course this morning about how to implement a sports medicine program across a big healthcare system with both academic, private, community hospitals. It's filling up fast in here, so I'm glad you guys are here early and have a good seat for the rest of the show. I'm sure it'll get very full sooner rather than later. And we have some great speakers this morning. The first is going to be our vice president of MGB, which is Mass General Brigham Sports Medicine, who has a background both as a clinician as well as an MBA. Second will be our terrific chairman, Dr. Ross Safant, who's both professor and chair of Physical Medicine Rehab at Harvard Medical School. He's the president of Spalding Healthcare System and the senior VP of Medical Affairs Research and Education. He's also the chief of Physical Medicine Rehab at Mass General Brigham, as well as Massachusetts General Hospital and leader in the Red Sox MGH home-based program. The last two speakers, Kelly McGinnis, who's the director of our Harvard Sports Medicine Fellowship, as well as director of Mass General Brigham Women's Sports Injury Performance Clinic Program and the director of physician recruitment for Mass General Brigham Sports Medicine, as well as team physician for many of the professional teams in the Boston area. I'm an associate professor and associate chair and chief of the Division of Sports and Musculoskeletal Rehabilitation in the Harvard Department, and newly, as of the past year or two, director of the Regenerative Medicine Program for Mass General Brigham Sports Medicine. So with that, we'll start with Mr. Gasset's presentation. He was unable to join us here this morning, so he prerecorded his presentation. And the good news is you know it will end in the allotted time, because it's been prerecorded. A little bit about myself. We wanted to put this in, not that I'm not big at tuning my own horn, but I'm a physical therapist with an MBA in healthcare. I've been a PT for a long time. I've been practicing since the middle to late 80s, so that means I'm old. The other piece is that I spent 25 years in private equity. Why is that important? It's most important because I have an entrepreneurial mindset, and I've been baptized in this business world that is fast-paced. It understands how to grow something, keeping people at the top of the list, followed by compliance and quality. And that was something that was attractive to Mass General Brigham, that I had a successful track record of growing organizations, keeping the people first, compliance second, quality right after that, and obviously appropriate growth. The other piece was that we had to balance our academic mission and our research-focused missions, despite a lack of profitability right out of the gate. Now, we did not go in this, and profitability in my mind is actually fifth or sixth on the list, because we were focused on people first, and compliance and quality all had a higher place in the hierarchy. But what has been nice is because of our focus on those pieces, we are profitable, actually, and we are doing well. But it was more of a focus on making sure we had a balance between academic mission, research mission, and taking care of patients and taking care of our people, and that means our personnel, that means our physicians, our nurses, our physical therapists, our researchers, everybody within sports medicine. The other piece that we work on, and this may sound silly, but we're entity agnostic. If you worked at one particular institution, you wanted what was best for that institution, and I get that. However, but with sports medicine, we wanted what was best for the patient. And if a patient came in through one institution, but the subspecialty in sports medicine was at a different institution, it's a success for us to have that patient get to the right subspecialty. That did not always happen in the past, but now it is happening regularly and successfully now that we are. I speak very quickly, and I usually pause occasionally, but since this is a recording, it's a little bit new for me. I also want to thank my physician colleagues. These are some amazing physicians. Dr. Rasselfant, I can't thank him for all the conversations I have with him at 4.30 in the morning. It's always eye-opening, literally. Dr. Joanne Borgstein, who runs the most organized work stream within sports medicine and RegenMed. Dr. Kelly McGinnis, obviously, who is in charge of our physician recruitment within sports medicine, as well as all these other wonderful physicians that I get to work with. I'm very lucky, very blessed that I work with some of the best physicians in the world. And with that, I say thank you, have a great conference, and I know my colleagues will be able to answer questions, and they will also share my contact information if any of you want to reach out to me personally. Thank you so much. Well, you're stuck next with me. So I'm going to do my best to sort of make a case to all of you that sport concussion is something sentinely physiatric and that we shouldn't give it up. Kelly, you agree? I have a plug. And I'll tell you why. Because it is a multifactorial disease process or injury process that really takes a need to look at the whole person. So these are my disclosures. They're mostly related to the book and some SABs I'm on. So today we'll talk about defining key elements. What do you need to do to set up a program? And I think some of you here we know already have that. We want to define a process and approach and we'll discuss some obstacles. And we want to review key components and paths. So in order to define it, what you want to do, you've got to know your business. To know your business, you've got to know the definition. And in our field anyway, and I come from a brain injury medicine background with an interest in concussion for over 25 years. And that is, there's not a great definition for concussion. It still lacks. And it lacks because there isn't a clean biologic readily available tie. But we'll talk about that at the end. This is some work on really trying to define what a mild TBI and a concussion is. And either Noah Silverberg or Grant Iverson who's with our group or Alexis Icarina or myself have been leads in pieces of this. The issue is, these are all consensus documents done by Delphi Statements for the American Congress of Rehab Medicine. And you can see how many of these are in place. Either definition of a concussion, definition of a mild brain injury, or definition of what it means to have post-concussive symptomatology. So for our purposes in defining this, we really said a concussion is a mild brain injury conceptualized on the milder end of the spectrum. To make it simple for our clinical referral persons. And we said that there would be, if someone had imaging, a negative neuroimaging. Because a positive puts people in the complicated sort of mild category. Now I will tell you that's a fib on my part. Because in sport concussions, certainly for the elite people who have had neuroimaging and have microhemorrhage, we still see those people within that program. And that concussions generally have a favorable prognosis. And we'll talk a little bit about it. And I think, could we get the timer to run, our friends? Just to make sure. That it's really important that we not inculcate negative beliefs into people early on. I would say the same about some musculoskeletal problems, but I clearly would say the same about concussion. Okay. So what was the goal? The goal was that we would provide a tremendous service to the sport community throughout Massachusetts and then an end referral pace for all of New England and even beyond from a national perspective. We wanted to think about how we served our whole community. Kelly, Joanne were critical parts of this. So how do we listen? And what we did in the beginning is we went on a listening tour to our primary care physicians, our ATCs, our other elements. What was missing? What wasn't being served? Where were their access problems? How do we address those? So instead of inventing the wheel and then having everybody come, we wanted to invent it or reinvent it in a way that was more affable and available. And then a critical part of our institution, and I think in all things that we should be doing, is how do we ensure equity, inclusion, and accessibility? So I talked about that listening tour, but we also had really broad involvement. And frankly, we built it on structures we already have. We built it on our work in professional sport, and I think we're very fortunate to have both Joanne and Kelly who do a tremendous amount of work in there. High school and college networks, travel teams, where I think there's a disproportionate exposure for young people, community presence, and a large research program. So we've had a research program in concussion for a number of years building on large international and national networks. So to construct a process, we wanted to think the following. We had to have people co-located. Now we're talking about how do you build something? And we needed to know that we had medical management, and to us that's PMNR or neurology in a collaborative way. I would say that at MGB we do the majority of it. Physical therapy, neuropsychology, and we wanted to be able to think about also having co-location for people who needed neuroendocrinology, for people who needed speech and language pathology. Most importantly, as you'll hear Dr. Iaccarino and I talk about tomorrow, behavioral health, which is incredibly underestimated in this process. Autonomic assessments, visual ocular, and a really fastidious approach to diagnosis and headache. What type of headache is it? How do we do that? Building a process along that. When you're constructing something, I think it's really important for us to think about space and design. How much space do we really need? Who do we need co-located? How many square feet do you want? So to put my practical other hat on that Joanne talked about, you're going to pay for more space that makes it more challenging to cover that overhead. Who do you need with you? What do you need access to? And as you build a larger and larger program, some of that space needs to be interactive and contiguous. So we wanted linkage to specialties, but team-based care. We're very associated with physical therapy, but with a number of other entities as I said, and testing needs are really important. I would argue too. approach it as all smoosh, we get into problems. Real big ones. And that's where kids linger. You also want a program that's evidence-based, that's up-to-date, that's really following along not only with the guidelines, because the guidelines tend to trail, but following along with the innovations in care. And we'll talk a little bit at the end about my testing issues, whether that's innovating in autonomic testing, understanding what's going on with You need the actual equipment to treat people if you're going to treat them there, whether that's visual-ocular movement, challenges, perturbational testing. You can't only be sending people out for home. And if you need... Whoa, that's flashing all over the place on my screen, but that's okay. that you have those supplies and other structures available. And I touched already on the space issue. So we built really three... Mass General Brigham Presence in collaboration with our colleagues in neurology, and a Boston site to be able to serve our communities in Boston as well as locally through our own clinical care networks. So we began to approach it via the following. How do we get our primary care folks converted to sending us everybody? How do we build an emergency medicine referral network for the kids who come through the ED, where I believe that there's a structural bias to who gets to the ED, and they're a high-risk group of people? And the Seabury article that you, I'm sure, all know about, says 50% of the people who should have gotten a secondary referral from the emergency department never do. And an ATC network, and Scott and Joanne and Kelly have been critical in doing this. or Dr. Ocarina or others and make life easy for people. So really not thinking it as singularity, but multiplicity. And who are the people we want to see? in any way right away. Anyone who comes from a sport team of any kind, travel team, people who are in colleges and of course colleges and professionals the same day the next day. And the clinic was what designed to not be something. but putting them into the sport concussion clinic is going to stop up the flood. It's not practical, at least in our world. did Grand Rounds. Alexis did a New England Journal of Medicine case record that was presented to concussion, we have a problem. And knowing who you have is really your first step in being a good concussion provider and having an elite clinic. of these issues that are going on, or maybe more than peripherally, and We want to think about who has risk. And when we think about this, we think about the time since injury. Is this acute, subacute, persistent? What are their symptoms? The more symptoms, the worse somebody is going to do. Almost invariably, that holds in the literature. There are other risks. People with early headache, dizziness, fogginess, and elements of an objective cognitive problems. What are their life circumstances? You mentioned high parental stress, but did this kid have a concussion before? Was it prolonged? on, and educating people, which is the most powerful thing we have. So we divided things into uncomplicated and complicated, not to be too inordinately sophisticated, and saying people who can't return to school in four days, people with a high number of symptoms after six days. So we tried to define that. And then we looked at the people who we often get, or physiatrists typically get, and we want all of them, because we want to manage kids well, of those people who have real risk, who have other issues, who are going to need therapeutics of one kind, who have a huge number of people who are going to need therapeutics of one kind, who are going to need therapeutics or they get very, very headachy. thoughtful way that doesn't bring about nocebo effects, right, that everybody's gonna get sick forever, is really important. Lastly, let me touch quickly before Joanne gets the hook on me, on biomarkers. So, too many head CTs. 30% of the CTs that are negative are MRI positives. So when you have a real question, unless you're meeting those criteria of severe headache, nausea, loss... the future is. The future is in pupillary reflexes, in eye tracking technology, video oculography, autonomic evaluation, auditory potentials. In other words, understanding, even, even having somebody read a paragraph, if they've baseline read it, we believe we're very close to saying this person's concussed. Ecological movement assessment, and can they avoid things just in a plane, visually. And blood based biomarkers. And I think if I was going to tell every one of you where the future is, it really is in physiologic and blood based biomarkers, which now are limited in use, positive, negative CT, but I think you'll see stunning things in the next 24 months. So the finance of this, Scott talked about that a little bit. It's overhead assignment, you have to understand that. How much volume are you really going to get? What are the space costs? What does testing and recovery actually bring in, as far as therapeutic, and what procedures can be associated with this? So lastly, development is possible and critical. Interdisciplinary work is critical as well. Working with others can enhance research and function. We see this as a multidisciplinary thing that we've developed throughout our network and are now adding on New Hampshire. Thank you to Joanne and Kelly for inviting me, and I apologize for being a trace over, but Scott probably covered me. Good morning everyone. Thanks for coming to our intimate session this morning. I love being back in person. It's so great to connect with friends and with colleagues, and I'm especially thrilled and happy for our trainees who are experiencing this in-person conference for the first time. It's just really great energy this year. So I want to thank Joanne for asking me to give this talk and thank the Academy for the opportunity. I'm going to talk about developing a women's sports medicine program, if I could advance the slide. Okay, thank you So I have no disclosures except to note that this program is developing. It just recently launched So it's really not a high-powered juggernaut yet. We hope it will be someday So why women's sports medicine? Well, it's certainly good timing as we celebrate 50 years of title 9 since June of 1972 we have come a long way in terms of equity in athletic participation And this is really across sports. We still have a long way to go But we have come a long way and this is in high school athletics Collegiate athletics and we set a record for female athlete participation in the Tokyo 2020 Olympics nearing 50% female athlete participation and You know women are exercising later in life. They're exercising through a lifespan recreational sports And playing and participating in exercise at least once a week However despite this burst in Participation there has been really a paucity of science and a clear gap in our understanding of this particular population of athletes There's really a mismatch with the growth of women in sports and the science Female participants are significantly underrepresented across sports medicine journals Women represent about a third of athlete subjects in three of our main sports medicine journals over the last decade So we need to recognize that there's this sex Disparity in the literature and when we look at the current evidence base we cannot always extrapolate from the evidence that exists which is Primarily male cohorts. We know that there's different biology with our female athletes and Oftentimes female athletes are training in different environments So it's difficult to extrapolate and so this this really highlights the importance of the study of women's sports and exercise medicine and the growing and advancing field that Really needs to be built on Investigation and that is really the foundation of what what we hope to accomplish So that someday I'm I'm a team physician for Harvard Athletics And I hope that someday when I enter the Harvard training room clinic and I treat these two athletes soccer players same sport same rules same equipment that I can treat them with the same level of evidence and That when I see this female lacrosse player and this male lacrosse player I can treat them with the same level of evidence Given that their sports have differences in terms of equipment and in terms of rules for contact Lacrosse is the fastest growing sport in the US And so we need to learn more about this sport both on the men men men's side and the women's side And then this athlete who comes into clinic I want to be able to treat her with the same level of evidence as a windmill pitcher in a female specific sport Compared to her male counterpart where there is tons of evidence on his throwing mechanics and how it impacts his shoulder pathology and elbow pathology so that we can then treat this little lady who is Likely to participate in sports when she grows up and we can set her up for success So as more women participate in sports female athletes are experiencing sports related injuries at a heightened rate and The anatomy and physiology of female athletes is different than that of men requiring specialized expertise and care the national market for female sports medicine services is currently highly Fragmented and while most providers and hospital systems treat female sports medicine patients There's really a lack of a service line dedicated Exclusively to the needs of the female athlete and so we believe that the service line will be most successful With a team-based approach a multidisciplinary approach That's not that different from what Ross described as the approach to concussion one of our experts Dr. Miho Tanaka, who's at one of our female orthopedists on this project Published a blueprint for women's sports medicine program and she describes four basic pillars multidisciplinary clinical care collaborative research Education and community outreach and so we've taken these four pillars and we have built them out But you know, these aren't novel ideas. A lot of people have had these ideas This is you know, this is this is an academic program has most of the time has these pillars What makes us different right now is that we have the support of the enterprise We have the resources to make this successful and so our executive board Which Ross is a part of has identified For four leaders. I am one of them Sherry Blauette who you may have heard of Is the other physiatrist and then we have two surgeons Dr. Tanaka as well as dr. Elizabeth Mattson Who's our orthopedist from the Brigham side of a Mass General Brigham? And we really formed this core work stream And we're supported by administrative staff and a project manager Which is really essential for progress and we have weekly meetings in our first meeting We decided what we wanted to be and we came up with a vision statement as well as a mission statement So we want to provide world-class care for the female athlete Through a comprehensive multidisciplinary team approach across the continuum of care This program will provide expertise in female injury assessment recovery and injury prevention. The program will lead research education Community outreach to advance the field of women's sports medicine. So we have a vision statement We have a mission statement now we needed to get to work so we started to answer basic questions and identified our target population of Female competitive athletes as well as recreational athletes and really following women in their exercise across across their lifespan from youth to adolescence to to pregnancy to postpartum to to menopause to the Masters athlete with a comprehensive service line and What we really found incredibly productive was taking a deep dive into our current state of affairs Where we had quite a few deficits What we traditionally viewed Women's sports medicine as really a theoretical concept and we had siloed Practitioners providers that were seeing female athletes and I was one of them and I felt like oh, I've been doing women's sports medicine for years But there was no standard patient intake process There was no there was variable workflows. That was really provider specific with an Inconsistent patient experience and we really weren't supporting the journey And so what we tried to do was what we want to do is create a standalone Concrete offering that is a destination for female athletes worldwide. We want to create a replicable operating model with standardized workflows for comprehensive care with Coordination of care and targeted touch points. So we have a more consistent journey for the female athlete Throughout our program. We want to attract elite athletes from around the world We want a system first marketing approach as opposed to what we had which was really an individual institutional approach We want to increase our marketing budget to surpass our peers, which has been a big factor here And we want to educate our primary care physicians We want to increase system-wide awareness about women's sports medicine, which was really lacking And we want to create a National Center of Excellence for women's sports medicine So we developed this led to a SWOT analysis where we outlined our strengths weaknesses opportunities and threats and so from that we were able to Start to formulate a business plan, which was the first time I had ever formulated a business plan So it was a learning experience for me to say the least so we started with value proposition What was what was our what's our value to patients? We want to provide different care We want to provide world-class clinical care and we felt like we had a lot of the pieces in place in terms of expertise across our system We still plan to make make some hires and some recruits. We felt like we had the foundational pieces we wanted our patients to have access to research and innovation and As well as education and community engagement and then the value to the enterprise, which is the big pitch the big sell market differentiation Global recognition and rank we hope to create some unique opportunities for talent management and workforce development and Really we wanted to expand the brand We didn't want the footprint of women's sports medicine to be within the current footprint We wanted to expand the footprint we want to attract unique patients patients that would not have come to us otherwise and Plug them into our system and try to prevent leakage. And so we created this clinical operating model Which is a little bit of a nauseating Sort of array of concentric circles here, which is a hundred percent my responsibility But I like the visual schematic of a group of core providers Within the sports medicine service with core offerings and that includes orthopedics sports physiatry sports PT sports nutrition and sports psychology as our real core providers within sports medicine as Well as ancillary support which includes specialists from multiple different departments across Mass General Brigham Newton Wellesley Hospital all of our institutions that each have their specific niche in Providing expertise for the female athlete and can intersect with a sports medicine service and the women's sports medicine program and some aspect of their practice and so we started to assemble a group of providers a Multidisciplinary team with common goals and we were fairly particular about our invitations and What we asked in terms of clinician engagement because we didn't just want it to be clinical care we wanted to be a program and we wanted a foundation of research of investigation and so we identified Experts with a special niche or interest in treating the female athlete and we asked them for buy-in Are you interested in participating in our multidisciplinary approach? Let's tell you a little bit about the the care pathway Are you willing to expedite appointments for our athletes within two weeks? It was our ask which is not an easy ask for endocrinology tell you that because right now at Mass General It's like two to three months same for neurology, which is more like six months So that was not an easy ask and some and some of them said I just can't pull it off And so then we moved on luckily we have this, you know, this great richness of resources We asked for research engagement and collaboration We asked for active participation in quarterly meetings and willingness to participate and present at our educational conferences so we really asked for buy-in for the program not just buy-in for the patients for the clinical patients and So what we did was we assembled about 3540 right now Individuals who are interested and we're working together We're collaborating as a team and this is across institutions across departments across divisions It's a special group of of people that are really Developing this program and right now we're completing phase one where we've identified three main objectives and we've Really been able to work through our identified key results and works kind of transitioning now to phase two Which is going to be Marketing and growing patient volume and really optimizing our patient pathway, but I think it's important to create As part of the business plan We created these very specific objectives with these very specific key results so that we could meet our goals and then and then move on to the next phase and So our budget was really heavy on on the staff side and the marketing side We really had the space and the equipment so that wasn't as much as a heavy lift and so once we had the budget approved we were able to move forward with some of our critical pieces in terms of our hires and Then we began to establish key performance indicators to measure our performance over time And so we're going to measure patient athlete. I'm sorry female athlete patient volume Hopefully scholarly activities and research production coming out of our program Patient experience and satisfaction as we already do look at our length of care including the number of providers seen across disciplines the time spent within our system and trying to prevent leakage elsewhere and really promotion and retention of Talent and you know, we always talk as a group our core four of we're not girls treating girls We're experts treating female athletes And so we have a number of male surgeons and non-operative specialists from different disciplines that Really see the need for improving care in the female athlete. And so they are a vital part of our program We are not girls treating girls So, you know perhaps our most measurable Improvement will be really advancing the bar raising the bar pushing this forward And we've come a long way over the last 50 years since 1972 but we still have a long way to go in terms of equity in this area And so we're hoping to push forward the investigation So that we can provide better care for for our female athletes and we're incredibly thankful for the support that we've had from the enterprise because we all have good ideas, but enacting them really Really takes those resources. And so I just want to thank our team Sherry me ho Liz we've worked quite well together. It's been a lot of fun And we've been productive. It's going to be really fun to see how this goes And hopefully we'll we'll raise the bar. So Joanne. Thanks so much for the invitation That was great I actually learned more about your process Than before if you could put up my slides and set the timer for 15 minutes, that would be super Just to say that I don't know exactly why but there's been some troubles in the Technical realm. So mr. Gassett's talk was not seen in its entirety So I'm going to work with the folks over in the AV to make sure that it's uploaded on the website So you can get the intervening 10 or 12 minutes That were lost because I think they're really important Especially from the if you're going back and want to sell this if you will to your institutions and your health care systems They also want to see a good business plan and a well-thought-out Trajectory, so I think that will be helpful and I'll try and make sure that that becomes available I'm gonna talk about how we do this from the regenerative medicine perspective. I have no disclosures Slides are not advancing And I will say this has been a journey of years Several years to see this coming to fruition at times It's been the most exhilarating experience of my career and at times it's been the most frightening as well. There are a lot of personalities and people and geography to contend with and want to make sure that everybody Plays together nicely in the sandbox enjoys the sandbox has a piece of sand that they consider their own And feels part of something important and not marginalized So I think that's that's kind of my my take on this. It's been a learning experience For me as well Could you put up my other slide file, please? Nope, there's the long slide file. All right, take two. Thankfully, this is like my 35th year at the academy, so my pulse doesn't go up quite that much when a little technical snafu occurs. So again, I still have no disclosures. I'm just going to run through sort of how we started our journey, what process we've made. I can't believe it's been three years over the past three years in this vein and where our next steps are going as well. And, you know, again, this was an opportunity because our healthcare system rebranded to Mass General Brigham from what used to be called Partners. It was supported from the very top and the sports medicine service line across the network was deemed to be a primary value and was well supported. And then within regenerative medicine, after all the fancy consultants came, you know, the business minds came, they determined that regenerative medicine was a growth area and should be part of what we do. So thankfully, we had the right people at the right time here supporting this journey. It's very hard to make this happen on your own. That's really the bottom line. And in so doing, we went from... Yeah, I don't know, how many people here practice in a large medical center or healthcare system? Great. So not everybody. And how many do regenerative medicine? Great. So, you know, this is a tricky dance specifically for regenerative medicine because there's a lot of competing interests out there. People unfortunately see dollar signs. You have a lot of corporate entities that are trying to encroach here. So we needed to have a vision for how we take care of patients, what is unique about our brand, what's going to be unique about your brand and your institution, and how to get people... You know, it started with just our core little cocoon at Spaulding Rehab Hospital who've been doing their thing with this for many years to then expand that to the network to make sure our colleagues in orthopedics and family medicine, etcetera, emergency medicine are included in the journey, yet not dilute what we've built over so many years. And with that, we were part of this, again, this bold Mass General Brigham initiative. And our mission statement, kind of similar to Kelly's, was to advance the field of regenerative sports medicine by delivering world-class, evidence-based, and value-driven clinical care, education, and research via an interdisciplinary program. Again, we made it to the spreadsheet. You got to make it to the spreadsheet. And we made it there because we were going to differentiate ourselves from other people. We also were seen as, oh, wow, this is really cool. This will support the joint preservation folks. This will support the arthroplasty folks. This helps support the master's athlete program. So we were seen to have value in that way as well. And we also pulled together some of the talent that we had in the healthcare system that we weren't necessarily collaborating with one-on-one on a day-to-day basis, including surgical, non-surgical, PT, strength and conditioning, athletic trainers, our new sports performance center, which is going to open in a couple of months. The legal team, thankfully, I never knew anybody in the legal team at Mass General Brigham, but I got to know them well over the past couple of years. So there were all these people out there that we needed to bring together to help foster the program. In addition, we were fortunate enough to have the support of the Spalding Research Institute. In addition to Mass General Brigham, Sports Medicine Research Program. So we got a lot of support from the director of the research program and we've been sort of one-on-one in parallel paths working together to have this larger-than-life infrastructure to support the journey. And I'll tell you about that at the end. Our goal with the initial business plan was to double the volume of regenerative medicine procedures by 2025. And I shouldn't tell this to the marketing team because I don't want them to get lazy, but even without marketing, just over the past few years with us getting out there, telling people what we're doing, increasing the number of providers, we have doubled the number of procedures. In 2018, it was a little over 600. And last year, this past year, obviously a little dip in 2020 with the pandemic, but this past fiscal year we're projected to have over 1,300 procedures. And if you look a little more closely, the advanced procedures are not the bulk of this. The bulk of this is the bread and butter stuff that we do on a day-to-day basis. I'd love a show of hands for PRP, right, and shockwave. All right. So there's room for growth even in this room. Those are the two big ones that lead. Prolotherapy and the advanced cell therapies are only a small percentage of what we do. So then the strategy became, well, how are we going to implement this? And we put together our working team, which included our non-op leaders, our physical therapy leaders, the surgical preservation folks, surgical cartilage folks, and myself. And we started much like you would if any new program were in your purview of just seeing what people are doing across our system. Again, we knew what was going on in our department. And our department, which had, and now has 24 sports medicine docs, was spread over the entire healthcare system. That's all we knew about. So we started to get a look at what was going on in the orthopedic world, in the foot and ankle world, in the primary care, family medicine, sports medicine world. We expanded, as our network expanded, to look at what was going on north of town. That's called the North Shore, north of Boston. We included over time the folks in our sister hospital in New Hampshire, Wentworth Douglas, and we are gonna be including the folks in Western Mass too. And a lot of different practice environments and different folks doing different things. But we just wanted to know what was going on in radiology, orthopedics, et cetera. In addition, we sort of really needed to identify who we were going to be. And we know this is a competitive market because folks here, and there are obviously access issues we need to deal with, but are expecting a certain amount of concierge feel to their experience, which is not often the case in a big healthcare system where you call a call center and you get routed to the right provider. And we also needed support for distinguishing ourselves in education, training, and academic productivity. And one of our star outcomes of this, I'll tell you about in just a little bit, is a program called StarNet, which I think you'll find exciting, hopefully as much as I do. We then had the opportunity to interview people from around the world and around the country that we viewed as leaders who had done this in various forms. So we had Dr. Elisabetta Kahn, who was wonderful, from Milan, Jerry Malango, who we will give tribute to this afternoon, been so informative, and we miss him already. Other folks from HSS, from Emory, Cedars-Sinai, and we invited them via Zoom to talk to our group. We had market research done on some of the programs outside of ours in the rest of the country, looking at both academic and private practice programs, seeing what they offered, how they delivered it, what was their calling card, so that we could perhaps learn from that and perhaps make our own new model. And with that, we were able to put this information together to define our scope of practice. This has also been a labor of love. And that is, if we're going to have, like you would, across a system, across a hospital, or across your private practice, you want to ensure that folks who are waving your brand flag are doing what you would consider a good quality of care and ethical service. So we went through the rather painstaking process of standardizing all operating procedures, all patient-facing documents, so that as we implement this across the network, we take best practices that will make our program shine. So this is now available to all our providers, the protocols. We recently brought in the physical therapy team, and I did not realize I was stepping into a little bit of a political landmine, since all physical therapists do not love and embrace each other across the entire institution. And I think the good thing was, I had no idea of that when I went to talk to them all. So there was a little naivete and innocence, and I just answered the questions appropriately. So I hopefully brought them together in a nice fashion, so we have good PT that are engaged across the entire network. We also had to start somewhere with where our hubs of care are going to be. The same three, two of the three hubs are the same as the women's in concussion, and that is our center in Foxborough, which is around the Patriots Stadium, the center in Waltham, which is a bit west of town, and the center, which is a Spalding Center in Wellesley, which is a community suburb about eight to 10 miles west of Boston. And I'm proud to say, again, we're all one healthcare system, but this is one situation where the tail was kind of wagging the dog in the sense that we were sort of the smaller folks, nobody knew about us that much, and then all of a sudden they realized, you know, hey, kids, they know what they're doing, and people started sending their staff to us to get trained, and it was a nice position to be able to be in, and I don't think we would have gotten this position had it not been a system-wide endeavor, for which I am incredibly grateful. Legal. This is a specific need related to regenerative medicine. You need to stay on the right side of the FDA regulations. We certainly felt that as a major healthcare system, if they're gonna come down on anyone, they're gonna look to bring us down. So we used and utilized the Mass General Brigham Legal Network. When they realized there were very nuanced aspects of this, they brought in a very expensive outside law firm in Boston to help go over every single thing that goes into our patient-facing materials, our protocols, our marketing, et cetera, and nothing reaches our website until it's reviewed by the legal team. We also came up with a budget. I'm not gonna review all that for you now. We came up with the core services that we wanted to include in this, which I'm sure many of you do. We included under the regenerative medicine algorithms needle tenotomy and the automated devices. We include Shockwave, and we also built in pathways to get people to our surgical cartilage colleagues so that we have the full spectrum available from one service line. As these guidelines came out for responsible use, again, we probably do a lot of this already, but made sure that folks know that these are out there and we are running by the guidelines in our own use and our own conversations with patients. What are the next steps? We also just recently kind of officially launched, so we had to train over the summer the call center staff down to the verbiage of what do you say when someone calls, and they call and ask for amniotic products. Well, oh my. You don't wanna lose the patient, but you don't wanna admit, of course we're not, that we're doing that, so how do you reroute that verbiage to keep them within our system? We also have now got cell counters and special freezers, and we are sort of ready to go at these three hubs. We're in the process... A new director of outcomes research has been hired. Research assistants will be hired. So we're setting up that infrastructure to succeed. This is the decision tree that we went through, and I made this video to educate people on regenerative medicine that hopefully is doing a good job. Our website just... Or our microsite within the website just went live last week and they've worked on some articles. So sort of the marketing plan is taking off a little bit, but we're not quite there yet. We've also worked very closely with the research council, as I mentioned, and the star, the baby for this, and I have to give literally full credit to Dr. Zafon. A few meetings ago at the AAP, he said, you guys got to do what they're doing in ALS. You can't leave this stuff on the table. You need to know what you're treating, and if you're going to be leaders in the field, this is what you need to do. So we reached out to the Center for Innovation and Bioinformatics at Mass General. We started working with them a few years ago. We came up... I remember Chris Visco and I were chatting about this a few years ago. So we came up with the name StarNet, which is Sports Treatment Assessment Research Network, because we hope to be part of a network that's not just our system. And this is going to be the clinical biorepository database, outcomes research hub for all that we do going forward. It will have several components to it that we're building out now, which includes the biobank, the patient reported outcomes registry, and certain baseline information that we'll want to have, which isn't easy, moved from Epic or copied from Epic into this database so everything is in one place. You know when you deal with Epic, or don't you know, it takes a while to get everybody to talk to each other. These poor StarNet people had to hire two new people just to talk to Epic, but it's happening and they've done it. We've also standardized what outcome measures we're going to get across the network. This looks very complicated, but it won't be. The new director of outcomes research I met with last week is going to be simplifying a lot of this for us and for our patients. We standardized the measures we want to collect for the biobank and the StarNet enterprise and we got tremendous support from Mass General Brigham Sports Medicine to do this. Everybody's going to get the same equipment. And then last, but gosh, certainly not least, and probably one of the most important aspects of all of this is building up the sort of basic science and translational science component of this so that we have the appropriate people to collaborate with. And through the efforts of Dr. Zafon and our healthcare system we were able to recruit Dr. Fabricio Ambrosio who started last month and will be pivotal and the new director of our Musculoskeletal Dissevery Center. And I hope and intend to go forward with her and others in the system to advance the science. And with that I also remind people that we don't really know what we're doing in terms of the rehabilitation. We borrow from other models. So part of this, again, as you roll these out in institutions is to really look at what we're doing in terms of rehabilitation post-procedure. And we're fortunate to have collaborations across our network in addition to the MGH Institute for Health Professionals which trains our PT colleagues and the Wyss Institute for Bioengineering. So we are lucky to actually just be in Boston and reap the benefit from that. So with that, again, I apologize for the technical aspects for Mr. Gassett, but we are done with the formal presentations. I hope this is helpful and I welcome some questions from everyone here about what you're doing or any questions for any of us. Thanks for attending. Thank you. Hi. You meet your neighbors, you know. So, the prelude I'm talking on, I think, is relevant to my question, though. Again, I'm in a private practice. We're also the Department of Orthopedics for Brown University, which is a separate university from, or separate from the hospital, Lifespan, and Care New England, the hospital systems. We fall under that private-demics model. So, the thing I'm most impressed with, again, is completely separate from the clinical areas you guys are talking about, but it's just the sophistication of what you pulled off from a change initiative, from the business planning to the legal side, to the data systems that you've put in to prove your accountability and your value. You know, is private practice dead? You know, you asked how many of us are in a large system here, and only half of us put up our hands. How can we do this if we're not part of something with this level of non-revenue generating people that you've touched on, you spoke about, but I'm not sure everybody really appreciates how... What was the... I think you used the term, resource-rich. I mean, the amount of work that went into this from a business standpoint is really impressive. And how can we pull this off on a system-wide level, you know, as healthcare evolves? Thanks. Yeah, so great question. So I'll start and let my two wonderful and more learned colleagues finish. I think this was, I would be fair to say, the first... I think they devoted a lot of time to it. The question about private practice. I would say I don't have much to add to that, but within the private practice sector, right, people can do a great job. I mean we have Dave Wang there who, you know, in his private practice is sort of a model of how regenerative medicine can be delivered thoughtfully and they're, you know, they advocate in Washington, they know the legal aspects of this, their website is good and up to date and won't get them, you know, into trouble, so it doesn't necessarily and you probably have a network of PTs that you work with, so it doesn't necessarily have to be this huge, it's our mission to make it a huge academic research thing, that's what we do for our careers, but it doesn't have to be that to be a good program. There are entities now that you can contract with that will measure your outcomes for you, for not that large a fee. I can't support any one, but that you could track your own outcomes. You can put them on your website and show them to your patients. So you can do a great job with a lot of this, I think, for not a ton of money in the private practice sector and you can't go away, because all of us in healthcare benefit from the fact that there's private practice out there. Private practice goes away, I don't think we'll have much to negotiate on and I think it'll be bad for medicine in general. Yeah, just to add to that point, I mean, and Joanne's point is great. I think what we'll likely see is that there are large wonderful private entities now that are large groups and those groups will contract with analytic entities to produce some elements of their own algorithms about what produces best outcome. Hi, my name is Andrea Agasson. I'm a sports medicine at University of Michigan and I'm amazed at how much you were able to achieve in a large institution. So we have also a large institution and it's very hard to change directions or coordinate lots of different departments for anybody's particular agenda. So my question is, what do you think led to your success with this? Was it that the initiative came from up above and brought in resources or like do you have suggestions of how to get similar buy-in and actually have it go all the way to fruition for other institutions? Oh, I would just say one other thing and, you know, offline I probably could introduce you to Scott Gassett. I mean, most of these are financial analyses as well and sports, I mean, you put this great healthcare system together, you've got cardiology, you've got world class everything. Why did they pick sports medicine to make it the first priority? And Ross probably knows better than I do, but, you know, there's a lot of orthopedic surgery procedures that come off of this. There's a lot of community recognition of this brand as the place that you want to go to have your healthcare in general. So sports medicine was a little, or is, a bit of a, come on, if you will, okay, my kid got his ACL fixed here, but, wow, they have great doctors and then that spins off to family and friends. I think it was also viewed as an entree to grow the patient base, improve the market share of your institution overall and not just in sports medicine. Good morning, I'm Diane Brause at the Medical College of Wisconsin. So I just want to say thank you for a great presentation. My question really is in the business plan development and mostly on the regenerative medicine side because I think those are very different business plans to put together when one is considering a cash basis for revenue as compared to insurance based, you know, revenue. And so just curious, not necessarily to talk about the dollars and how you do it, but more how did you factor those elements into design of your business plan for this type of program, especially since it maybe could be market sensitive or region sensitive. So any high points that you could share with us, how you felt those aspects come into a business plan to show its potential impact. I can comment a little bit of this. Ross may be able to help. I feel like the ultimate accounting here, upper level, is a little bit fuzzy because we're all one big health care system, but the hospitals individually still and the entities and the locations and the practices still have to be able to turn on the lights and it's more expensive to do business at one place than another. And as we started this fiscal analysis we realized that two of our sites were grossly undercharging for the services. So I think we kind of looked at what our expenses were overall, where we were benchmarked to other entities in our region and across the country, and then how we would fund this via marketing and what we would need to support it. I was a little bit lucky in that the first budget had a huge budget for research and that was like 70 percent of the budget and the head of the research thing said, eh, I'll take them under the research budget. I'm like, okay, you can have that. That'll work nicely for our bottom line. So... And I can go over some of the particulars and I think the other little funny point is we'd like everyone across the entity to be charging the same thing for the same procedures so the person on the third floor doesn't charge less or more than the person on the fourth floor and that's a little sticky because we come to these analyses and they've been approved by the bean counters, but not everyone feels comfortable with them. And like, what is my authority to tell you and your practice how to charge for what you've been charging all along? And maybe you can help in terms of how it looks fiscally. question and comment. One, those are phenomenal. It's nice to see great people do such great work, so thank you. This comment is mainly directed at Ross. So, you enter a big institution with sports neurology maybe doing, having a mature concussion program, primary care sports medicine having a mature concussion program, and then there's PM&R. So, how do you bring those three entities together in a sense? And Kelly, you sort of spoke about this with two sports medicine, very mature programs out there. How do you bring this together as a physiatrist? We're good at team management and putting people together, but neurologists and primary care sports feel very attached to these two, this entity of concussion. We do, we do, we absolutely do. I think we've maxed out our time and then some a little bit. So I'm just grateful to see everyone. I hope you appreciated and enjoyed the course. Thank you. Thank you, guys.

sports medicine programs

healthcare system

collaboration

multidisciplinary approach

patient needs

women's sports medicine

comprehensive program

research

education

regenerative medicine

clear vision

data collection