detailers in Australia. Debra has worked closely with NPS Medicinewise since their inception and has provided consultancies to other national and international academic detailing programmes. Debra is an experienced academic detailer with expertise in designing, developing, training, implementing and evaluating academic detailing programmes. Debra has served as the President of the Australian Pharmacy Council and is currently the Vice President of the Council of Pharmacy Schools. Debra has worked extensively in the area of quality use of medicines, inter-professional practice, policy and health workforce development in Australia. Debra is a member of the national Drug Utilisation Sub-Committee of the Australian Pharmaceutical Benefits Advisory Committee (PBAC).
An interview with Julie Anne Bell, MPH, Program Manager of Clinical Operations, Bureau of HIV, New York City Department of Health and Mental Hygiene. The mission of the Clinical Operations and Technical Assistance Program (COTA) is to provide innovative, culturally responsive, needs-based technical assistance and training to organizations and individuals working with people impacted by HIV.
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
Anna: Thanks for joining us today, Julie Anne! Can you tell us about yourself and what brought you to your role as Program Manager of Clinical Operations at the New York City Department of Health and Mental Hygiene?
Julie Anne: My first position out of graduate school was as a research assistant in the HIV program at the State University of New York. I’ve moved through a lot of sexual health work and have been with the Bureau of HIV at the New York City Department of Health and Mental Hygiene for three years.
I love the programmatic work that I do in my current role. I deliver training, tailored technical assistance and public health detailing to clinical and non-clinical providers who care for people with HIV. Being a content expert and bringing the information directly to the clinics to support them is rewarding and, most of all, fun.
Anna: It sounds like your career path has led you to a wonderful position! What detailing topic is your program currently working on?
Julie Anne: We’ve been focused on developing a public health e-Detailing campaign to support and strengthen providers’ initiation of immediate antiretroviral treatment, or “iART”. iART is for people newly diagnosed with HIV or returning to care after a long lapse. It recently became a standard of care in New York. Immediate initiation of ART is associated with several health benefits for people with HIV, including a significant decrease in the time to viral suppression, which ultimately, reduces the risk of disease progression, morbidity, and mortality for people with HIV as well as onward transmission and new HIV diagnoses. Prescribing ART immediately versus waiting for the patient to return after all lab work/genotype results come back can feel like a paradigm shift for providers, but HIV medications have advanced so much in terms of their high threshold to resistance and there is no longer a need to wait.
Anna: Your team recently completed a campaign on strengthening the integrated care approach, which is a team-based approach where mental health care and medical care is offered to patients in the same setting. How did your previous campaign help shape your new iART campaign?
Julie Anne: During our previous campaign, we brought providers an array of materials and resources to help them meet New York City’s Ending the Epidemic benchmark. We included HIV-specific materials and resources, as well as additional tools to address substance use, housing, and mental health in order to strengthen their integrated care approach. Among those HIV-specific materials and resources was information about iART. During our detailing sessions, providers were consistently reporting the same barriers to implementing iART in their clinics. Barriers that were reported were lack of clinic workflow for iART, not knowing how to get the medications covered/paid for immediately, and feeling uncomfortable prescribing ART before receiving a lab based confirmatory HIV test and genotype testing result. We began to realize that the providers needed more support around this topic.
Because our work is heavily data driven, we used the feedback we received from providers on the barriers they were experiencing around implementing iART to create our iART campaign and associated public health detailing action kit. The tools and resources in our detailing action kit highlight each component of iART, including HIV testing, payment options, genotype testing, and example clinic workflow. In the past, our program developed the public health detailing action kits and would hire consultants to do the detailing. For these campaigns, my colleague and I wanted to deliver the messages to the clinics ourselves and focus on relationship building.
Anna: Having strong detailer-clinician relationships is an integral piece of a successful academic detailing program. How have you been able to build strong relationships with clinicians?
Julie Anne: We visited over 100 clinics that provide HIV services in New York City during our last detailing campaign, and we now have friendly relationships with these providers because of the trusting relationships we’ve built with them through our previous detailing work. Our team also attends regional group meetings for HIV providers to bring more awareness to our work and continue to build relationships and connections.
We recently hosted a virtual launch event for our iART campaign and we had over 200 providers register. We provided an overview of COTA, our services, and e-Detailing. We wanted the providers to know exactly how we’ve pivoted during COVID-19, why this work is still important, and that we would reach out to them in the coming weeks for an e-Detailing visit.
Being with the health department, we know where people are getting their care for HIV in New York City. We’d love to reach everyone who’s working with people who are impacted by HIV, including non-clinical providers. Since iART is an integrated care approach, both clinical and non-clinical providers are an integral part of the process. The first steps in the iART process begin with a positive HIV test which can happen in a non-clinical setting, such as a community-based organization. The next steps include looping in a medical provider with the addition of non-clinical support, such as benefit navigation, social work, and peer navigation. It can take multiple providers of different training and expertise to work together to achieve iART seamlessly.
Anna: Wow! You’re certainly connected to a lot of clinics and it doesn’t sound like you’ll have issues recruiting clinical or non-clinical providers for your upcoming e-Detailing visits. How has your team prepared for e-Detailing?
Julie Anne: When the reality of the pandemic hit, the idea of transitioning our detailing program to a virtual platform was overwhelming. We did a deep dive into the existing literature to see how programs have done virtual detailing in the past. NaRCAD has also been an amazing resource to learn from and we continually check the website for new resources on e-Detailing.
We then developed a Standard Operating Procedure (SOP) for our iART e-Detailing campaign. We worked as a team to create a step-by-step guidebook that includes our key messages, how to do a needs assessment, and how to address barriers that we expect might come up. We’re currently working on doing mock e-Detailing sessions with our colleagues and with providers who are iART champions in New York City. Our SOP will help guide us during these mock sessions and help prepare us for our field visits this fall.
Anna: Creating a Standard Operating Procedure is a great idea and will be extremely beneficial to prepare for field visits. What are some challenges that you expect to face when you begin your e-Detailing work?
Julie Anne: We’re expecting the usual technical problems like poor internet connection and access issues, but we’re working on strategies to overcome this. We also expect that providers will be experiencing burn out, so they may be hesitant to make some of the changes in their clinic to implement iART, such as establishing a new clinic workflow.
However, the resources we’ve selected and created for our iART detailing action kit are a direct result of what providers reported that they needed during our last detailing campaign. We’re hopeful that the tools we’re providing will enable an easy transition for providers to adopt our key messages related to iART.
Anna: It’s remarkable that you’ve been able to create your e-Detailing campaign based on the specific needs of the providers in your community. How else is your team working towards sustainability?
Julie Anne: iART is a sustainable practice because once providers understand the “why” and “how” to do it and the steps involved, there is no reason to go back to waiting to initiate a patient with HIV on ART. It’s important that people with HIV are given the opportunity to start ART immediately because it provides individual and public health benefits. iART is the new standard of care in New York, which encourages providers’ commitment to the practice, and the iART detailing kit will introduce tools and resources to increase the knowledge and confidence of providers to prescribe ART immediately.
Additionally, COTA offers ongoing technical assistance at the request of the providers and full-day trainings on iART for new providers. We’re currently focused on our iART e-Detailing project, but it’s always an open-door relationship with providers. Right now, it’s iART, but providers can reach out to us about anything they’re struggling with and we’ll work with them to overcome the challenges they’re facing.
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Biography. Julie Anne began working at the NYC Health Department in 2016 with the Bureau of Sexually Transmitted Infections in a research role. She transferred to the Bureau of HIV in 2017 where she focused on health policy work, and was promoted to her current role with the Clinical Operations team. She now manages the team that focuses on providing data-driven technical assistance to clinical and non-clinical HIV providers across New York City on HIV specific and supportive topics that address social determinants of health for people with HIV. Julie Anne is currently preparing to conduct e-detailing visits with NYC providers to support and strengthen practices for initiation of immediate antiretroviral treatment (iART) for people with HIV.
An interview with Tara Hensle, a research coordinator with the University of Illinois - Chicago, School of Pharmacy (UIC) and Illinois ADVANCE (Academic Detailing Visits And New Evidence CEnter).
by Winnie Ho, Program Coordinator
Winnie: Hi Tara! It’s been a crazy year so far, hasn’t it? We want to check in with you and the University of Illinois, Chicago (UIC) team about your experiences in navigating the pandemic. Can you tell us a little more about yourself and your role in the ADVANCE academic detailing team?
Tara: I was hired about 7 months ago as the research coordinator, and it’s been one heck of a 7-month run. The majority of my work is focused on implementation, so I do all the scheduling and outreach to hospitals to talk to providers. I develop and establish relationships with office managers and providers, and I assign detailers to visits.
W: Our team at NaRCAD has been lucky to have worked with the UIC and ADVANCE team for a while through our trainings and your presentations at our conferences and our webinar series, and we’re excited about the research intervention that had been planned. Can you tell us a little bit more about the mission?
T: Our intervention is a CDC-sponsored, three pronged approach that’s built off a pilot program that we started in 2018 for Chicago-land providers. We have a team of about 30 detailers who are now trying to cover as much of the state as possible. We wanted to follow-up with providers to get a sense of whether or not the ‘dosage’ of AD made a difference, but we also wanted to expand the providers we worked with, and to introduce updated topics like the new features of the Illinois PMP or opioid alternatives. The third prong is creating a toolkit to give programs a blueprint and resources of what was effective for us. We would love to make the “how to” of AD more accessible to other groups.
W: Compared to other programs, you have quite a large and robust team at UIC. It must have been difficult for the pandemic to hit right in the middle getting your program launched.
T: It really impacted our recruitment as we had called providers from the end of January through early March 2020. There are a lot of things going on right now. Even a small ask, such as 15 minutes of their day, can feel like a big ask for providers.
W: Right, and interventions are very carefully laid out and planned ahead of time. COVID-19 has disrupted everything – especially those on the frontlines who are both detailing and being detailed. Can you tell us a little bit more about how else the impact on your original plans for the intervention?
T: We had been so focused on ramping up that by the time we hit mid-March, we had many people on deck reaching out to providers. We started hearing “No, we can’t do this right now” or “this is a really bad time” often.
Once the stay-at-home order came through, we stopped contacting offices for about 2 months. We had to sort out so many protocols and even our IRB to make amends for virtual visits. What we’ve found since we’ve resumed virtual visits in May is that there’s a lot of variability – some offices have capacity because they aren’t seeing many patients, while others have providers that have been transferred to hospitals and have no idea when they’ll be available. We’re also talking about layoffs and burn-out and low morale.
W: There are many of considerations on how best to proceed safely right now. One is looking at the impact on the critical work you’ve done on opioid safety. Unfortunately, the pandemic has only exacerbated the overdose epidemic. What progress has been made on your opioid initiative?
T: One of the ways our team has shifted has been moving to virtual visits. We knew that these would have its own difficulties, such as concerns about “no-shows”. But our team is relatively tech-savvy, and now my job is making sure they’re all familiar with how to troubleshoot the technological pieces of virtual visits.
There are a lot of tech issues that can interrupt a visit. So we do mock detailing and have the detailers practice with each other, where we introduce certain needs and obstacles, maybe even a tech problem for instance, we role play a provider not turning on the webcam, or not being able to see your screen. Practice to strengthen adaptability and resilience become important in ensuring the detailers are prepared.
W: There’s definitely no time like right now to test detailing skill and ability to think on your feet! As a research coordinator, what do you think you’ve learned in the past few months?
T: How to be flexible! There are all sorts of external pressures right now to keep our project on track, but the most important part is keeping the human aspect in check. Having some insight and empathy for providers is important to understand what they’re going through. We can get bogged down into the guide posts, the bench posts, or the numbers – but this era reminds us that it’s all about empathy.
W: At the end of the day, we want better for our patients, for our communities, and for health outcomes everywhere, right?
Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!
Tara Hensle is a research project coordinator at the University of Illinois – Chicago for a CDC-funded research study investigating the effectiveness of academic detailing for opioid prescribing. She received her Bachelor of Science in Behavioral Science and Speech Pathology at Purdue University, and has worked in a variety of healthcare research settings before coming to UIC. Since working on this project, she is inspired by academic detailing’s simplicity, versatility, and the variety of topics to which it could be applied.
An interview with Kelsey Bolton, Continuing Professional Development Consultant, Gundersen Health System
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
Anna: Hi, Kelsey! Thanks for taking the time to chat with us today. Can you tell us a bit about your academic detailing program in Wisconsin and your role?
Kelsey: I’m a Continuing Professional Development Consultant in the Continuing Medical Education (CME) Department at Gundersen Health System. Gundersen Health System is a teaching hospital with a multitude of specialties that serves patients in Wisconsin, Minnesota, and Iowa.
As part of my CME work, academic detailing stood out as an effective tool to disseminate our information and meet our clinicians’ educational needs. We started our detailing program last fall and have been focused on tobacco cessation. The detailing intervention is a spinoff of a performance improvement project we are working on for diabetes.
I’m currently a one-woman show; I’m the program coordinator and the sole detailer. I detail physicians, NPs and PAs across the health system.
Anna: Wow, it’s incredible that you’ve been able to build your detailing program from the ground up! Can you tell us what that’s been like?
Kelsey: Academic detailing was a new concept to me prior to being introduced to it by my former manager, who sent me to the NaRCAD training in May 2019.
Academic detailing is not a well-known concept in our hospital system. It was difficult to get past the gatekeepers and “enlighten” them about academic detailing. There are still misconceptions when I walk into a room for a meeting with a clinician – they often think that I’m a drug sales rep, that I’m an internal quality control person, or that I’m there for punitive reasons. I must quickly refute that and explain that I’m there to support and unburden them, not to make judgments about their work.
Anna: Those misconceptions are quite common when starting a new academic detailing program. How are you able to “enlighten” the gatekeepers?
Kelsey: It was bumpy at first and we tried a few different approaches, but I think we’ve finally been able to smooth it out. I have an advantage because I’m internal and I’m contacting clinicians from an internal email or phone number. I’ve also had our medical program coordinator, the doctor who is partnering with me to learn the clinical information, send out emails to gatekeepers prior to my detailing visits.
Anna: Stakeholder buy-in is imperative when building a new detailing program.
Kelsey: Absolutely. Building relationships with key stakeholders has made all the difference. The medical program coordinator I work with, as well as other experts in the organization, helped me curate my detailing aid and key messages.
I practiced my detailing sessions with these stakeholders before going out in the field. It was an easy way to build relationships and get them on board – it only took a 15-minute practice detailing session!
I’m also fortunate enough to have support from senior leadership. They’ve been able to open doors by letting people throughout the organization know that they support the academic detailing work I’m doing.
Anna: It sounds like both managing your academic detailing program and being in the field has helped you be successful in getting your program off the ground. What has it been like to grow and manage your AD program?
Kelsey: It’s like herding cats! The detailing program is 25% of my workload, so completing all the administrative work plus the detailing visits is quite a commitment. By the end of this year, I will have detailed over 200 clinicians.
“Marathon detailing” has put me in a groove. It has definitely been challenging, but I appreciate that I know the ins and outs of it now – both the administrative tasks and the field work. I feel prepared to help train others. I plan to start training one of my colleagues to become a detailer in the fall.
Anna: When thinking about team expansion, it’s also important to think about the impact of COVID-19. How has COVID-19 impacted your program?
Kelsey: We paused our detailing visits for about 3 months, and by the time we started talking about bringing them back, NaRCAD was putting out a lot of information about e-Detailing.
Before COVID, I had barely done anything with video calling, but getting thrown into working from home, we jumped into a lot of video calls. I learned how to work virtually on the fly, which made it easier to adapt to e-Detailing.
I did a few practice e-Detailing sessions with my colleagues and I’ve now successfully completed several visits virtually. The NaRCAD webinars were a lifesaver. We plan to continue e-Detailing until it’s safe to return to in-person visits.
Anna: A lot of academic detailing programs had to adapt quickly to e-Detailing during the pandemic. What does the future look like for your program?
Kelsey: For the more near future, we are working on collecting data for the tobacco cessation campaign to eventually publish research on the efficacy of the academic detailing intervention. We’re going to pull patient data from the EMR, as well as look at the qualitative data from the evaluation surveys. This research will help inform our organization on the benefits of academic detailing as an educational intervention.
We would also like to continue the program with other strategic initiatives like substance use disorder, social determinants of health, and cancer screening. I have a soft spot for topics similar to tobacco cessation that are sometimes discouraging to clinicians because they don’t feel like they can make a difference. I know that through detailing, I’m able to give them a fresh take on these topics, and reinvigorate them in providing the best care for their patients.
Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!
Biography. Kelsey Bolton is a Continuing Professional Development Consultant in the CME department at Gundersen Health System in La Crosse, WI and the program lead for its Academic Detailing program. She received her Bachelor of Arts degree in Communication Studies in 2015, Healthcare CPD Certificate in 2019, and is currently pursuing her Master’s in Organizational Leadership. She has completed over 100 detailing visits and is presently conducting a research project on the efficacy of tobacco cessation academic detailing.
An interview with Marlys LeBras, PharmD, a clinical pharmacist with RxFiles Academic Detailing Program.
by Winnie Ho, Program Coordinator
Winnie: Thank you for speaking with us today Marlys! Can you tell us a little bit about your work with the RxFiles Academic Detailing team?
Marlys: Absolutely! I’ve been with RxFiles for just over 4 years as an Information Support Pharmacist doing both frontline academic detailing as well as co-leading various academic detailing training sessions, with the most recent being this past April. Our program covers Saskatchewan, Canada, but our website, app, and book are used outside of the province and Canada as well.
W: RxFiles is definitely one of the larger and more established programs we’ve had the honor of partnering with through the years. Can you tell me how maintaining the daily operations of your program have been impacted by COVID-19?
M: One of the bigger things that’s changed for our team has been moving our academic detailing training sessions online for our team of 12 detailers. We had to shorten our two-day in-person training, and shifted to hosting shorter sessions and offering more pre-training day and post-training day webinars to cover all of the content, including “how-to virtually detail”.
W: No matter how well virtual substitutions are planned, it’s not the same as being together. We’re all really missing our colleagues, and it’s heightening a sense of isolation. How do you think your team has adjusted to moving the training online?
M: I think our team adjusted quite well to the training adaptations. We were able to give them enough notice about the shift. What came out from training days is that our team members really do miss being in-person and having that social interaction – even the chit-chat in between sessions. For in-person trainings, we typically have time for a team-building activity in the evening where people catch up. We’ve been trying to incorporate more games and fun into our virtual training to have that social aspect. Personally, I really miss debriefing with colleagues in-person after detailing visits.
W: It seems like keeping the team connected is a big part of your team culture. How has your team stayed connected through the pandemic?
M: We typically do a roundtable at the mid-point of a detailing topic. We typically go around and share a little bit about our detailing experiences. Pre-COVID, no one wanted to turn on their cameras. It was never a requirement, but now everyone is turning them on. It’s been really nice just seeing people’s faces. Also, one of the things that’s been nice about going virtual is that we are able to open up staff meetings and invite more detailers to participate with us. We would have never been able to do that as easily in person.
W: We’ve seen opportunities like these spring up as teams need to be particularly innovative under tough circumstances that prevent in-person connection. Speaking of teams, dream teams don’t come out of nowhere. A lot of work goes into creating and maintaining a strong, positive, and connected team. At NaRCAD, we talk a lot about what makes a good detailer, but what are some of the hallmarks of a strong detailing team?
M: Team work is a really interesting thing to dive into. I reflected on this question, and think that a strong detailing team supports one another. That support can be helping each other out in the detailing session itself (e.g. co-detailing), or through communicating with each other about the providers we serve and in between detailing sessions (e.g. a prescriber moved from one detailing area to another). We want the team to be successful in moving towards our goals together. Another thing that COVID brought to my attention is that a strong detailing team also has a positive attitude. I really feel that during our transitions, everyone has been really positive and embraced the changes.
W: You’ve shared a lot of examples of how your team regularly communicates at various points during a detailing campaign, which shows a culture of checking in and making sure no detailer is left out. Can you speak a little about how that culture’s been built up at RxFiles and how you maintain it?
M: I think Loren Regier, who is in charge of Projects, Transitions and Training, has been such an asset in the development of our program, has really emphasized checking in. He really showed us the value of that, and not only does he talk about it, he has made it very easy for someone to approach him and talk about how the detail went, both the successes and challenges.
W: Having access to mentorship, and making sure a team-based approach is emphasized by leadership is key. It’s clear that the RxFiles team is doing well in adapting to these challenges faced by so many detailing teams. Maintaining positivity and seeing challenges as opportunities for growth is something that’s critical for teams to continue to have an impact.
Have thoughts on our DETAILS Blog posts?
You can head on over to our Discussion Forum to continue the conversation!
Marlys LeBras is a clinical pharmacist with the RxFiles Academic Detailing Program at the University of Saskatchewan. She completed her Bachelor of Science in Pharmacy at the University of Saskatchewan, her Hospital Residency with the former Regina Qu’appelle Health Region, and her post-graduate Doctor of Pharmacy (PharmD) degree at the University of British Columbia.
An interview with Mary Liz Doyle Tadduni, PhD, MBA, MSN, RN, Education Consultant, Independent Drug Information Service and Expert Training Consultant, National Resource Center for Academic Detailing
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
Anna: Hi, Mary Liz! We’re excited to learn more about what the pivot to e-Detailing has been like for you as an expert academic detailer for over 16 years and a NaRCAD training facilitator. Can you tell us briefly how your role as an academic detailer at Alosa Health has changed since the COVID-19 pandemic began?
Mary Liz: The restrictions on in-person meetings has resulted in all of my detailing visits switching over to phone or video calls. The number of providers I’ve been detailing has also considerably decreased due to time constraints and office restrictions related to COVID-19. In terms of the topics I’ve been detailing on, our team has been maintaining focus on delivering our planned modules, but I do discuss the impact of COVID-19 quite a bit with providers.
Our current topic for Pennsylvania’s Pharmaceutical Assistance Contract for the Elderly (PACE) is dementia, which is important as it relates to COVID-19. Patients with dementia who reside in nursing care facilities in Pennsylvania can’t see their loved ones due to restrictive visiting policies. Primary care providers are dealing with the challenges and consequences of this every day – and academic detailers can’t ignore it.
Anna: It’s crucial that detailers understand the ways COVID-19 impacts the work of frontline care providers.
Mary Liz: Absolutely. With COVID, healthcare delivery has changed dramatically and there’s been a large increase in telehealth visits. Many providers in Pennsylvania are working from home and not going into the office or seeing only a limited number of patients in the office setting. Even if they are seeing patients in person, the process of seeing a patient has changed. The offices sometimes have front desk staff working from home and require patients to wait in their cars before entering the building. Primary care providers are still trying to adjust to all of this. You need to consider what is really happening on the ground for providers during your detailing visits – it’s part of your needs assessment. The needs of the primary care provider right now differ greatly from the pre-COVID era.
Anna: Assessing a clinician’s individual needs is an integral piece of a traditional academic detailing visit. How have you been able to implement AD in its intended form when detailing virtually?
Mary Liz: The original model of academic detailing with Dr. Jerry Avorn has always been 1:1, face-to-face encounters, but that doesn’t mean you can’t have a productive visit virtually. It’s just another venue to deliver the evidence. I really do believe that it’s better to be in person, but delivering the evidence, no matter what the platform, is better than having a provider not know what they need to deliver the best care.
Anna: You’ve carried out this traditional, in-person model for over 16 years – what challenges have you faced when detailing providers virtually, especially during the pandemic?
Mary Liz: Time has been a barrier due to the overall stress on the healthcare system. There are also more distractions when visits are done virtually because providers are taken out of a controlled office setting. A provider could be home with their kids, or even driving in a car during a visit. You never know where a provider will be during a virtual detailing visit.
Some offices in my area also aren’t picking up their phones, so you can’t have conversations on the phone or "stop in" for a cold call. Having a scheduled in-person visit with a provider is much easier than trying to connect with a provider over Zoom. You add another step to your process when you have to work through technology glitches.
Virtual platforms or telephone calls can also be difficult for providers who are visual learners. You need to be creative with the way you share materials. But there are many similarities to in-person visits; no visit is “one-size-fits-all”. You need to consider the provider, their situation, and their environment and decide what will be the best way to deliver the evidence.
Anna: You’re right! It’s never one-size-fits-all when it comes to academic detailing. This has become even more evident as programs around the world have pivoted to e-Detailing. Do you believe that virtual visits can be as effective as traditional, in-person visits?
Mary Liz: I do. It may not be as personal as an environment, but if you have a relationship with the provider, it shouldn’t matter whether it’s in person or virtual. I would continue to detail virtually in the future if a provider requested it, but I do favor in-person visits – it’s what I’ve done for so many years and I’d rather see the providers face-to-face. You get even more out of a detailing visit when you have that interaction.
Anna: There’s certainly something to be said about the impact of the original model’s focus on in-person, 1:1 interactivity; it’s what has been studied for many years as effective and impactful.
In a time where being flexible is critical, what are some tips you would offer to detailers during this time?
Mary Liz: It’s crucial that you’re attentive to the provider you’re detailing. Continue to focus on the needs assessment. While you need to communicate your key messages, if you aren’t doing a proper needs assessment, you aren’t operating under the guidelines of academic detailing, which is all about listening and being interested in how someone is practicing. This leads you to be able to provide the evidence in the most effective way.
Also, remember to be patient with providers! They’re still adjusting to this new world and they may even have questions about the impact of COVID-19 on the future of healthcare, as well as on their place within the healthcare system.
Mitigate that impact by offering providers community resources that will support them through the pandemic – if you do that, then you’re fully realizing the true purpose of academic detailing as a supportive service that’s customized to real-world challenges.
Dr. Mary Liz Doyle Tadduni’s background has included critical care and medical-surgical nursing, nursing administration, and hospital administration in major university teaching hospitals in the city of Philadelphia. Dr. Doyle Tadduni is a training facilitator at NaRCAD, and an academic detailer with the Independent Drug Information Service of the Alosa Foundation.
Dr. Doyle Tadduni is a BSN graduate of DeSales University. She completed her MSN, with a concentration in Nursing Administration, from Widener University.
Dr. Doyle Tadduni was awarded the MBA degree, with a concentration in Healthcare Management Services Administration, from Widener University where she was the recipient of the Healthcare Management Services Administration’s Student Excellence Award. Following her graduate work in both nursing and business, Dr. Doyle Tadduni completed her administrative residency at the Hospital of the University of Pennsylvania in Philadelphia. She completed her Ph.D. in Nursing from Widener University. Dr. Doyle Tadduni presented her doctoral research, “Terrorism Preparedness: Perceptions of Connectivity of Emergency Nurses of the Emergency Nurses Association,” at the 10th Annual Interdisciplinary Research Conference in Dublin, Ireland.
by Winnie Ho, Program Coordinator
The past few months have represented incredible and unexpected challenges to the world of AD, encompassing everything from adjusting to brand new work routines, transitioning AD materials into a virtual format, and deciding exactly which corner of your workspace had the best lighting for all the videoconferencing meetings being scheduled in place of face-to-face ones.
The pandemic has largely disrupted many of the best laid plans of 2020 for a majority of us. However, through all of the obstacles that the COVID-19 pandemic has represented, the NaRCAD team has also seen incredible resilience and adaptability from the AD community as we take on these challenges together.
We've seen the AD community persevere even as colleagues find themselves continuing to devote much of their time to pandemic responses, with AD project plans being forced to adapt. For a profession that prioritizes the benefits of face-to-face conversations, e-Detailing has given us all an opportunity to explore adaptations to the original model, encouraging AD community members to connect to each other in new ways, and leaning on one another’s experiences and expertise to clear hurdles.
NaRCAD's response and virtual offerings have been shaped by your feedback, gathered through continuous conversation, as well as through our Needs Assessment Survey. We have continued to see record breaking attendance at our 2020 Webinar Series and our e-Detailing Community of Practice opportunities, with a focus on facilitating richer and deeper conversations and resource sharing. Our Peer Connection program has launched with a diverse cohort of detailers and program managers, forging brand new partnerships to tackle shared goals, sometimes from thousands of miles away.
We've also just launched an exciting new space for ongoing discussion on all things AD via our Discussion Forum, with threads on subtopics ranging from program sustainability to addressing clinician stigma and exploring e-Detailing’s potential. We're proud to note that during a time where there are fewer opportunities for in-person connection, our active community members are sharing and learning together more than ever before.
We're committed to fostering connection and providing support to all of you who are working hard to improve care for so many patients who need it most. As we continue to navigate all that comes next, we invite you, our expert program staff and detailers in the field, to continue to share your successes, challenges, and best practices in e-Detailing.
Each of your stories adds to the strength and knowledge of our community, from those who are just beginning to navigate e-Detailing to those who are veterans at this approach. We invite you to connect with us through registering for upcoming webinars and roundtables, taking a minute to fill out our Needs Assessment Survey, introducing yourself on our forum, or writing to us at email@example.com with thoughts on what you would like to see from us in the near future.
The team @NaRCAD
An interview with Ramona Shayegani, PharmD, Program Lead, Academic Detailing Service, Veterans Affairs Southern Nevada Healthcare System
by Kristina Stefanini, NaRCAD Project Manager
Kristina: Programs are transitioning their academic detailing (AD) efforts to e-Detailing or virtual detailing amid the COVID-19 pandemic. As part of your role at the Veterans Health Administration (VHA) Academic Detailing Service, you’ve completed e-Detailing visits, which you presented on at the NaRCAD 2019 conference. I wanted to interview you today, Ramona, to learn more about how you transitioned to e-Detailing. First, how did your program decide to do e-Detailing?
Ramona: Thanks for interviewing me! We heard about an e-Detailing pilot project from our national office and we were excited to participate as our region is spread out and rural, covering Nevada, northern California, Hawaii, and Manilla, Philippines. We felt this would be an excellent setting in which to incorporate video calls into our communication with clinicians. As a result, e-Detailing has allowed us to reach our full potential as a service.
Kristina: Amplifying a program’s impact and reach through e-Detailing is something many other programs want to experience. Have providers been receptive to e-Detailing visits given the current COVID-19 pandemic?
Ramona: I think it varies by site, but for the most part, providers are very eager to learn about the VHA’s telehealth program. Initially, when we started e-Detailing, we launched a campaign to encourage clinicians to complete telehealth visits with patients. Now providers remember our names, and they reach out about setting up telehealth meetings with their patients and figuring out how to conduct video calls. It’s very rare for providers to reach out to academic detailers for help. We usually have to initiate outreach requests.
Kristina: That’s terrific that clinicians are the ones reaching out for the service. When you’re getting ready for an e-Detailing visit, do you prepare the same way as you would for an in-person visit? What materials do you use, and how do you use them?
Ramona: The campaigns we’re working now are so fast-paced, so we’re sharing materials via PowerPoint presentations on a video conferencing platform; we also use electronic PDFs.
In addition to showing providers electronic materials, you can still model an approach as you would in person by holding up some of the materials on the camera. For example, with naloxone education, we have naloxone spray “dummy” versions that I show providers on video; I ask if they have ever seen what a naloxone spray looks like, and whether they would be interested if I sent a model version, which they usually say yes to.
Kristina: That’s something we try and tell detailers who are pivoting to e-Detailing, which is that much of the interactive approach of an in-person visit is still accessible via video! Many detailers who are trying this out for the first time are eager to find ways to build a meaningful, trusting relationship with clinicians--do you have any advice for strong relationship-building approaches during e-Detailing visits?
Ramona: Sometimes, especially if it’s a new provider, I try to remind myself that I might not get to talk about any of the key messages. It’s really important to take that time to introduce yourself and your service. I don’t feel like it’s anything different than meeting someone face-to-face for the first time. However, detailers need some time to try this with each other, their team, or providers that they have a good relationship with. Detailers need to build that confidence before they go out and try these video calls with people they’ve never spoken with. The more I do it, the more confident I feel, which is key in building these relationships.
Kristina: That makes sense—it’s about comfort and confidence as much as knowing the evidence. We’ve also encouraged detailers to know that it may take more time to build up to delivering the key messages than you’d like it to, and to be patient and focus on building the relationship when carrying out visits online. In your experience, have you seen any drawbacks to e-Detailing?
Ramona: One thing is that detailers don’t have the luxury of getting a feel of what the clinic is like, which would be easy to observe in person. A lot of times when I am in a clinic, I get a chance to talk to an auxiliary support team, or I could just walk to the other room and talk to the nurse. I’ve found ways to adapt to e-Detailing to try and have more of the team’s perspective; I’ll often ask providers if they think it would helpful for the nurse to be on the call so we can have a group discussion.
Kristina: It’s really about thinking outside the box and adapting the in-person approach, while trying to maintain connection. Is there anything else you’d like to share from your experiences with implementing e-Detailing?
Ramona: Detailers should acknowledge that this is a brand-new approach; you may not feel like this is your preferred way to talk to providers. Remember that it will take some time to get comfortable with it. There’s a learning curve. Now that I use this approach full-time, I just love it, and I don’t want to go back! It’s just as effective, a lot more efficient, and it allows you to be flexible.
Ramona Shayegani is the program lead for VHA’s Academic Detailing service in northern California, Nevada, Hawaii and Manila. She received her Doctor of Pharmacy degree from Oregon State University in 2014 and has clinical background in mental health and addiction medicine. She was one of the first detailers to pilot e-Detailing at the VA and has completed over 400 virtual detailing visits.
An interview with Lindsay Bevan, MScHQ candidate, Project Manager, Primary Care Academic Detailing Service, Centre for Effective Practice
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
Anna: Hi Lindsay! Thanks for chatting with us today about the exciting work happening at Centre for Effective Practice (CEP) in Canada. Can you tell us about your role and share some highlights from your team’s recent work?
Lindsay: I’m the manager of the primary care academic detailing service at CEP. We have a provincial service, which started in March of 2018 that serves family physicians across Ontario. Prior to our current service, we have run services in long-term care to support appropriate prescribing as well as primary care to support diabetes management. Our current service is still growing, but we’ve served just over 880 family physicians to date. Our focus has mainly been around opioids and chronic pain. We were just about to launch a series of “visits” (campaign topics) on prescribing in older adults, but we quickly pivoted to meet the needs of family physicians and began working on a visit around managing primary care in the COVID-19 context.
Anna: It’s so important to understand and meet the needs of family physicians when it comes to academic detailing, especially during a tremendously stressful time. Can you tell us a little bit more about the COVID-19 visit and the process behind its launch?
Lindsay: Our provincial government declared a state of emergency in Ontario on March 17th, so we knew COVID-19 would be top of mind for our physicians and that they’d need more information. We also knew that we’d have to deliver the visits virtually, which was a fairly new territory for us.
We had to modify our usual content development and detailer “upskilling” (bringing detailers up to speed on the content, key messages, and evidence around the topic) processes in order to meet the demands of family physicians by getting them information around COVID-19 when they needed it. The content development process for our other visits typically takes six months, with the detailer upskilling taking the last month and a half of that six-month period. COVID-19 turned everything upside down and made us rethink what we assumed was impossible. Within two weeks of the declaration of emergency, we started pulling together content for our COVID-19 resource centre (clinical tool for this visit, which is also available to all primary care providers), one week later we started training our detailers and within a month, we were delivering virtual visits to family physicians.
Anna: It’s impressive how quickly your team was able to launch this visit. COVID-19 is different from other topics that your team has focused on because the information and guidelines are continuously changing. How has your program kept detailers up to date?
Lindsay: The detailer upskilling process for other visits includes weekly webinars to review key messages and the surrounding evidence, and a two day in-person workshop where detailers get to practice their visit discussions with each other and family physicians prior to launching visits. We also use a content development team for our detailing tools and bring those tools to the detailers to review when they’re about 90% complete. We typically don’t edit or change those tools after visits have begun.
For our COVID-19 visit however, the detailer upskilling weekly webinars and the content development for our ever-evolving online COVID-19 resource centre have been continuous, ongoing processes. Our detailers have also taken on a larger role within both processes. Each detailer has been responsible for searching for, appraising and synthesizing information on a specific sub-topic of COVID-19, and then submitting this information for inclusion in our resource centre as well as presenting it at our weekly webinars to their fellow detailers. Our detailers need to be up-to-date on the emerging and evolving evidence and jurisdictional guidance around COVID-19 because family physicians don’t have time to sort through all the information being made available to them daily during the outbreak.
Anna: It’s critical to provide physicians with the most up-to-date information, especially in situations like the COVID-19 pandemic where they’re bombarded with new recommendations and guidelines from multiple sources on a daily basis. How many COVID-related visits has your detailing service provided to physicians during this time?
Lindsay: We’ve had 95 initial visits to date and approximately 12% of those visits have been with physicians whom we’ve never detailed before. We’re just starting to reach back out to physicians to see if they would like a follow-up visit since evidence has evolved and challenges have changed since we first started. The initial conversations were focused on testing, assessing and managing patients with the virus, and we’re now seeing those conversations shift to focus on resuming primary care services within the COVID-19 context. The detailers have done an amazing job in transitioning their detailing conversations to ensure they’re always covering the emerging areas of interest and need for family physicians.
We’ve seen little to no requests from physicians for detailing visits on anything but COVID-19 or on maintaining care in the context of COVID-19, which speaks to the impact this topic has had on family physicians.
Anna: Wow – it’s amazing that your service has been able to detail so many physicians on COVID-19 while also recruiting new ones.
Lindsay: Yes, overall, the visits have been well-received. We were a bit more cautious with our approach to promoting our COVID-19 visit and recruiting new family physicians. We didn’t want to add to the current noise at this time.
Instead, we took a more passive but strategic approach, like adding a banner to our website where family physicians can quickly sign up for a visit, and having our partners share our visit and resource centre with their membership base. One of the neat things about this visit is that because we’re offering it virtually, we’re able to expand our geographical reach and provide our detailing service to more physicians.
Anna: Using a virtual platform certainly has its pros, especially within the world of academic detailing! What has your program’s experience been like with integrating e-Detailing into your service?
Lindsay: The transition wasn’t unsurmountable for our detailers because they are quick learners, and we’ve had a lot of support through the resources offered by NaRCAD and our partnership with the Canadian Academic Detailing Collaboration (CADC). We also did internal virtual training sessions with our detailers where they were able to practice using all the features of the Zoom videoconferencing platform. Overall, it’s been a positive learning experience, and one that has furthered our team’s ability to be adaptable and enhanced our problem-solving skills.
We do feel however that there’s been an impact on the detailer-physician relationship since we’ve transitioned to virtual detailing, especially for the 12% of family physicians who are new to our service. When a detailer is in a physician’s practice, they can see how busy a waiting room is or how stressed the staff appear to be. When family physicians join a virtual detailing visit, it’s much harder to gauge what kind of day they might be having and adjust the discussion accordingly. Furthermore, the act of going into a physician’s practice itself can create goodwill that helps establish and strengthen the detailer-physician relationship, and that opportunity is lost during virtual detailing.
Anna: That’s an excellent point. Observing the waiting room and interacting with office staff is also essential to a detailer’s needs assessment. Detailers lose this piece of a visit when the detailing is done virtually. Is virtual detailing something that CEP will continue doing once COVID-19 related restrictions are lifted?
Lindsay: Our detailers and family physicians would like to return to in-person visits. There seems to be some conversations that lend themselves better to virtual communication, and others for which an in-person presence offers greater value and impact. When it comes to relationship building, in-person interactions still offer something special.
We would also like to build off the momentum we’ve started with our virtual visits. We’re exploring the idea of offering virtual detailing to family physicians who would otherwise have their visit rescheduled due to extreme weather or to family physicians located where we don’t already have a detailer covering the area.
We’ve all done what we thought was impossible in providing the majority of healthcare visits virtually. I hope that folks across the healthcare system will continue to use that momentum moving forward to increase access to care.
Lindsay Bevan works for the Centre for Effective Practice (CEP) where she collaborates with a team of amazing individuals to develop and implement evidence-based supports and services to help narrow the gap between best evidence and care in Ontario. As a project manager, she oversees the planning and implementation of the CEP’s primary care academic detailing service, which serves family physicians across Ontario. Prior to joining CEP, Lindsay worked at the University Health Network in the infection prevention and control unit, where she updated internal infection control policies and developed patient and provider educational material. Lindsay is currently completing her Master of Science in Healthcare Quality at Queen’s University.
An interview with Megan DeNubila, Provider Relations Manager, and Jessica Alward, Academic Detailer, from the Bureau of Infectious Disease Control with the state of New Hampshire. Their mission is to improve public health by promoting evidence-based practices in the areas of infection prevention, screening, testing, and management for HIV, TB, STD/STIs, and Hepatitis.
by Winnie Ho, Program Coordinator
Winnie: Thank you both again for joining us today! In one of our past technical assistance discussions together, we’ve gone into depth about some common clinician stigma and barriers. In particular, you shared with us that because New Hampshire was a lower incidence state for HIV, you would encounter clinicians who felt that that particular issue didn’t really fall within their patient population. It’s a common barrier we hear from many detailing programs, whether they address opioid use disorder (OUD) or infectious diseases. Can you go into more depth about your experiences with this phenomenon, and how you’ve addressed it?
Megan: Providers are extremely busy, and they’re often expected to be an expert on so many topics. Our program helps bring providers filter through new information so they can start to bring it up with their patients. By walking them through the best practices, the recommendations, and local and state-specific data, we can show them that it’s something that is impacting their patient population.
In addition, one of the things that stuck with me from the NaRCAD training we attended was that because there’s so much new information, providers would be expected to read up to 17 papers a day just to stay current. Something like HIV would be one of many things that providers are concerned with on a daily basis. Our job is to help bring the most relevant and evidence-based information to the surface for them and their patients.
Jess: Megan is completely right on this! I’m in provider offices a lot. What I hear is that they often feel like they're just treading water and not able to keep up with new information. What we try to do is bring that info to them in a way that doesn’t feel like just one more thing to squeeze into a day. When we talk to them about stigma, we don’t want to start there. We want to start with some easy and really useful information and tools that will make their job easier. By doing that work first, they feel like the precious time they are giving to us is worth it. After a couple visits, emails, or phone connections have happened, that's the time to bring up new approaches and topics.
Winnie: I really appreciate that your lens on this barrier embodies a ‘How do we best support you?’ attitude. The goal of academic detailing is to navigate and close knowledge gaps in hopes of changing clinician behavior. Sharing knowledge and having difficult conversations is our best tools to address clinician stigma and discomfort. It’s not a battle against them and certainly the goal isn’t to shame clinicians. This is a collaborative operation to improve health outcomes.
Megan: Right, in the end, our mission is to close health inequities altogether. If I were a clinician and wasn't comfortable or familiar with best practices for preventing HIV, then I might feel a high level of hesitation trying to broach something like taking a sexual history from my patient. But if it’s something that I get more comfortable with, I’m more likely to bring it up and ask the right questions.
Ultimately, we’re trying to build a relationship with the provider so they see us as a resource when a new practice, tool, or clinical guideline comes out. They can then use those tools and information to address stigma that a patient may be experiencing. Providers constantly have new information and guidelines thrown at them, and we would like to help make it easier for them to take that information and apply it in their daily work.
Jess: Whenever I address something uncomfortable with a provider, stigma or otherwise, I try to create an environment where we can work collaboratively on the issue and the provider feels as though I am a resource for them. I will say something like, ‘the last we talked, you mentioned this to me and it really got me thinking….” Or “I was talking with a colleague the other day about….” Then I will find a way to circle back around to the original topic. By approaching the topic in this manner allows them to feel we are a partner and have a shared goal.
Winnie: I want to circle back to your team’s mission of addressing health inequities. Inequity is the core of why we discuss things like stigma and discomfort. We need to approach clinician stigma with a human approach, but we also need to address the very real impact that it can have on patient health outcomes.
Megan: In a mostly rural state like New Hampshire, healthcare access is limited to begin with, and clinician stigma could drive patients who need help to either forego care or have to travel very far to seek care that they are comfortable with. We know providers want the best outcomes for their patients, and through detailing, we want to help the providers achieve those outcomes. Looking at potential stigma is one of the keys to making sure we address health inequities.
Winnie: A lot of these experiences about clinician stigma are anecdotal, but as you just outlined, they have a very real impact on health outcomes. From our previous call, we have discussed and imagined a tracking tool for these encounters with clinician stigma and barriers. What would you find useful about a tracking tool like this, and what would you hope to learn from the data?
Megan: A tracking tool would help us better understand and represent the stigmatic responses that are out there. It would help us focus our efforts to help a provider address stigma in their practice. Anecdotes are helpful, but it can be hard to grasp. We don’t want to make decisions by theorizing what patients are experiencing. As a small state program with limited resources, this would help us optimize our response and to make sure we’re heading in the right direction by seeing if stigmatic behaviors change.
Winnie: It would be extremely exciting to see a tool like this become available and specialized for the hundreds of detailers who do this work.
Megan: Yes, it’s a theoretical tool at the moment, but we were in discussions prior to COVID-19 about how to develop it. It would be amazing to see programs collaborate on something like this. I can only imagine how much further we’ll go with that as a resource.
Megan DeNubila is the Provider Relations Manager for the Bureau of Infectious Disease Control, New Hampshire Division of Public Health Services. She has been leading the Public Health Education and Detailing team since August of 2018. Megan has over 8 years of public health experience in capacity building, coalition development, and community health. She earned her Master of Public Health degree from the Boston University School of Public Health with a concentration in Maternal and Child Health in 2016/2017 and her Bachelor of Arts degree in Health: Science, Society and Policy from Brandeis University in 2012.
Jessica Alward has been with the State of New Hampshire Division of Public Health Services for almost two years and recently earned her MS in Homeland Security and Emergency Management. With a background in education and training, she works full time as an academic detailer all over the state. In her spare time she enjoys directing community theatre productions, running and hiking. She is married to Scott and mom to two grown sons.
An interview with Nadejda Razi-Robertson, PhD, LCSW, Managing Director, Synergy Health Consulting and Andrew Suchocki , MD, MPH, Medical Director, Clackamas Health Centers
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
Anna: Thank you Nadejda and Andrew for spending time with us today to discuss the impressive work being done in your leadership roles around practice transformation at Synergy Health Consulting. Can you tell us a little bit about Synergy and its impact on opioid safety-related care improvement?
Nadejda: Our team works with health systems across the state of Oregon. Our first phase of work started several years ago when we were largely focused on helping systems implement the CDC guidelines around opioid safety. Our work has since evolved, and we’re now focused on helping clinicians develop medication-assisted treatment programs, integrate behavioral health into primary care, and address the opioid epidemic at the community level.
We often use academic detailing as one of the many tools in our toolbox when we work with different health systems on opioid safety. We take the basic concepts, such as conducting a needs assessment and identifying clinician barriers, from the traditional model of a detailing visit, and implement them on a larger scale.
Andrew: Many members of our team are practicing healthcare professionals in the field, which roots a lot of our work at Synergy. I take what I’m seeing on the ground as both an administrator and a provider at a busy clinical practice and incorporate those experiences into my work at Synergy.
Anna: It’s so important to build teams where members have varied expertise and professional training when working together on practice transformation. How have you incorporated academic detailing strategies into the work being done at Synergy, and how has it been received?
Andrew: Some of the academic detailing work I’ve done has been with providers who need extra support from a peer, or from someone else working in the field. When it comes to opioids, chronic pain, and addictions in primary care, there’s a tremendous amount of stigma and information that was accurate at one time, but as we’ve shifted as a society, many primary care providers are yet to catch up.
Stigma isn’t something that folks are actively choosing, it’s more of what they’ve been taught. Changing that culture of practice is much more difficult compared to asking prescribers to prescribe cholesterol-lowering therapy. There’s very little societal baggage when it comes to improving cholesterol than there is when it comes to destigmatizing addictions or chronic pain.
Nadejda: We use the same fundamental approach when working with systems, clinics, or individuals. We start with a needs assessment, provide a group training based on those needs, and follow that up with 1:1 academic detailing visits to address barriers, provide materials, and explore personal bias that may be getting in the way of providing treatment.
I’m currently working to schedule a training for several providers in a rural county in Oregon. A number of those providers are X waivered (allowing them to prescribe medication therapy for patients with opioid use disorder), but they aren’t using their X waivers to prescribe buprenorphine. A needs assessment will provide me with a better understanding of what the challenges and barriers are, what is working well, and where there may be bias, stigma, or gaps in knowledge. We also use the needs assessment as a “listening session” that creates a sense of safety, fosters an experience that participants are being heard, and serves to “normalize” experiences across settings and practitioners. This process is also strategic in that it helps us understand where to focus our educational outreach and academic detailing efforts.
The more we are doing this work, the more we are finding that this approach is effective in getting care teams, medical providers, and service providers across many sectors into increased “philosophical alignment” which is critical to effectively foster culture change around issues of pain, addiction, and trauma.
Anna: Bias, stigma, and gaps in knowledge around chronic pain and addiction are common, especially in primary care. We’ve found that many detailers have been successful in helping providers “catch up” to society and overcome personal bias through their detailing visits. Speaking of detailing visits, face-to-face visits have clearly been impacted by COVID-19. Can you tell us more about other ways that COVID-19 has impacted the work at Synergy?
Nadejda: Again, we’ve gone back to the wisdom of the original academic detailing model. The needs of each setting have changed significantly, and we’ve been pivoting our work to meet those needs. Providers want to know how to best support their patients who are dealing with pain during this time. One thing we were able to provide early in the pandemic was a list of recommendations and resources around pain management for both providers and patients.
Andrew: We saw the need to adapt to massive changes related to COVID-19, and to do so essentially overnight. We’ve had questions about conducting urine drug screenings, initiating treatment over the phone, and maintaining the patient-clinician relationship.
There’s also a shared vulnerability among providers and patients when visits are conducted virtually. Our patients have had requests for increased medication use, which is understandable because they’re not able to do activities that they’ve typically been able to do to keep themselves resilient. That conversation is a difficult one - in some ways it is easier because you don’t have to see someone in person, but it also makes for a very ineffective conversation because you’re not able to demonstrate your humanity through body language. Our team is struggling to wrap our head around this as we try to provide leadership and guide clinicians who are looking to us, or our state, for collective ideas around this field and how we practice.
Anna: COVID-19 has certainly impacted the way we think about responding to changing needs for those who are trying to manage their pain. Can you tell us about some of the other major changes you’ve seen in pain management over the past few years?
Andrew: The biggest thing I’ve seen is insurance expansion. We’ve known for years what you need to have effective pain management and how important it is to shift the idea of living with pain and accepting pain versus eliminating pain. We’ve seen Medicaid expansion and expansion of benefits, especially in the Northwest, that has given patients access to modalities that are effective for safer pain management.
Historically, things we knew that worked like, gym memberships, physical therapy, occupational therapy, mindfulness, and chronic pain groups, were never paid for or weren’t available. As society has changed how it believes pain should be managed, we’ve started to see the insurance side supporting these modalities more. There’s also been heavy reporting on the opioid crisis in the media that has led patients to understand that opioids have risks.
Nadejda: We’ve continued to grow and learn as a team over the past several years. Our entry point into communication around chronic pain and pain management has continued to be centered around assessing if patients and their care teams have an understanding about how pain works. We want to make sure that clinicians have the proper training and are up-to-date on evidence and resources.
Andrew: We’ve known some of this information about pain management and how pain works for a while, but it takes many years to take what we know from as a research perspective and translate it into practice. One of our roles at Synergy is to accelerate that. We’re seeing our evolution as a group mimic and reflect the experience we’re having as a culture as we start to dial in to the most effective ways to manage pain.
Anna: As Synergy continues to respond to changing societal needs around pain management, what insights can you share about the impact of academic detailing to date?
Andrew: One thing I’ve learned about academic detailing is that it’s only as effective as your intervention across an entire system. I’ve realized that any work that I’m doing is irrelevant unless I’m addressing the entire system and the culture. If the front desk staff isn’t on board, if the medical assistant isn’t a believer, if the nurse doesn’t understand addiction, if the CEO doesn’t understand that the health system is already treating these patients, there will be challenges that will be harder to overcome.
Nadejda: Because academic detailing has been an arm of a larger change approach we’re using, it’s hard to measure its effects. We don’t have data to show that only detailing has moved the needle around these topics in these ways. Sometimes I see academic detailing as the “cherry on top” after there’s a lot of work that’s been done in prepping a system. I’ve recently been doing practice facilitation work with providers and clinics just to understand the barriers in a system—there’s an art to the change process in the pain management space. Academic detailing comes in after you’ve truly understood what the barriers are. After you understand the barriers, you can bring in nuggets of evidence and information in a way that the system is ready to receive.
Nadejda Razi-Robertson is the Managing Director of Synergy Health Consulting, as well as Synergy’s project lead for the Oregon Health Authority’s Prescription Drug Overdose Prevention Project. Nadejda is a practice facilitator within health systems around the State of Oregon and provides technical assistance to clinics that are focusing QI efforts around safe opiate prescribing, MAT program development, and behavioral health integration. Over the past twelve years, she has worked in private practice with a specialty in trauma treatment, as a behavioral health provider in two Federally Qualified Health Centers (FQHCs), and as a consultant with Oregon’s Coordinated Care Organizations (CCOs) and the Oregon Health Authority supporting efforts in addressing the opioid epidemic throughout the state of Oregon.
Dr. Andrew Suchocki is a family physician with additional training in Preventive Medicine. He has worked in underserved medicine with a focus on chronic pain and addiction for ten years, and has been a medical director at an FQHC in the Portland, Oregon region for the past five. Andrew provides educational outreach and consultation in the areas of system change in primary care around opiate prescribing, MAT system design and capacity growth, coordinated specialty care, and reducing risk. Dr. Suchocki is an Oregon Opioid Prescribing Guidelines Task Force member and Oregon Medical Board consultant. He provides technical support and academic detailing for the Oregon Psychiatric Assistance Line (OPAL) which provides immediate referral sources for primary care. Dr. Suchocki also provides strategic planning, creation of innovative clinical decision support tools, physician mentoring, and health system process mapping for Yamhill County Health and Human Services, Community Corrections and Specialty Behavioral Health. He is a regular presenter at national and international pain related conferences.
An interview with Sarah Ball, PharmD, Research Assistant Professor, Division of General Internal Medicine, Medical University of South Carolina and Megan Pruitt, PharmD, Clinical Pharmacy Consultant, SCORxE Academic Detailing Service and Assistant Professor, Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
Anna: Hi Sarah and Megan- thanks for taking the time to chat! Can you tell us a bit about your program, SCORxE, and how your AD work has concentrated on improving opioid safety?
Sarah: SCORxE began in 2007 as an academic detailing service at the South Carolina College of Pharmacy and is now part of the Medical University of South Carolina (MUSC) College of Pharmacy. Our current efforts are around addressing the opioid epidemic. We’re fully funded by the South Carolina Department of Health and Human Services, and our agreement talks about bringing together quality initiatives for safer opioid prescribing and expanding access to MAT.
We’ve been able to effectively bring together quality initiatives from different state agencies that span prevention and treatment. This braiding has been a unique experience for our academic detailing service. Regardless of the specific topic, our detailers promote opioid risk reduction strategies, help recruit and support MAT providers, and work to reduce stigma around MAT. We’re currently shifting our focus from chronic pain to acute pain. We’ll be detailing both primary care providers and surgeons on post-surgical pain.
Anna: Detailing surgeons is a unique approach – we’d love to hear about the results of that process in the future. And you’re working on other topics outside of opioid safety, too – tell us more.
Sarah: Our providers always welcome new topics. While our focus is on the opioid epidemic, we try to expand our content reach when possible. We recently detailed on depression and anxiety screening, and touched on alcohol use disorder in our topic on naltrexone. We’ve always offered CME credits and our current strategy is shorter and more focused visits that offer a half hour of CME credit, as opposed to one or two hours of credit. This allows us to have multiple visits with each provider and to individualize next topic selection.
Megan: As a detailer, it’s helpful to have a menu of shorter topics that providers can choose from – it makes our visits more flexible.
Anna: Speaking of flexibility - how are you continuing to detail and run your program given the current COVID-19 pandemic?
Sarah: We haven’t previously engaged in virtual visits or e-detailing. We’re planning to reach out to our network of academic detailing colleagues who’ve had e-detailing visits in the past to see what their experience has been like. It’s times like these that show how valuable it is to have a network of academic detailing services. Being able to share ideas and find out what other folks have done will help us determine what will work best in our state.
Megan: We’ve been using the past few weeks to work on creating materials and scripts for upcoming topics. It’s been a good time to refresh on a lot of our content and update various internal documents. I’m going to begin reaching out to providers within the next few weeks and gauge their interest and comfort level in using a virtual platform.
Sarah: We know this is a difficult time for primary care providers, so it’s important for us to be compassionate in how we go about scheduling visits. We want to be sensitive to our providers’ time and respect what they’re going through, while still offering our detailing service around topics related to the opioid epidemic.
Anna: You’re not alone in figuring out this balance! You also mentioned that peer learning is an important component to a successful intervention. Can you tell us about your own peers on your team, and how they enhance your overall detailing service?
Sarah: Our program is under the College of Pharmacy, so we’ve recruited all our detailers from there and they’ve all been clinical pharmacists. We’re fortunate to have pharmacists because they’re well-respected among providers we visit. We have two full-time detailers, which is a privilege, and they’re very passionate about their work. Being able to have two people fully commit to detailing is far greater than the number implies. Both of our detailers have different personalities and different experiences to share – I think they complement each other very well!
Detailing can be lonely, though. When you have more detailers in your program that add up to two full time equivalents, what we have had in the past, you have more people sharing experiences during debriefs and more people to bounce ideas off; there are pros and cons to both scenarios.
Megan: My colleague, Lauren, and I come from different clinical backgrounds. When we work on our content development and role playing, we’re able to help each other consider things differently. It’s been fun to work with somebody who differs so much from me!
Anna: It sounds like you balance each other out well. How are the detailers in your program trained?
Sarah: All of our detailers have gone through pretty intense academic detailing training on the marketing of evidence-informed clinical ideas. Our most recent hires have gone through NaRCAD training, but before there was a NaRCAD, our pharmacists went through a training developed by a group in Australia. That training gave us a step up on everything when we first started our program, as NaRCAD also does with programs just getting started. We garnered our baseline of how we develop content, how we develop our supporting materials, and essentially how we put together our whole intervention.
Anna: It sounds like the detailers in your program are trained well and prepared for the field. Do you have certain strategies for getting in the door? Are there key stakeholders who your program has connected with that have helped you to do this?
Megan: Showing up at the office has repeatedly proven to work for us. We bring a letter to share with the first gatekeeper at the front desk, so that we can get face-to-face time with the providers for introductions. We’re usually able to schedule a meeting fairly easily after that. If we can’t meet with the provider face-to-face, we try to speak with the Office Manager.
Recently, we’ve been leveraging our group presentations at clinics to get more 1:1 visits. We try to promote our detailing visits during our presentations and grab contact information from providers afterwards. We’ve also found that it’s been helpful to stay in the break room at an office after a visit - we might stay there all day and introduce ourselves to a number of providers who end up wanting to either schedule a visit that day or in the future. We’ve found great success in being present for providers when they’re ready.
Sarah: When you can get face-to-face with the providers for a brief introduction, it’s a beautiful thing-it’s how we’ve gotten most of our visits over the years. When we first started, gaining access happened in different ways. We had champions in the area that supported what we were doing, and we could use that to get our detailers in the door. Our program was also previously part of a demonstration project where providers were required to have an academic detailing visit as part of the initiative. I would say that our cold calls became “warm calls” during that time because all the offices and providers knew we were coming.
Anna: I’m sure having providers in the area know about your detailing service has helped to build your program. Can you tell us more about how your program is working towards sustainability?
Sarah: We’re more sustainable than we’ve been for a while. Part of that is due to the funding that we have for opioid-related topics, but it’s also been due to the effort our program has put into effectively bringing together different quality initiatives over the years. We’ve had funding come in from multiple sources in that process.
One agency asked us to take on the topic of naloxone for pharmacists--our ability to respond to such requests helps up strengthen relationships, and may help us with future sustainability. It is also important that our interprofessional teams at MUSC see value in academic detailing.
Additionally, our detailers help us with sustainability through their visit documentation and tracking. The data they collect is included in our reporting and helps illustrate the value of academic detailing. Our clinical pharmacists are amazing people, and they both bring so much to what we do in the academic detailing world– programs are only as sustainable as the strength of their individual detailers!
Sarah Ball, PharmD is a Research Assistant Professor in the Division of General Internal Medicine at the Medical University of South Carolina (MUSC), with a focus on patient-centered care, patient safety, and educational outreach. She has had direct involvement with academic detailing for over twelve years, beginning with the development and implementation of the SCORxE Academic Service under the SC College of Pharmacy in 2007. Current efforts include the integration of research and programmatic opportunities to identify interventions that change prescriber behavior to reduce the risk of opioid overuse, misuse, abuse, and overdose. Dr. Ball is currently leading the MUSC team partnering with the South Carolina Department of Health and Human Services for the provision of drug utilization review (DUR) services, which includes educational outreach to primary care providers and surgeons. Dr. Ball has twenty plus years with a career focus on improving patient care through the application of technology and effective communication of clinical knowledge, information, and data-derived findings. She is a graduate of the Medical University of South Carolina, where she received both a B.S. in Pharmacy and Pharm.D.
Dr. Megan Pruitt is a South Carolina Offering Prescribing Excellence (SCORxE) clinical pharmacy consultant and assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the Medical University of South Carolina in Charleston, South Carolina. She received her bachelor of science in health science from Clemson University and her doctor of pharmacy from the South Carolina College of Pharmacy. She has published an Amazon ebook, Catalyst (pharmD): The Next Generation Pharmacy Student, and has previous experience as a community pharmacist at Federally Qualified Health Center in South Carolina. In her current role as a SCORxE clinical pharmacy consultant, she provides academic detailing visits to primary care providers on monitoring practices to promote safe opioid use and to reduce the risk of misuse and abuse in South Carolina.
Bevin K. Shagoury, Communications & Education Director
A Letter from Our Team
To our AD Community:
By the time you read this, certain adjectives will have moved to the top of your frequently-used list. Words like “unprecedented”, “strange”, and “unsettling” are just a few that our home team has been using most commonly, and we’re sure that you, our community of AD peers, have been, too.
During the COVID-19 pandemic, priorities are changing quickly and frequently—many of our public health colleagues have found themselves focused primarily, if not entirely, on the situation at hand, with critical response demands shape-shifting hourly.
For those of us who spend our time more removed from frontline healthcare and have been focused on clinical outreach education or adjacent health improvement initiatives, challenging questions have arisen.
The answers to these and other questions are context-dependent, ever-changing, and don’t always have easy solutions. There are changes and disappointments to adapt to—for us, we’ve accepted the need to prioritize safety and postpone our March and June 2020 trainings (keep your eye on our Training Series page for reschedule dates), and we appreciate your patience as we wait to figure out next steps.
But we’re equally aware that there are just as many opportunities for growth. At NaRCAD, our goal right now is to support our colleagues as we all face the very real impacts of COVID-19. Concretely, we’re working hard to bridge some of the gaps that make the original, face-to-face model of AD temporarily impossible. We’re proud to share that we just launched our first e-Detailing Community of Practice, e-Detailing Toolkit, and are shifting focus on our 2020 Webinar Series this month to tend to the needs of those programs who must pivot to e-detailing and quickly.
As such, we encourage you to complete our 1-minute e-Detailing Needs Assessment survey, so we can design tools and resources that fit your needs. Based on your responses, we’ll translate your needs into tailored support to help you realistically maintain the work that you can, rebalance your priorities, and focus on future programming efforts during a time when the present is hard to navigate.
As we all try to take the current realities of our world one day at time, NaRCAD is dedicated to finding creative solutions for you all to continue supporting clinicians as best you can in making the kinds of decisions that will have a long-term impact on the health of their patients. We’re dedicated to growing with you as you inform how we grow and change our team’s priorities to match yours.
Join us in our Community of Practice, send us an e-mail, or better yet—take a deep breath. As you all try to face the daily challenges that arise during a time unlike any other, know that our team is here when you need us, as your colleagues, and as community members who care.
The Team @ NaRCAD
An interview with Elisabeth Fowlie Mock, MD, MPH from the Maine Independent Clinical Information Service (MICIS).
by Winnie Ho, Program Coordinator
Winnie: We appreciate you taking the time to speak with us today about the work that MICIS (Maine Independent Clinical Information Service) has done supporting evidence-based prescribing since 2008, and safer opioid prescribing since 2016. Can you tell us a little bit more about MICIS?
Elisabeth: We’re a small program created by legislation in the state of Maine, housed within the Maine Medical Association. We serve over 8600 prescribers including physicians, pharmacists, nurse practitioners, and physician assistants across the entire state. Our two detailers are contracted to work about 5 hours a week each, which includes all of our administrative and detailing time.
Winnie: That’s an amazing feat to be serving such a large population with a small team. How have you built and maintained all of those relationships?
Elisabeth: We have always used more of a general educational outreach approach than the traditional one-on-one academic detailing model. We have limited resources with our contract, and the only way to reach that number of prescribers is to do small groups or lectures.
Winnie: We understand that there are many programs who adapt the original model of detailing to allow for more than one provider at a time to participate. While it’s a common workaround solution to having limited resources and a long list of providers to detail, it can be more difficult to discuss challenging topics, especially something like opioids and related stigma. How have you been able to navigate those challenges?
Elisabeth: When we detail in our groups, we focus on small group discussions. One method I use involves flashcards with myths or biases about Opioid Use Disorder (OUD) and Medication-Assisted Treatment (MAT), and asking two or three of the attendees to discuss that amongst themselves. We have also used a language sheet that guides providers in what to say.
We have people talk about the language commonly used in practice, and how that can affect the care that’s provided. I think just like any other place, we encounter people who have all of the biases that you’ve heard of when it comes to opioid use disorder – that it’s not a disease, that buprenorphine and methadone are just trading one drug for another.
Winnie: There must be a lot to unpack when discussing the root of where these beliefs come from. It’s a core component of what we hope to achieve through academic detailing – an honest dialogue that leads to positive clinical practice outcomes.
Elisabeth: Exactly. I think it’s important to understand that, for example, with chronic pain prescribing, there are a lot of people who are reluctant to embrace evidence from the past five years that shows no benefit from opioids, and more significant evidence of harm. It’s been interesting to see how people have been stuck on what they learned twenty years ago, and to see them reject the newer information.
Winnie: It’s incredibly important that detailers remember in navigating tough conversations about stigma that there is a shared goal of promoting patient health. No provider undergoes training and hard work with the intention of harming patients.
Elisabeth: I think these tough conversations can produce some cognitive dissonance in people. Basically, if I, as a physician myself, agree with the premise that what I did fifteen years ago actually contributed to OUD in my patients, and if I admit that, then I also have to carry a burden that it was my fault. It’s a hard jump for people who made it their life’s work to care for people.
Winnie: It’s absolutely a human response. What have you found to be an effective way of addressing the problems caused by stigma, while also addressing the fact that providers are human?
Elisabeth: People don’t want to be overwhelmed by data, but repeated snippets of data over time can help you reinforce the message, which is what we do with academic detailing. I think of myself in my work as a physician – I started on opioid education projects more than half a decade ago. It wasn’t my top choice, but I became more and more educated about the crisis and heard the information in multiple ways. It really changed my way of thinking to the point of realizing I needed to be part of the solution. I received my X-Waiver back in 2016 and started prescribing buprenorphine.
Winnie: That’s a wonderful reflection on how repeated messaging helped change your mindset as a provider. It’s important to understand that people can change, no matter what holds them back.
Elisabeth: I think that as academic detailers, we might not always recognize the impact right away. We might not get the immediate positive feedback from a clinician after an interaction, but especially if you’re lucky enough to grow relationships with the people you detail over time, you can see the change. I think that’s the most effective and rewarding part of detailing.
I prescribe buprenorphine because I can teach about it, but I also do it because it’s important. This work gives us an opportunity to be leaders for people who don’t always have a voice, and because of stigma, aren’t being listened to. Most of our patients with OUD are on the margins and struggle even during stable economic times. Especially right now with the COVID-19 pandemic, the rest of the country may not be worrying about how we’re going to safely maintain our patients on buprenorphine, but we need to worry about it.
An interview with Kristefer Stojanovski, MPH, PhD(c), Public Health Researcher and Evaluation Specialist, Capacity Building Assistance Program, San Francisco Department of Public Health
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
NaRCAD: Hi, Kristefer! Thanks for taking the time to chat with us today. Can you tell us a bit about your background and the work you’re currently doing as it relates to academic detailing?
Kristefer: Thanks for having me. I’m a public health researcher and an evaluation specialist with the Capacity Building Assistance Program at San Francisco Department of Public Health. I serve as a specialist and a technical assistance provider for the West region of the United States. My work is focused on data and evaluation of academic detailing programs that are working on topics like sexual health, HIV, and PrEP. My main goal is to help folks measure, or think about, what “success” may look like for an academic detailing program.
NaRCAD: What data do you think is most important for academic detailers to track during their visits when measuring or thinking about success?
Kristefer: I see evaluation data and detailing efforts as one complete package. Detailers should think about their data at a high level and focus on the information they’re collecting and how that information serves the overall goal of detailing, which is to improve knowledge, attitudes, intentions, and behaviors of providers and clinics.
At the same time, detailers should think about how they can show that they’re achieving that goal. For example, it’s useful to track how many providers they’ve seen, how much time was spent with providers, what they talked about during the visit, the resources that were provided, how the providers plan to use those resources, if a follow-up visit was scheduled, and the purpose of that follow-up visit. It’s important to track a mix of quantitative and qualitative data, but the critical components that should be tracked are the outcomes and the process of detailing.
NaRCAD: What about academic detailing programs? What data should they collect?
Kristefer: In a typical detailing program, detailers have a longitudinal, continuous outreach to providers. There’s an interesting conversation to be had about how we can use that temporal matrix as a tool and strategy for evaluation. I’m interested in how we can use the work academic detailers are doing – the actual visits themselves - as pieces of data over time.
For example, if detailers are collecting some of the rich conversation that they’re having with providers or clinics, it’s fascinating to track those conversations over time and see how the detailing program is changing the knowledge, attitudes, intentions, and behaviors of those providers and clinics. There’s a lot of work that detailers are already doing that can be easily turned into data sources for both the detailing effort and the evaluation effort. I like to think about how we can make things as simple as possible.
NaRCAD: Is there a specific platform that makes things simple and is best for collecting data for academic detailers and programs?
Kristefer: That certainly becomes a little bit more individualistic when thinking about the needs, challenges, and abilities of each jurisdiction. Detailing is a conversational effort that is attempting to make concrete behavior change, so it becomes more convoluted when you think about how to track a conversation. Some jurisdictions might have a place to track conversations in their electronic health record, where others may not.
At the most basic level, detailers can chart their conversations on one-page Word documents. The detailers I worked with charted their conversations with providers over time and eventually put it in one large PDF that could be easily uploaded into a qualitative data analysis software. You have to be creative when it comes to tracking this information.
NaRCAD: How would you recommend that programs with limited resources go about data collection and evaluation?
Kristefer: A lot of times we say we want to have high-tech solutions when we don’t actually need them. For a resource constrained department, having that one-page Word document that allows detailers to chart their interactions is more than enough data. Charting for just five minutes after a detailing visit about everything that took place becomes a wealth of information. You can also use an Excel document to input data from provider surveys.
There are many low-tech ways to track information and it’s important to be aware of the low hanging fruit in terms of data collection. You want to be able to easily collect data that serves the detailing efforts, the program, and the evaluation and improvement process.
NaRCAD: That’s a great way to look at it. What are some best practices for using data for leadership buy-in?
Kristefer: I can’t stress enough how important data is in getting leadership buy-in. Data is not only quantitative and qualitative, but also using the information gathered to tell a story. It would be a strong statement if someone was able to go to leadership with a story about how providers have changed their practices based on the detailing effort. Using concrete results and showing leadership that detailing is making a change is extremely helpful for buy-in.
Being able to show crazy big outcomes with your data won’t happen, but sharing stories from providers and clinics about how detailing has helped them is quite moving. I’ve heard some amazing stories during my evaluation. For example, detailers helped providers at some clinics to provide patients with directly observed therapy for PrEP at the same time that they were providing them with medication-assisted treatment for opioid use disorder. It’s impressive that detailing at those sites was able to make the clinics think creatively and be able to provide PrEP to these patients.
NaRCAD: That certainly is impressive! What has surprised you the most about the academic detailing data you’ve evaluated?
Kristefer: I can’t help but to think that pharmaceutical companies spend millions of dollars and resources on this model and they certainly wouldn’t have been doing this for decades if it didn’t work. We’re almost a little late to the game as public health practitioners, but through my experience evaluating some of this work and reading other evaluations, I’ve been shocked by how much providers truly value detailers.
It’s fascinating to see how these health systems and departments are viewed as trusted partners by providers and clinics and how detailing has served as a role to improve that partnership and collaboration. Providers have often said how crucial this information has been in getting access to Department of Public Health resources they didn’t even know existed, which is pretty sad. Seeing public health and the medical system working side by side in this kind of way has been breathtaking.
Kristefer Stojanovski is a PhD Candidate in the Department of Health Behavior & Health Education, School of Public Health at the University of Michigan. Kristefer has been doing community-based mixed methods research since 2010. His research explores the social and structural determinants to sexual health and HIV outcomes among key populations in the U.S. and in Southeastern Europe. Kristefer’s work interrogates how stigma drives HIV risk and infection using complex systems theory, structural equation, agent-based and multilevel modeling. Kristefer also translates his research into policy and decision-making. He is an evaluation specialist with the Capacity Building Assistance program with the San Francisco Department of Public Health.
An interview with Terryn Naumann BSc(Pharm), PharmD the Director of Academic Detailing and Optimal Use at the British Columbia Ministry of Health by Winnie Ho, NaRCAD Program Coordinator.
Overview: Terryn previously spoke about her experiences on a virtual detailing panel at the NaRCAD2019 conference. You can watch the video recording here.
NaRCAD: Terryn, thank you so much for speaking with us today about your experiences with detailing in the province of British Columbia. The BC Provincial Academic Detailing (PAD) Service certainly has a lot of ground to cover. Tell us about the program goals and geography.
Terryn: For reference, British Columbia is geographically larger than Texas, but the population of British Columbia is only about 5 million people. We provide our detailing services to family practice physicians, nurse practitioners, and a few other healthcare professionals. Our detailers each do more than 175 visits per year, and collectively, they see about 2000 providers per topic, which includes about a third or so, of all the family physicians in BC.
We have 12 detailers in total, half of whom are working in less densely populated areas. For example, the northern end of the province is mostly small communities with only 3-4 providers in each town. One year, one of the detailers drove over 17,000 km (10,563mi) for her visits alone!
NaRCAD: That’s an incredible amount of work that your detailers have been up to! And you yourself have been active in AD for a long time. What was your experience then like?
Terryn: I started in 1993 with the program that would one day expand to become the PAD service, and I detailed for about 7 years. I came back to academic detailing in 2008 as the coordinator of the provincial program. When I started in 1993, I had just graduated with my PharmD. I had read about AD and was excited to try something new.
You have to realize, at the time, technology wasn’t that advanced... I didn’t even have an e-mail address when I first started. You couldn’t just send people a note and say “When would you like to meet?” It wasn’t simple to access people.
NaRCAD: How would you describe how AD has changed since you started?
Terryn: When I started, I was the first academic detailer in Canada. There were about 70 physicians that I would go out to visit for each of the topics I put together after having the content reviewed by a local physician specialist from within our own community. One of the things that has changed is the breadth of resources and the growth of the AD community. There are so many more people involved, content is more thoroughly researched, and the literature is more readily accessible through technology.
NaRCAD: Technology has certainly changed the way the world works, and it’s something that detailing programs are turning to more and more to tackle the challenges you’ve mentioned, such as trying to serve a large and scattered population with a limited team. We’ve seen the increased use of tele-communications to do detailing. What has your experience been with virtual detailing, also commonly called ‘e-detailing’?
Terryn: One of the things we value about AD is that truly interactive, face-to-face encounter and that ability to individualize sessions to the provider’s learning needs. Virtual detailing uses a different methodology altogether. I think there are advantages to virtual detailing, but sometimes I think that it’s not as simple as moving AD to a web platform. I worry about the personal elements you can lose, even when using a web platform where you can see each other. My detailers often end up making slides of the original materials, which sometimes turns the session into more of a presentation.
NaRCAD: Can you elaborate further on the nuances you’ve seen with this new approach?
Terryn: We started with something we called Technology-Enabled AD (TEAD) which was a limited study done to compare the efficacy of TEAD versus a traditional face-to-face visit. They found that there was an effective knowledge exchange during both types of sessions, but the time it took for TEAD was far shorter. However, when we added TEAD as an optional feature for our providers, we ran into multiple challenges, such as detailers and providers not being familiar enough with the technology. The large majority of our providers choose to meet in person when they have that option.
That said, virtual detailing has been useful considering BC’s terrain and rough winters. Some regions have winter 8 months of the year and travel is limited for safety reasons. We have used virtual detailing, but find that we need detailers that are tech-savvy and can guide providers through accessing the platform easily.
The key is maintaining the interactivity component and having the session not become a presentation. If we can embrace virtual detailing as its own, unique skillset, we may be able to take advantage of all of its benefits. I think that we’re also at a changing point in technology – the next generation of providers (and detailers) will have grown up with and be more comfortable using technology.
NaRCAD: There will be a lot of growth in detailing as we are able to incorporate more options into how we reach providers, with the emphasis being on building a strong relationship.
Terryn: The goal of AD has always been to have a clinician who values a discussion about the evidence, and then is able to incorporate the evidence into their own practice and drug therapy decision making. E-detailing is just another modality for doing that.
We found that virtual detailing is most effective after establishing a prior relationship with the provider during a face-to-face visit. We received fantastic feedback from one provider who felt the virtual detailing session that he participated in from the comfort and privacy of his home allowed him to ask questions he might otherwise have avoided asking in a group setting. If we can use technology to build relationships like that, then ultimately isn’t that what we want?
I would say that it is.
Terryn Naumann is the Director of Academic Detailing and Optimal Use at British Columbia’s Ministry of Health’s Pharmaceutical Services Division. She earned her pharmacy degrees from the University of British Columbia and completed a hospital pharmacy residency at St. Paul’s Hospital in Vancouver. Terryn began her career in academic detailing in 1993 when she worked at Lions Gate Hospital in North Vancouver as the clinical pharmacist for the Community Drug Utilization Program – the first academic detailing program in Canada.
Since 2008, Terryn has led BC’s Provincial Academic Detailing (PAD) Service, a team of 12 academic detailing pharmacists who conduct over 2000 academic detailing/small group learning sessions each year. She is a member of the Canadian Academic Detailing Collaboration, having served as chairperson and secretary. She has also been a facilitator at several of the Centre for Effective Practice’s Basic Academic Detailing workshops.
An interview with Brandon Mizroch, MD, MBBS, Provider Network Supervisor, Louisiana Department of Health
by Anna Morgan, RN, BSN, MPH, NaRCAD Program Manager
NaRCAD: Thanks for chatting with us today, Brandon! We’re excited to be catching up with you. Can you tell us about your program at the Louisiana Department of Health and the work you’re currently doing?
Brandon: Absolutely. I was hired to do work around PrEP and PEP, detailing providers across the state of Louisiana, in 2017. Since then, my role has expanded and I promote education for providers about syphilis, congenital syphilis, and Hepatitis C. Our department now has 3 detailers, including myself.
Louisiana became the first state in the country to undergo an incredibly revolutionary Hepatitis C Elimination Plan, which has caused my detailing focus to shift. There’s been huge advancements in the drugs that treat Hepatitis C, but they’ve been inaccessible to much of the population due to cost. We negotiated a fixed rate price for Hepatitis C treatment and can now treat 100% of the population, compared to the 3% of the population we could treat previously. There’s been a big push to identify and train providers who’ve never previously treated patients with Hepatitis C. I’ve been leading the charge by getting the word out, running symposiums, and working with the marketing team that’s creating our statewide campaign.
NaRCAD: Wow, that sounds like innovative and exciting work. Can you explain your program’s approach a bit more?
Brandon: I try to blend a few different approaches together. I attended the NaRCAD training during my first year as a detailer. NaRCAD built the foundation of detailing for me. I always use the NaRCAD methodology to get my foot in the door and identify providers who can be champions within their practices. I find it much easier to follow up and do longer didactic sessions about complex clinical topics when I use the techniques of academic detailing during my first face-to-face visits with providers.
I connect with about 20 providers in this 1:1 model each month. I also work with residency programs, hospital systems, and present at Grand Rounds to expand my reach. There’ve even been instances where I’ve attended dinners for physicians that are hosted by pharmaceutical companies to network and identify new clinics that would benefit from detailing.
NaRCAD: We’re happy to see that you’re blending academic detailing with other approaches. Do you provide follow-up to providers after your visits?
Brandon: Follow-up is incredibly important, no matter what approach is being used. I like to send an email after each visit that includes digital resources for both providers and patients. I also offer providers the ability to call, text, or email me because of the apprehension that exists around topics where the knowledge base is still growing. Maintaining relationships with providers also ensures that we have a strong provider network that we can continue to educate on other clinical topics down the road.
NaRCAD: Building a connection with providers is imperative, especially as you move into different clinical topics. Your program spans the entire state. Do you find that there’s a difference when you provide clinical outreach education in rural vs. urban communities?
Brandon: Yes, there’s certainly a difference. The providers in urban areas tend to have a higher knowledge base when it comes to PrEP and syphilis, perhaps due to marketing efforts or higher patient loads. This makes starting the conversation a bit easier. Additionally, urban communities have access to navigators, who help with non-medical aspects, like transportation issues, lack of health insurance, and long commute times that all prevent folks from getting the treatment they need. Providers in urban areas are also busier and easily distracted during 1:1 visits, which can make detailing a bit difficult.
On the other hand, rural communities are quite the opposite. Providers tend to have more time in their schedules and are excited to sit down with somebody from the state office. They’re eager to learn, but there’s typically less of a knowledge base, making it slightly more difficult to start the conversation.
I’ve also learned about patient barriers as well, which affect access and provider care. Patients in rural areas are often friends or family with those throughout the community, including those who work at clinics. The notion that you would know the receptionist or provider at a clinic is enough to deter folks from seeking medical care around a topic like sexual health. To encourage access, our state has created a TelePrEP program that offers PrEP services to anyone via telemedicine. Consultations take place over the phone, labs are obtained at third party lab companies, and medications are mailed right to the front doors of patients. It was originally created to help folks in rural communities who face stigma-related barriers, but we’ve expanded the program across the entire state of Louisiana. It’s a great referral service that I can share with providers.
NaRCAD: It’s wonderful that you’re able to identify these challenges and have resources and tools to address them. What’s one piece of advice you’d give to folks who are detailing on a similar clinical topic or have a large geographical region to cover?
Brandon: It’s important to have several different ways of presenting information to the providers you’re detailing and to use varied approaches depending on the barrier(s) they’re facing. I typically focus on emotional connection, financial concerns, and the evidence and science behind the key messages I’m delivering. I’m also ready for provider resistance, and am prepared to address it, which is something I learned from NaRCAD.
When it comes to detailing over a large and diverse geography, it’s always necessary to plan ahead. My general rule of thumb is that however many hours it takes to drive to a location, that’s how many providers I want to meet with while I’m there. I typically try to use larger educational events, like meetings with clinics over lunch, as my anchor point for longer trips. After I have that scheduled, I search for smaller clinics around the area where I can meet with providers 1:1. It’s all about maximizing your time.
Brandon Mizroch received his MD/MBBS from the University of Queensland/Ochsner Clinical School Program in November of 2016. Since taking over as the PEP/PrEP Provider Outreach Specialist at the Louisiana Department of Health in August, 2017, he has worked with hundreds of doctors statewide on HIV prevention best practice. Since then he has expanded his educational base and now serves as the head of the academic detailing department at the Louisiana Department of Health, Office of Public Health, STD/HIV/Hepatitis program. As the Provider Network Supervisor he has helped lead the provider Outreach for the state’s first-in-the-nation Hepatitis C Elimination program. From grand rounds presentations at LSU-Shreveport Hospital and Baton Rouge General, to state-wide symposia and conferences, to one-on-one counseling encounters at dozens of clinics all over Louisiana, he has helped spread awareness and education on HIV prevention, syphilis screening and treatment, and HCV screening and treatment through evidence-based care.
Highlighting Best Practices
We highlight what's working in clinical education through interviews, features, event recaps, and guest blogs, offering clinical educators the chance to share successes and lessons learned from around the country & beyond.