All right, so we have a lot of great content tonight. So I'm going to go ahead and get started in the interest of everyone's time. Welcome to our Member May session for the Pediatric Rehabilitation Council on Innovations in Pediatric Rehabilitation Medicine. I'm Elizabeth Martin, I'm the Vice Chair, I am stepping in for Kim Hartman, who unfortunately had a family emergency and wasn't able to be with us. But I just want to acknowledge she's done a lot of hard work as well as the rest of the Council on making tonight possible. So I want to give them all a chance to introduce themselves so you can put some faces with names for those who don't already know them. Becky, do you want to say hi first? Hi, I'm Becky. I am the Vice Chair of Communications. And Emily? Hi, everyone. My name is Emily Kivlehan. I am the Vice Chair of Education. And then we have Dinesh and Jeremy. Hey, everyone. I'm Dinesh. I am Jeremy. So we have a just very brief overview of some of the content that's gonna be coming up this year. And then we'll focus most of the time on our speakers tonight. So I'm going to turn it over to Emily and to Dinesh and Jeremy so they can go over this. So Emily, I'll turn it over to you for this next section. Great. So just wanted to review our current educational offerings from the community. So we kind of have a couple different segments. First is the one that I am most involved with, which is the National Lecture Series. So this is the lecture series that was started during COVID. At the beginning of COVID, Mary Dubon organized this and we have been happy to continue it. Based on some feedback, we have it at a set time, which, as you can imagine, has pros and cons. The hope was to protect for programs to be able to protect time for their trainees to be able to join the lectures. But obviously, that means it's not always the best time for everyone. But they are available online. And we actually I counted last night and we have 48 available online for asynchronous learning. So a really wonderful resource for everyone. So don't forget about that. It's on the online learning portal. And it is CME. These are CME eligible. So you just have to fill out a survey in the online learning portal to get your CME. And these are every second Tuesday at 12 o'clock Central Time. And we have a few scheduled, although actually June, we don't have anyone. So if anyone has an extra lecture to give, let us know. And then we also separately have a series that's really more targeted towards the Peds Rehab Medicine trainees. So Jeremy and Dinesh organized that and that is a lot of board level reviews, questions to help with board preparation. And then we also have a Peds Rehab Journal Club. And that one is every few months. So I will let Jeremy and Dinesh speak to those segments of our education as well. So we have a Pediatric Rehabilitation Medicine Fellowship Fair that's going to be coming up. We are going to have two sessions for prospective applicants as well as any residents to just be involved to get to know the programs. And those are going to be on June 11, and the 20th. And we are tentatively planning for those to be at 6.30pm Eastern Standard Time. And then we would also like to have a separate section on June 13, where the prospective applicants can just meet with those that have newly matched those that are in their first year of fellowship and those that are completing their fellowship, just to kind of hear their thought process on what was virtual interviews like, and just to be non-program specific on giving their journey and their feedback through that. Lecture series, I guess definitely stuff is on this slide as well. You can speak to that. But next upcoming trainee reviews series, Journal Club, July 25. Dr. Sproth and Dr. Gabler will be giving a talk on how to review and break down an article. And then on August 22, Dr. Matt Severson, I'm sorry, about if I mispronounce your name, will be giving a journal club on the topic that is TBD. We're still we're rotating Journal Club times around so that we get a mix and match of different people who can join. So looking forward to seeing everyone at all these events. Thank you. And please feel free to reach out. We put the emails down there if you're potentially interested in participating in one of these as well. Also know, this fall, we've got our PEDS day being hosted by UC San Diego, it's going to be happening on November 6. And then at the actual AAPMR Annual Assembly, we have our this is the first time we'll be having an advanced clinical focus day. So this will all be PEDS topics happening on November 7. And then we'll be having our community business meeting still waiting on the date for that. So for tonight's session, we've got some great speakers. We're going to start with a very quick five minute update on AAPMNR BOLD by Dr. Bernalde. We're going to ask to hold on questions for this that we can leave the majority of the time for our two lectures. But any questions can be directed offline. And then we'll start with there's a build for that the role of pediatric physiatrists in clinical informatics by Dr. Ashley Jaffe. And exploring a new frontier neuromuscular diagnoses on the inpatient rehab unit by Drs. Jacqueline Amura and Molly Fuentes. And then don't forget, following the lectures to go ahead and go on to the AAPMR online learning portal so you can claim your CME. So I'm going to stop sharing and turn this over to Dr. Jaffe so we can go ahead and get started. Sorry, Dr. Jaffe, Dr. Bernalde, please go ahead. Yeah, I was just gonna say I thought I was after Dr. Bernalde. Sorry. Actually, Ashley can talk if she wants. No, thanks, Elizabeth. I, I'm thrilled to have just a couple minutes of your guys time to talk about what's been going on with BOLD. It came to our, I think, collective consciousness at the last AAPMNR annual assembly that there was that disconnect between what you guys were doing and what we were trying to accomplish on BOLD and felt it would be a really good idea to spend just a few minutes catching everybody up on what's happening with BOLD. So you guys know what's in the works behind the scenes when the Academy. So for those of you who I think everybody knows what BOLD is, in this group, just to kind of read, I think, review what what BOLD, how BOLD is structured, is BOLD as a larger entity is a program sort of philosophy that the Academy has taken on now for over a decade, with the idea of advancing PMNR nationally, internationally, engaging the membership in these activities and improving advocacy. There are five practice areas within BOLD that each have their own subcommittees, BOLD subcommittees. Pediatrics is one of them. MSK is another, cancer rehab is another, rehab care continuum is another one, and then pain and spine. I think we're really, really fortunate to be able to claim one of these subcommittees as ours. I think that shows what the Academy has done for pediatric rehab over the past years, in really taking on pediatric rehab as an important element within the Academy and within what rehab is. That didn't used to be the case for those of you older docs, you know, well aware of what I'm talking about. But we do have a very important foothold now. So I'm the co-chair of the Pediatric Rehab Medicine BOLD subcommittee, along with Jolene Brandenburg. We've had the subcommittee in place now for about three to four years. We created a strategic plan for that subcommittee years ago before these practice, these sort of subcommittees developed, we all developed strategic plans within our own subcommittee. And that strategic plan has been sort of the guiding map for the Academy in advancing our specific areas. We do have a broad strategic plan within pediatric rehab. We've decided to focus most of our heavy lifting over the past few years on one of the major issues and one of the major objectives for our subcommittee, which is increasing workforce. And we're talking about that before this meeting started. And it's a really, I think, critical area for us to be addressing as a subspecialty right now. The other areas that we are addressing, to varying degrees of effort right now, because workforce has taken a pretty heavy lift for us over the past few years, the other areas we're looking at are improving medical education and pediatric rehab, whether that's within medical schools, whether that's within PM&R residency programs, whether that's in pediatric residency programs, just kind of expanding everybody's knowledge of what we do. Increasing awareness and brand value for what pediatric rehab medicine is in the healthcare landscape, improving advocacy of our brand, both at the legislative level, the insurance level, and also at the healthcare landscape level otherwise. And then really improving what we're doing based upon data and quality information. So we're addressing a number of different areas. Again, workforce has been the heaviest lift we've taken because we realized the critical nature of that. What we've seen and why this became so important to us is the recognition that although we have had a great number of fellowship programs in place since the early 2000s, our applicant numbers really have not increased that much over the past 10 to 12 years. We've sort of stagnated between about 12 and maybe 16 applicants per year. So we're not cranking out enough trainees given the increasing need for pediatric rehab services. So there's this disconnect between our training programs, the number of people we're putting out, the number of people getting certified in pediatric rehab, and the need. Obviously, there's an increasing number of kids with special needs. We're all well aware of that. There's an increasing, I think, desire for expansion of our reach. We're now getting to things such as cardiac rehab, cancer rehab, neonatal rehab, telemedicine, the demands for telemedicine to expand our reach are there as well. So there are increasing demands for our services and recognition for what we bring to the table, again, within the healthcare landscape and across the continuum of pediatric care. And of course, increasing job openings. I think last count, there were 45 plus job openings out there, and we're only producing, you know, again, 12 to 13, 14 fellows a year. So we're not producing enough people. So we've taken on workforce as the number one goal. We have collaborated over the past couple years, we have sort of, I'm going to say floundered, because we've not really known how to forward this agenda for workforce. At the same time, the ABPM&R has been working over the same issue, as has the AAP, not the American Academy of Pediatrics, the Association of Academic Physiatrists, our AAP. So because we've all been sort of, you know, tossing this idea through our heads, we decided to join forces in this past year, we developed a collaborative task force with representatives from the AAPM&R, the AAP, and the ABPM&R to really dig into this issue about workforce, and looking at ways that we can increase our numbers. I think we're looking at a lot of different models in that realm. I think the biggest one people have probably heard about and think about is increasing potential pathways into our fellowship programs. That is one thing we're looking at, that is not the sole issue we're looking at. A lot of that discussion has revolved around allowing general pediatric, categorical pediatric residents into our fellowship without doing a rehab residency. That's been something we've discussed, gosh, I'm old enough, we've been discussing that for probably 12 years now, 13 years. And as part of this larger, larger issue, larger task force agenda of looking at increasing workforce, that is one thing we're looking at discussing, not the only thing clearly. Other things we've looked at are increasing the number of double programs, double training, dual training programs, combined programs. We're looking at potential of certification programs for folks doing general PM&R, who might have an interest in pediatric rehab, where there's a need in the communities they're serving. There are a lot, again, a lot of different models we're looking at to increase our ability to take care of the kids out there. So we are about six months into the collaborative with the ABPM&R and the AAP. We've held a number of workgroup sessions with different stakeholders, including folks from pediatric subspecialties, including neurology, rheumatology, developmental, behavioral pediatrics, neurodevelopmental pediatrics to get their input. We've held workforce sessions with program directors of fellowship programs, and combined programs. So we're, and we've held, interestingly, we held a workforce session with, I'm going to call them the old guard. They were my mentors growing up in pediatric rehab, but some of the some of the, I think, pioneers in pediatric rehab, Peggy Turt, Bruce Gans, those folks, we had a session with them as well to get their thoughts on the evolution of pediatric rehab and where they felt it should be going given their vast, incredible depth of understanding of our subspecialty. So combined, we're collecting all that information, we're going to set a path forward on what we think are some of the best routes for us to begin addressing the workforce need. So that's kind of a quick and dirty update of what we're doing in bold. Again, the main thing is looking at workforce. I know that's on everybody's mind. So we're going to be addressing that formally. And looking to create some, I think some really, really nice options for us as a subspecialty to really increase our numbers. That's about all I got. We remain very active. We want input from you guys. If you have thoughts, ideas, Jolene and I are always available by email, text, whatever the case may be to run things by us and happy to chat. Thank you. That's such important work. And I know we could all talk about this for hours. We appreciate the update. And again, lots of offline opportunities to talk about that more. Sorry, Dr. Duffy, now we can upload your slides and get going. Of course, no problem. All right, hopefully we are good there. You able to see my screen? Perfect. Thank you so much. Alright, so thank you, everybody. I'm really excited to be here to talk to you a little bit about the role of the pediatric physiatrist and clinical informatics. So there's nothing to disclose. But I do want the slight disclaimer that I work at an institution that uses a single recognizable electronic medical record. So the screenshots and examples will come from that program. So the objectives tonight, first, I would like to explain the interconnectivity of quality improvement and clinical informatics. We're going to analyze two examples of high effort, high impact interventions at a single institution, and examine the emerging role of provider builders. So many of you are familiar with quality improvement, this is something that, you know, is near and dear to my heart. And there's also the field of clinical informatics. And while these feel like distinct fields, a lot of the time, the reality is there's quite a convergence between them. So as many of you know, quality improvement uses a systematic approach. And depending on your institution's flavor du jour, this could be something like a Lean Six Sigma, this could be using an IHI model, you may have an internal model, but often there is a standard model that is applied. Often you are applying the model then to try to standardize processes and structure of different components of whether it's clinical care, or whatever you're applying your quality improvement work to, you're also looking to achieve predictable results. And usually you start with some type of smart aim statement to help you set a target and try to work towards that. And finally, many things that quality improvement is addressing is really improving care delivery. Clinical informatics is similar but different. So the things that differ, this is more of an information based approach, and we're going to kind of go through using clinical decision support as a model. But you'll see that this is more about the information that's available. This also tries to evaluate and refine processes. And usually clinical informatics is focusing on improving the clinical information systems. Both the quality improvement and clinical informatics, they sort of overlap each other because they're both data driven, and both looking to improve outcomes, but going at it in a different approach. So I just want to make sure everyone is on the same page with the five rights of clinical decision support. So this is a really important tenet in clinical informatics. So it talks about giving the right information to the right person in the right format, through the right channel at the right time in the workflow. And we're going to apply this to our cases this evening. So commonly, when you're working in quality improvement frameworks, your QI project team has a multitude of ideas for different interventions or solutions. Sometimes you have quick hits and others take more time. But oftentimes you find yourself where the total amount of work that might completely improve your process is exceeding the capacity of your team. So what does a good QI person do? You build an impact effort matrix. And so for those of you who aren't familiar, you have effort on one axis and impact on the other. And oftentimes this can have different adjectives or sort of words on it, but it's the same concept. And then you try to take your ideas and you may put them on Post-it notes or in a virtual format may enter ideas into a combined PowerPoint slide. But you're trying to decide and grade all of these. So sometimes you have certain ideas for improvements that are easy effort and high impact. And these quick wins are often things that your team will tackle first. They are the easiest to achieve and you believe that they're going to have the most impact. The next section is sort of your easy effort items you come up with, but these are lower impact. And so you might consider these and if they're truly very simple, you may actually move forward with pursuing these, especially if you're really trying to make marginal or slight improvements if you've already made quite a robust improvement with a quick win. The next category is your hard items that have low impact. And these are usually the don't do. So it would be rare and probably not make a lot of sense for you to focus your efforts on these types of improvements. And then finally, you have this other blue box. These are the hard, high effort items that you believe will have high impact. And when I was doing a lot of QI work, these were my favorite initiatives. And these were the things that I really wanted an intervention to target. And I was often told this is too much work or too much build. And so I decided let's not just plan for this, but I thought that we could really build it. And so I got super interested in how some of these high impact, high effort things could actually be initiated. So I'm going to share some of these with you. So the first one is the intrathecal baclofen pump patient population. So a problem that we saw at our institution, and I am guessing that we are not the only one, is that the manual lists that we have often required a lot of active maintenance. So we were unable to view our population as a whole. There was maybe some Excel spreadsheets going on or maybe scribbles on a Post-it on somebody's desk. And also there was no easy way to be alerted to important dates like an ERI or estimated replacement interval or an alarm date for our patient. So it's time to put on your informatics hat and let's think about how you might tackle this problem. So using the five rights of clinical decision support, here's how you could apply it here. So the right information. So oftentimes we want to know, we want it to be able to see our population as a whole, as well as easily drill down to an individual patient. And we really wanted some key data points about those patients. We wanted it to be for the right person. So there are different individuals with different roles that needed to access this data. So we have a nurse that was supporting our ITV program. We have admins that may need to know things about scheduling. And then we also have the provider that wanted to know that their patients were not right up, ready for an alarm date. The right format was a unified dashboard where you could have something that updated in real time and patients would kind of fall in and fall off of the list based on whether or not they had a pump. So if somebody has a pump taken out, you don't want them to still be on your list. The right channel would be embedded in the electronic medical records so that you could access this easily when you were on your computer and not have, you know, that piece of paper that you left on your desk. And finally, the right time in the workflow. So we wanted this to be accessible at the point of care. So this is what it ended up looking like. So these columns are sortable by header, and this is just sort of a generic view of our snippet of our patient list. And at the population level, I can quickly scan for any upcoming alarm dates. You can see that those are highlighted using different color coding. We can also monitor the ERI dates for our patients to plan ahead for neurosurgery. So I could sort by that column and see if anybody is due. And then also we can look at complications at a population level. So these are items that we're entering data into at the patient level, but then it's visible in this way. Also, when I click on an individual patient, I can start to take a look at all types of different information about that patient's pump. And I do have the ability to track changes to providers over time. You can see here, you know, this patient happened to change providers for some reason within our clinic. And I can also sort of monitor their dose changes longitudinally. So I can go way back, you know, a couple of years or even further, depending on when their pump was put in, and I can kind of see the escalation of their VACLFIN dose over time in a very easy format. And there's other rows, or sorry, columns in between these screenshots. So this is just more for demonstration purposes. And so this dashboard that had certain benefits, so this automatically incorporates the patient in and out of the cohort. It's a one-stop shop for interested parties to view the data that we need. There's longitudinal data tracking in an easy-to-view format. And this was aligned with our procedure note to help decrease errors in data entry. Some of the drawbacks are that it requires accurate data entry that was from the Medtronic tablet into the EMR, so that's a limitation at the moment of the tablet not being able to directly sort of dump those numbers into our electronic medical record. And hopefully that would be something that may be possible in the future. So the next question and project that I wanted to talk about was our cerebral palsy, or CP HIP surveillance. So the problem with this, for those of you that take care of these kids, is that it's really hard to remember when to do an X-ray. So once again, let's put on our informatics hat and think about this problem. So when we look at the five rights of clinical decision support in this situation, we think about the right information. So some type of, you know, whether it's AACPDM or a different HIP surveillance screening guidelines, but I want to see those guidelines based on my specific patient at that specific age on the day that I'm seeing them. I want to know the right person, or for the right person I want to know at the time of my office visit. I don't necessarily want to see this if they're not in the office and able to get an X-ray at that time. The right format, we have a pop-up alert that's automatically linking the desired X-ray order when the X-ray is due. And in terms of the right channel, this is embedded in the electronic medical record. And then finally, the right time in the workflow, this is after the patient chart is open. So if they're pre-charting and working ahead, we don't necessarily want this to pop up and suggest an X-ray at that time. So this build is a little bit more complex, but we have a monitoring report that we built. And you can see here, this patient, what's happening is it's highlighting that this patient has never been diagnosed with cerebral palsy. So it's saying you may need to add this diagnosis or use this for information purposes only. And as you can imagine, there are other patients with different diagnoses. And sometimes we do like to use a hip screening guideline for those individuals, but it's also just available in the background. So then let's say we have added the CP diagnosis. And this is now telling me, because it knows the age and it knows the GMFCS level, that this patient in front of me is due for an X-ray. But if I have questions and I would like to understand more, I can click this link to find out more. So then we have this pop-up alert. And like, hold on, let me spin that. Okay, so I divided it in half so you could read, not turn your head sideways. And this does cascade open in a different way, but I expanded it so you could see. But essentially this is telling you up here, this patient is due for a hip X-ray and also a GMFCS level review. So we do prompt our clinicians to do a GMFCS level review at age four, age six, and age 12, just to align with the guidelines when this was built. We also have some of the orders pre-suggested. So you don't see that here because we don't have the GMFCS level entered for this fake patient that I pulled up the alert for, but you would have this pre-selected if it was indicated. But this is now giving me the chance to document. So the GMFCS level, do we have a group for hemiplegia gait pattern? And then also sometimes as a clinician, you want to override the protocol. Maybe you know something's high risk or you're worried, or maybe their family says, we want to skip screening for a year. You have the ability to kind of snooze the alert on a different timeline than what the guidelines might suggest. You also have the opportunity to defer an X-ray because you have maybe an X-ray from an abdominal film, from the ER, from a recent stomach bug or a telemedicine visit or something like that, or the family declined. And then finally you can potentially discharge the patient if they follow with like an orthopedic surgeon and they are getting all of their X-rays ordered through that, or if they've already had hip surgery. We can also track these migration percentages and document things about their hip dislocation. So the other thing we have built in is what will pop up is age-based guidance for the different GMFCS levels. So you can see this patient was 12 to 18, but if they were maybe age seven, I would have sort of different descriptive text popping up for me. And then I have documented here, there's just sort of guidelines for CFCS and max just as help guide documentation. And then once you've put in these levels, we have some different things that you can see here. So first and foremost, we have the rehab provider's GMFCS level that is entered by the clinician, but we also have a patient entered questionnaire that the parent is documenting. And additionally, if there's a GMFM score, that's also displayed for the clinician. So sometimes this gives us a lot of really great, rich information. If a family puts a different number for their child than what we might think as a clinician, it's a good talking point. We also will have the previous migration percentage data here, and then the last hip X-ray report will be displayed here for us. So if the patient is due and we already documented their GMFCS level, it will default to tell us to order. And this is the name of the film that we usually use. However, we have other providers in our multi-D clinics who like different X-ray orders. And so we have those available if needed for our nurses. So that is kind of it for the CP thing. And then the final thing that I wanted to talk about was just sort of the role of the provider builder. So it takes varying degrees of skills to actually build on behalf of your colleagues, but there's all different levels from very basic training to much more advanced degrees, much more advanced certification and training to be able to build some of the things I showed today. It's also really helpful if you have an understanding of how informatics works, because you can help implement important changes quickly. So for example, as a certified provider builder in our electronic medical record, if somebody notices, like if we hire a new attending or we have a new fellow, I can easily go into the system and modify some of the lists of people's names and make changes if there's a new phone number somewhere in addition to more important things down the road. But this sort of offloads the need of tickets to be entered for our IT colleagues to put those changes in. I also help prioritize projects that require build. So oftentimes analyst time is limited. And so it can be really helpful to have a physiatrist that understands which projects are much more high impact and much more timely than others. It's also important to have expertise to help develop some of this clinical decision support. So oftentimes you can't really give, expect somebody to build out, any sort of evidence-based guidelines into an electronic medical record or decision support system without having physician or provider expertise to help with that build. Because there's a lot of micro decisions that are made for every single line of code that they're putting in. It's also important to have the knowledge to interface with analysts on complex projects. So they'll come back and kind of tell you what's possible, but maybe you wanna ask for something different. And so it's really can be helpful to be a provider builder to have those conversations. It also improves engagement and satisfaction with the EHR to have a provider builder embedded in your division or your department or however you're set up. There's some good studies kind of looking at that. It also helps reduce burnout. If some of those little pain points and things that drive you crazy can be coded out of the system or improved, it can be really helpful. And finally, you can have a positive financial impact. So sometimes you notice that there are maybe changes in sort of billing guidelines or other types of coding things. And you can make sure that those end up in the system as well as potentially helping your providers and your division operate at the top of their effectiveness. So that was a really quick just overview of a few things. I am happy to answer questions. I will stop sharing. Hi, Dr. Jaffe. All right, we have a couple of questions that came through the chat. From Dr. Martin, for HIP surveillance, are you able to go back and search what was entered in the records retrospectively to track compliance with the tool for QI purposes? Yeah, so great question. So there is, for those of you that use, well, there's a couple of ways you can do it. So the way that we do it, we have an external sort of dashboard at the moment through an R-based dashboard that is actually looking at this on the backend. But the other way is for those of you who happen to also use Epic, there's something called Phrase Health that your institution may have partnered with that provides a data layer overlay onto Epic where you can do individual queries that kind of operate like a Google search. So I can actually look at the click rates. I can look at everybody's comments. I can actually look at sort of the, how my clinical decision support tool works in real life and kind of look at that data as well. The dashboard that we have kind of looks at how well we're doing with our screening stratified out by provider, by GMFCS level, things like that. Like you might, I sort of hypothesize that maybe, if somebody's GMFCS 5, I might do better about remembering to X-ray because it's more frequent than maybe the patient that's more intermittently needing an X-ray. So I can kind of look at the data and tease some of those things out. The next question is from Dr. Puente. Do you have support to enter all this information into the flow sheet or is this part of your clinic workflow and the physician does it during the visit? So I would say it is either the physician or the nurse. Oftentimes during our pump refills, we do have either an advanced practice provider or a nurse or potentially a fellow, somebody also, like there's often two of us basically in the room to provide extra hands and somebody can also enter that data in, but just as easily, it's a pretty quick two minute data entry to put it into a flow sheet and it will populate your note as well as your thing. Since also there is a recent thing, we are going live next week with Proctoc, which is just a new feature in Epic that will make it even easier in a pop-up button format to kind of enter some of this data. So even faster. All right, we have a few more questions. Next one is which EMR system is this because most of my current platforms don't support these types of builds. So this is Epic based. Okay, the following question is, you mentioned during a dashboard for the intrathecal back-up and pump patients and then showed screenshots from a report. Did you also make other reports on the dashboard for staff on intrathecal back-up and pumps? As someone who used to work for this EMR company on their reporting tools, good stuff. So I'm calling it a dashboard. It's an aggregated list of patients. It's healthy planet build for those of you who are aware on the backend. And so on the front end, it's run through the reporting section. I was just trying to use more sort of... I was trying not to use Epic specific language in presenting tonight, but it's the idea of aggregating patients on a unified list. And that specific build is supported by a flow sheet, but it will be smart form enabled by June 1st. So we are updating our dashboard with the changes with Epic. Yeah, and this will be the last question for now. If anyone has further questions, we can answer them after the next talk. But can this be shared across institutions that use the same EMR, or is this something that has to be built at each site? So, yes and yes. So the directions for how to build it is something that are easily shareable. And also anybody who's an Epic customer has actually... You have access through the user web to grab tools that other people build and copy them for your own institution. It's not like a copy paste kind of situation, but if you have an analyst that knows how to mine that, or you find it on the user web, you can bring that and put in a ticket or however you operate to get that built. So it is quite feasible. And I would say that the build of the CP work that I presented is on a health maintenance platform. And so that has the capability to sort of expand out to build in all of the other guidelines. We just haven't gotten there yet. I was waiting for some of the health maintenance bill to catch up to more modern data entry before we build it out. But ideally you can have a lot of this running in the background for all kinds of health maintenance issues, vitamin D screening, bone health, et cetera, all kinds of things. Thank you so much. That was fantastic. I suspect you're gonna be getting a lot of emails with questions on how we can implement these or borrow these moving forward, because this is so great for practice and improving our practice as well as just the ease of day-to-day. So we're gonna move on to our next presentation and then hopefully at the end too, we'll have additional time for lots of discussion. Does that look okay? Can you see our slides? Yes, they're currently in note mode, if that matters. Is that better? Yes, that looks perfect. Thank you. Hi, I'm Jacqueline Omura. And I'm Molly Fuentes. And we are coming to you from Seattle, Washington at Seattle Children's Hospital and affiliated with the University of Washington. And we are going to change gears and talk about Exploring a New Frontier, Neuromuscular Disorders on Inpatient Rehab. Thank you for having us. We have no financial disclosures, but our non-financial disclosures are that we are both pediatric physiatrists. And then I like to include that I am disability adjacent, so I have siblings with physical, intellectual, and mental health disabilities, including siblings who have gone through inpatient rehabilitation as children. Thank you, Dr. Fuentes. Hopefully by the end of this talk today, we will have described the successful use of inpatient rehabilitation admissions for patients with neuromuscular diagnoses and also discussed the impact of bringing some potentially non-traditional candidates or persons who are perceived as non-traditional candidates to inpatient rehab on the inpatient rehab team. So we're going to go ahead and start with some cases. And these are cases that have happened here in Seattle. I have permission to share this information from the families. Case one is a child with spinal muscular atrophy. She had three copies of SMN2 who received gene therapy or on a SEMNA gene of a Parvovec at 9 months old, also known as Zolgensma. She was 22 months at the time that we are going to be discussing. And we Zoomed her into clinic. This was during COVID. And parents were reporting that she was doing some physical therapy. She was actually starting to crawl, but very slowly and very short distances. Her tolerance for things like sitting and standing was poor, but getting a little bit better, but really just limiting developmentally appropriate play at that time. The admission goals for her were potentially to improve her crawling efficiency and also to improve her independent standing tolerance. The pertinent context of this and why we were thinking about inpatient rehab for her is she lived in an area where there was not great access to therapy. And she was getting therapy in her home about once every other week. During this time, her therapist was noting that she was gaining skills, maybe at a little bit of a faster pace than she had been previously. And so we thought to bring her to inpatient rehab to see what may happen if we did sort of up the dose of her therapy for one to two weeks. What happened during her time on inpatient rehab is that she actually made some nice improvements. So this is a table actually from a paper that we published about her in the Purple Journal looking at some of the assessment tools that are commonly used in spinal muscular atrophy. So her Hines score on admission was 19. She improved to 20 at the time of discharge. She had a 14-day stay on inpatient rehab. The other notable improvements we saw for her were in her Hammersmith functional motor skills and Hammersmith functional motor skills evaluations where she improved during her stay with us as well. These improvements on the Hammersmith scores were mostly seen in her ability to prop up on extended arms and also in her four-point kneeling. So sort of going towards some of the family's goals, which are to improve the efficiency of her crawling. We also took a look at her WeFim scores because she was on inpatient rehab and the WeFim is very important outcome measure there. And for her mobility, she also gained points from admission to discharge. And when kids are young, we look at something called the developmental functional quotient, which helps us to better understand and sort of adjust for age-appropriate differences in development and function. So she had a notable increase of nearly 10% in her developmental functional quotient as well. From a subjective standpoint, the family gave some nice feedback about her inpatient rehab stay, and they really felt like it improved their confidence with being able to kind of push her at home. It let them know sort of what her abilities were at that time and how to continue improving her skills over time. The one sort of downside of her inpatient rehab stay was that she was away from some of her family members, and so that was sort of hard from a social and emotional standpoint, though family told us they would do it again in a heartbeat. The next case is a patient with Duchenne muscular dystrophy who came to the inpatient rehab unit after a bilateral Healy's lengthening for severe plantar flexion contractures. He was 10 years old at the time of his surgery, at the time of his inpatient rehab evaluation. And sort of the decision for why he had surgery is a whole other conversation, but in short, his ankle plantar flexion contractures were about 55 degrees, which is rather severe, and really started to impact his ability to ambulate. And so the decision was made to proceed with surgery in hopes of potentially allowing him to ambulate for longer and not having those plantar flexion contractures contributing to his loss of ambulation. After surgery, he was having a significant amount of pain and anxiety, which were really impairing his ability to transfer, walk, perform any self-care skills. He had gone into surgery being a household ambulator, doing most of his self-care skills by himself, and immediately after surgery had become dependent for basically everything, and his parents were carrying him around the house. At time of admission, the things we were working towards were improving his ability to do transfers, so doing a stand-pivot transfer with minimal assistance, hopefully being able to walk with a walker around his house, and decrease his pain and anxiety behaviors with both pharmacologic and non-pharmacologic approaches. Again, this child was having a lot of kinesiophobia and just fear of bearing weight on his limbs. He was in CAF immediately following surgery, which is really common after these soft tissue releases. To give a better sense of some other things that we looked at for him in terms of his range of motion and how much his kinesiophobia was playing a role, prior to surgery, his knee extension was full, his popliteal angles were fairly tight already, and his hip extension was full bilaterally. Immediately post-op, about a week post-op, his knee extension was starting to decrease and decreased even further just over a couple of days due to the significant pain he was having. With two-week inpatient rehab stay, we were able to improve his knee extension and comfort with that, not quite all the way back to his baseline but to more of a functional level. Similar story with his popliteal angle. Those were fairly tight prior to surgery and then were consistently tight after surgery, but with an intensive stretching and weight-bearing program, we were able to improve those as well by the end of his inpatient rehab stay. A little bit of a similar story with his hip extension. I think most notably with this inpatient rehab stay were his WEFIM improvements. He came in, his mobility score was 5 out of 35, and we improved that to 16 out of 35, where he was actually participating in his transfers, really requiring just that minimal assistance and doing some short-distance walking with a walker. His self-care skills also improved significantly throughout his rehab stay from a score of 17 to 28, and his total WEFIM change was 22. This child, with his neuromuscular disorder after surgery, made some nice improvement with inpatient rehab and allowed him to go home at a lower level of assistance that he was requiring before his stay. The third case we're going to talk about is a child, a teenager with spinal muscular atrophy, lower extremity dominant. This is one of those even more rare neuromuscular disorders, but this child had quite a severe scoliosis, as you can see in the picture. It's okay. About a 51 degree curve and 78 degrees in that thoracolumbar region, a double S curve, and she had a planned fusion. After fusion, her biomechanics for transfers changed a lot. She was able to independently transfer herself prior to surgery, and she was unable to do this independently after surgery. She was also having a fair amount of discomfort, limiting the time she was spending up in her power wheelchair, which is her primary means of mobility both in the home and in the community. Her overall course was a little bit complicated with the wound assistance and needing to go back to the OR for a washout, but while she was on rehab, she did quite well. Let's see if the slides will advance. Okay, there we go. She had some nice change during her rehab course as well. You can see here that the most impacted self-care skills from her fusion were her ability to bathe herself, dress herself, and do transfers, both sort of those transfers for ADLs and also transfers for her mobility. Her mobility score changed significantly. I think it's important to point out she started as a 1 just because her tolerance was so limited prior to inpatient rehab that she really didn't want to get up into her power wheelchair and try and do this. Over the course of her rehab stay, she improved significantly, again, with her ADLs and her mobility skills. It was very important for us to have a rehab psychologist involved in her case who saw her daily to every other day while she was here to talk about some non-pharmacologic coping strategies for pain management as well as some of the anxiety that she was experiencing. She did require some pain medicines that were able to be weaned off during her inpatient rehab stay and she went home on some neuropathic agents to sort of help her and continued on some of her other baseline medicines for some of her other mental health concerns. She did really well and maintained her level of independence over the past couple of years. The last patient I'm going to talk about is another patient who had a spine fusion. This patient had a diagnosis of Charcot-Marie-Tooth disease, CMT type 1A. He had, as a result of that, bilateral severe cavo-aquinovarus ankle contractures, but he also had a Schurman kyphosis and eventually had a T2 to L3 posterior spine fusion and Ponte osteotomies. He had his spine fusion prior to his foot surgery. It's a very complex story, but partially relating to one of our foot surgeons retiring, so that couldn't happen first. He had his spine fused first. After his spine was fused and we straightened him out, he had a much more difficult time ambulating because his feet continued to look like this. He had a lot of different things going on with his biomechanics and affecting his gait. His goals prior to surgery were to help him with his ADLs and with his ambulation around the home because this had become very challenging and he was feeling extremely unstable, where he had been actually ambulating okay at home prior to his surgery. He was also having trouble with ADLs, transfers, including going to the bathroom and things like this. He was just really needing a lot more help than he had prior to surgery. We see a similar trend here where we see quite a bit of improvement during his inpatient rehab stay. He was also a stay of about two weeks where we improved his abilities to do his self-care skills more independently. We improved his ability to navigate his home environment and the community with some assistive devices and he started to work on his stairs as well. This was another case where we saw some really nice improvement with an inpatient rehab stay in these last two cases for patients with neuromuscular disorders following some orthopedic procedures. Now we're going to switch gears and talk a bit about how neuromuscular diagnoses impact the inpatient rehabilitation team. Our inpatient rehab unit is much more neuro-rehab focused, mainly acquired brain injury. The kids who aren't acquired brain injury are usually post-cancer or after STEML, so kids with CP, post-rhizotomy. When we bring patients with neuromuscular disorders, our inpatient rehab team, our therapists and the other team members often aren't as familiar with that neuromuscular disorder. They're then asking questions like, how much improvement can we expect? Does this child have inpatient level therapy goals? How much can I push this kid before I'm causing harm? They need a lot of education and preparation to really help them feel comfortable in working with the children and providing appropriate therapy. This is guidance on the safe level of activity and intensity, specifically for our kids who have Duchenne muscular dystrophy, the types of muscle contractions or movements to avoid to avoid further muscle damage. The neurocognitive changes that are associated with different types of neuromuscular disorders, so knowing which disorders are associated with autism-like features or cognitive impairment features so that the therapists are ready to meet the children where they are and our rehab psychologists and other supporting team members can be prepped to support participation in therapy and those aspects of kinesiophobia. Also, that education and preparation for the team really leads to then feasible goal setting and clear communication coming not just from the rehab physicians who are admitting the children but from all of the different team members, which lets the family know that everybody is on board and everybody is ready. Lessons learned from bringing kids with the non-traditional neuromuscular diagnoses onto the inpatient rehab unit. The first piece is just that absolute importance of acknowledging what the family and caregiver's goals are going to be for that stay. That's something that's usually happening on the outpatient setting before surgery is even happening. Especially when the kids are coming from home, knowing what very specific targets we're going to be working on. Rehab psychology is very key to optimizing the functional improvement due to kinesiophobia and other premorbid neurocognitive changes so that the children can participate optimally in the therapy activities. Our rehab psychologists provide a lot of family coaching and family guidance so that the families can feel comfortable continuing to push their children and setting up the structures for them to be successful, both on the inpatient rehab unit and then also when they return home so that they can see durable outcomes for our improvements in function. Planned orthopedic interventions really require that multidisciplinary functional assessment before the surgery happens. That's where the pediatric physiatrist can really play a role is because we can provide that anticipatory guidance on those potential changes in function and then think, is this something that can be addressed in the outpatient setting or really would an inpatient rehab stay be most appropriate for addressing those changes? Then a very important lesson learned is that we need to have a plan for non-formulary disease modifying treatments. Oftentimes this would mean having the family bring the medication from home. Our institution has pretty strict home medication policies. It needs to be unopened bottles. It needs to be clearly written. Basically, most pharmacies don't have Dysplasia Court for boys who are using that and don't want to spend the insane amount of money to get the medication. Having the families just bring it from home is the best way to go. Why should you include neuromuscular disorders on your pediatric and patient rehab units? First off, serving that broader range of diagnoses improves the team expertise so that they're ready and prepared to serve children in the future. It provides an improved availability for the full spectrum of patient and family-centered rehab options. We should be providing the services they are available. That broader patient population can increase your financial bottom line, so increasing the number of patients that you serve, more beds filled, more resources to further run your unit. And then finally, there's a lot of increased opportunity for partnership with neuromuscular care centers, which I think we take for granted sometimes since there's a strong neuromuscular program at Seattle Children's Hospital as well as a hospital-based pediatric rehabilitation unit. But not all MGA care centers have associated inpatient rehab units. Not all MGA care centers, and so this is a map that just shows where all of the Muscular Dystrophy Association care centers are located. Can't separate out adult and pediatric. We're not able or didn't have the bandwidth to go through and identify which of these centers has pediatric rehab medicine providers part of the multidisciplinary clinic and then which ones have inpatient rehab unit care. Just looking at the map, we can see that there are some gaps in overlap between care centers and inpatient rehab units. And then if we look specifically at certified Duchenne care centers, this is from Parent Project Muscular Dystrophy, there are even fewer care centers that have that overlapping expertise between the neuromuscular care and the inpatient rehab unit yet. I feel like there's a lot of opportunity for further inroads and really kind of establishing pediatric societrists as essential team members for the care of these children. And that would be getting inroads both not just with neurology but also with the orthopedic surgery colleagues who are performing the surgeries. This is basically what I was saying before, that not all care centers have affiliation with peds inpatient rehab and not all peds inpatient rehab units have affiliation with care centers. And so these are opportunities for growth, partnership, improved care, and better outcomes for the patients that we serve. Thank you, Molly. And so I think that sometimes if folks are not as familiar with or not as routinely taking care of children with neuromuscular disorders, it can be a little bit intimidating or daunting or we don't know what to do or what the limits are. And so we wanted to share a very small handful of neuromuscular pearls that we have learned or that we know about in case anyone else is thinking about trying to bring patients with neuromuscular disorders to their inpatient rehab units. So we already mentioned this a little bit, but there are several new-ish and probably more novel disease-modifying therapies or medications that are really coming from specialized pharmacies. And so if we're thinking that these children may need to come to inpatient rehab, really doing a little bit of homework beforehand and talking to families or your pharmacy to figure out how to make sure these children can stay on their medication regimen. Many of them are daily medications. Some of them you can withdraw from. Some of them are just extremely important to have so that we can make sure we maintain their function. So having a little bit of a plan for that can be extremely helpful. And then a couple of disease-specific considerations. So for our patients with Duchenne muscular dystrophy, most of them are on some type of steroid therapy. And so just keeping in the back of our minds that if they're on an inpatient rehab unit and they get sick or they need a procedure, they will likely need stress dosing of steroids. Also keeping in mind that if you're getting labs for some reason and you throw on some LFTs, those are likely going to be elevated. AST and ALT are nonspecific to liver, and so your GGT is going to be really the thing that helps you better understand if there's some sort of liver pathology happening. Similarly, creatinine levels can be unreliable in these patients and can be unreliable in other patients with neuromuscular disorders as well due to just their poor muscle bulk. And so a Cystatin C can be more reliable if you're worried about something happening with their renal function. In SMA, more classically, sort of your type 2s or what we're maybe calling more now your SITRs are at increased risk of non-ketotic hypoglycemia with prolonged NPO time. So just keeping that in mind in case a patient with SMA is on your unit or in the hospital and needs to be NPO-ed for a procedure or otherwise making sure they're getting some sort of dextrose or IV that will help them with that. Get a little bit of calories is something to keep in mind for your patients with SMA. There are other things like breathing considerations, but if they're getting sick, hopefully you'd be getting a little extra help from that from your pulmonary or sleep colleagues. We wanted to leave some time to open it up for questions. I think we have a few minutes. Open up for questions and also hear from you all about your experience if you've admitted patients at your institution who have neuromuscular disorders at your inpatient rehab unit and what was it for and what was your overall unit's experience with those cases. Thank you. Thank you for that. Two amazing talks. So we have a couple questions in the chat. Any suggestions on what needs to be presented to insurance companies to get insurance authorization to admit these patients from home or are you only able to admit immediately post-op while they're still admitted? So one of those patients was from home, two of those patients were from home and we were able to use sort of, in the patient with SMA that we brought from home, we were able to sort of demonstrate some maybe rapid change in her skills and so can we take advantage of this change and also tossing out like, and she got this million dollar drug and we have no idea what it will do so how do we optimize that? And then the patient with, you know, lots of these patients sort of have these standardized testing that are done at certain intervals and so showing sort of this is a pre-op, this is a pre-op score and this is a post-op score and how different they are, let's get them back to baseline was I think really helpful too. So that's what I would suggest. And then there's patients I think we have to be, I have learned we have to be really intentional when someone is going in for an orthopedic procedure and having those discussions beforehand and maybe advocating for our patients to stay an extra night in the hospital so we can have therapies and patient evaluate them so that we could get them into patient rehab quicker and avoid going home and losing skills. And then for the patient who had Duchenne muscular dystrophy and who had gone home, one of the compelling arguments from an insurance standpoint was his geographic location, he only had one pediatric rehab therapy clinic in his home community, he did see them once outpatient and that therapist was like, oh, I don't have the resources to move forward with treating this child and so the next nearest outpatient therapy clinic would have been like an hour and a half away and so the geographic component of it definitely I think played a role for that child and then the other child coming from home too where they just didn't have outpatient therapies available to them in their home communities. But I think the specificity of goals too and being able to very clearly state kind of what you're going to be achieving with that daily skilled therapy is key, just like with everything and it's a lot of education for the insurance companies as well too. Since a lot of resources were spent by that insurance company to do the surgery, that's another way to be like, hey, you guys just spent a bunch of money to make an outcome better, spend a little bit more to actually make it better. There's another question in the chat about how to argue for the daily physiatrist oversight medical need. I can speak to the child who had Duchenne, I was actually his inpatient attending doctor, we were making lots of medication changes to try to, we added gabapentin, we were doing lots of different things on the pharmacologic side for pain management in order to help get his knees stretched back out. There's a biomechanical issue with, because his ankles were fixed in the cast and his knees weren't extending anymore, we needed to get that knee extension back in order for him to actually be upright because he had marginal hip extensor strength. And so we were throwing pretty much the kitchen sink at him to try to get him to tolerate his knee extension exercises and his knee immobilizer braces. And so just documenting every day what we were doing for the pain management as well as kind of our general oversight with keeping on track of the therapist and making sure that we weren't doing any activities that would be causing harm and specifically documenting about that every day. The next question is, do you think this could become standard of care for these types of patients or is it really case by case? I think that we should think about it more than we do. Basically, all of my patients with neuromuscular diagnoses that may be thinking about having a spine fusion, I'm thinking about it or mentioning it in clinics because they, in my experience, and I'd love to hear from others, they just struggle after that big of a surgery or hip reconstruction to get back to their baseline and it takes them a long time. And in some of these disorders, time is literally muscle. And so we need to get them back doing what they were doing as soon as possible and in a way that feels safe to them. And also they tend to have, like probably most kids with spine fusion, a lot of pain and just fear of moving the muscles they do have. And so I do think we need to think about it more. Thank you for mentioning GTT. We've had to intervene multiple times with kids admitted for liver biopsy because of elevated OFTs. Yeah. I feel like that should be programmed into Epic for the people who use Epic. A big warning that pops up, that your patient has Duchenne muscular dystrophy. Do not biopsy their liver. What guidance did you give your therapists? Do you change typical therapy times or adjust in other ways? We, specifically for the patient with DMD, we had sort of a joint meeting with myself and Dr. Fuentes, who also is in our neuromuscular clinic, but I was sort of the primary neuromuscular provider for this child. Probably like a 45-minute meeting with just the therapist to talk about maybe the do's and don'ts or what you can do and how hard you can push him. Because I think that therapists that don't often work with kids with neuromuscular disorder sort of remember, the big thing they remember is we can't push them or we're not sure who we can push and who we cannot. And so that was a big sort of topic of discussion in that case. So I think that the other cases I do recall having correspondence with the nurses and the therapists about some sort of general guidelines and things. We did not change our typical therapy times. I think for the toddler with SMA, she had a nap, but that's not uncommon on rehab units for folks to have their naps. But you bring up a good point, like, should we have maybe tried to, or did you try and bulk his therapies in the morning but I think you'll deal with fatigue either way, potentially. Yeah, I think that what I recall, we tried to find the times for his therapy sessions where we were front-loading more of his gross motor skills and then doing his kind of more self-care skills, OT-level skills in the afternoon just so that he wasn't fatigued and that we were giving breaks throughout the day probably more intentionally than we otherwise would have. So he had some pretty firm blocks on his schedule so that he wouldn't over-fatigue. And then the rehab psychologist actually deliberately blocked out her schedule so that she could participate and do co-treats with most of his PT sessions, especially at that first week where he was starting to get to know our team and the team was getting to know him so that there was kind of optimal support for that. And so that was a heavy ask of our rehab psychologist, which actually our unit was pretty full at that time so it was not a barrier to having that level of support. Yeah, I'm just looking at this last question. Yeah, so this is my question. Yeah, so this is more like you have, a lot of times our spine surgeons are waiting until, or maybe they are new to our clinic, they have SMA, they've never gotten treatment before, baseline, their total assist for all their mobility and ADLs and then they have this big surgery and like it changes a little bit but really doesn't change enough to qualify for inpatient rehab. And I think we come up with that from a lot of our, not just neuromuscular patients but our combined rhizotomy patients, our patients who, even if they don't have CPR, functionally at a GMFCS level five and then have a big surgery. And how do you take those kids? How do you argue for that? And what are your thoughts? I think we haven't, at least on the neuromuscular side and I think that that's where the question of like, what are the goals and what's the right dose of rehab for that kid, right? And so I think those are the things that I would think about for them. I think there is a large argument for having pediatric rehab or rehab intimately involved with their post-op course to make sure their pain and positioning is being thought about in a way that addresses sort of their overall picture. But I think those do become a little bit trickier when you're thinking about like an intensive rehab program and what you're hoping to accomplish. I think that's just where our consideration of the rehab ecosystem has to come into play too and what the resources are kind of within the hospital and then within the child's home community and kind of crafting a compelling narrative if the right place within the ecosystem is the inpatient rehab unit. Which I think we usually will rely a lot on geographies just since we have some very geographically remote patient populations that we serve. And I'd say too, the shift in inpatient rehab is towards those more medically complex patients and more and more of our quote unquote simpler patients are getting shift to more intensive outpatient. So, I mean, does that geographic factor really play the biggest part then because it's harder for them to get access as opposed to trying to stay locally, trying to go to an intensive outpatient as opposed to being able to stay inpatient and get the daily oversight. Thank you. Well, Annie, I think we have one more minute. Anybody have any questions or discussion points or anything that they wanna bring up? Just wanted to maybe circle back and explain my comment in the chat. So, Epic, just for anyone who has Epic and this has been a constant frustration, they have steering boards for every primary medical specialty. Some other special interest groups and many subspecialties. So, a lot of pediatric groups have their own group. And these are the groups that actually put out all the recommendations for what is built and PM&R has zero representation. Like there is no board, it does not exist. There's a rehab therapist board. So, they have things that support inpatient rehab and all these cool things that they could then deploy to all of us. But I've been lobbying for two years to try to get a board started or to join the therapist board and expand it to just say rehab professionals. So, I put the email address in the comments. If anyone else is frustrated, I wanna serve on this board. Some of you may want to, it doesn't, it's easy to get the people, but they have to create the board so we can apply and be represented. So, highly recommend that we all like blast, maybe I'll put some details of a sample email on the Facebook group in the next couple of days so that we can like tell them that we need to be represented. So, sorry, I didn't say that before, but it's important. That's really important. And just in the context of talking about burnout too, and all the time we spent in charting, do you feel like any of these builds have reduced some of that effort or that time that you spend? So, not the two that I shared tonight, but other work that I've done. We're currently rolling out a new outpatient note to all of our physiatrists, but also I'm working on doing the new note for all of our specialists at the entire institution. So, we are looking at cutting out a lot of things. There's a lot of old billing guidelines support. There's a lot of unnecessary documentation that's happening. There's a lot of newer, smarter tools that can be used to decrease your documentation as well as share documentation amongst your team. So, there's a lot of work we're doing in that space and anyone who can use the user web can like look up our build, but otherwise maybe for a future talk, we can present on some of the stuff we're doing in that to help with wellness and decrease burnout. Or maybe we can loop you back in with the PM&R bold committee and start getting some advocacy there through a PM&R too. Well, thank you so much to everyone for joining us. Thank you to the speakers. This was incredible. We really appreciate all of this information you're presenting tonight and everyone enjoy their evening. We'll look forward to some upcoming events as we presented earlier.

Pediatric Rehabilitation Council

Dr. Jaffe

clinical informatics

neuromuscular disorders

inpatient rehabilitation

therapy approaches

medication management

psychological support

insurance authorization

interdisciplinary collaboration

EHR systems