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Altarum Institute Policy Roundtable Proceedings

Learning How Pediatric BMI Surveillance Can Lead to Approaches to Combating Childhood Obesity Cosponsored by Emory University Department of Pediatrics and Children’s Healthcare of Atlanta November 7, 2011 Emory Conference Center Atlanta, Georgia

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Learning How Pediatric BMI Surveillance Can Lead to Approaches to Combating Childhood Obesity

Table of Contents

I. Background II. Introductory Remarks III. Summary of Roundtable Presentations IV. Questions and Answers V. Appendices Appendix A: Altarum Institute Appendix B: Emory University Department of Pediatrics; Children’s Healthcare of Atlanta Appendix C: Roundtable Attendee List

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I. Background

The childhood obesity epidemic in the United States is threatening to reverse decades of improvements to human health. Rates of childhood obesity have tripled in the last three decades, and pediatric overweight and obesity have been correlated with increased risk for Type 2 Diabetes Mellitus, high blood cholesterol levels, high blood pressure, asthma, liver disease, sleep apnea, depression, and social discrimination. The burden that obesity is placing on our entire health system is also significant; annual medical costs of treating adult obesity have been estimated at $147 billion, or roughly 10% of all national health care expenditures.

The increases in childhood obesity prevalence noted above have been identified and monitored by federal surveillance systems that capture height and weight information from national-level samples of children. Body mass index (BMI), an indirect measure of body fatness calculated from height and weight, is the most widely used measurement from which population-level obesity prevalence rates are determined. Local-level data on obesity prevalence and trends are needed to ensure that prevention and treatment resources are allocated where most needed and to inform efforts to plan and evaluate interventions.

National and state datasets used to assess obesity rates have significant gaps in coverage, validity, and analytic power. Existing sources of BMI surveillance data do not allow organizations operating on the front lines of the epidemic to optimally mobilize childhood obesity prevention resources or to monitor and evaluate effects that state and local policies and interventions might have on childhood obesity rates.

One emerging model of state and local BMI surveillance uses existing registries. In registry-based BMI surveillance systems, height and weight data are collected in an ongoing and systematic manner by health care providers. Measurements are then entered into an existing public health registry, such as an immunization registry, also known as an immunization information system (IIS). The data from these systems are then available to public health authorities for monitoring obesity trends among populations and geographic areas. This model also offers other potential benefits beyond BMI surveillance, such as preventing and managing pediatric obesity by promoting the increased screening of children for obesity in the health care setting.

This Altarum Institute Health Policy Forum Roundtable examines how pediatric BMI surveillance can lead to approaches to combating childhood obesity. This discussion panel will include those in nutrition, epidemiology, behavioral health, health policy, health informatics, and pediatrics.

Speakers

Brook Belay, MD, MPH, Senior Service Fellow, Obesity Prevention and Control Branch, Division of Nutrition, Physical Activity and Obesity, Centers for Disease Control and Prevention (CDC)

Christopher Bolling, MD, Program Chairman, American Academy of Pediatrics Provisional Section on Obesity

Alyson B. Goodman, MD, MPH, Epidemic Intelligence Service Officer, Division of Nutrition, Physical Activity & Obesity, CDC

Trina Histon, PhD, Senior Manager-Clinical Process Improvement Director, Weight Management Initiative, Kaiser Permanente Care Management Institute

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Therese Hoyle, Consultant, Public Health Informatics Institute, Michigan Department of Community Health

Akaki Lekiachvili, MD, MBA, Informatics Science Section Lead, Office of Informatics and Information Resources Management, Centers for Disease Control and Prevention

Gary Urquhart, Chief, Immunization Information Systems Support Branch, National Center for Immunization and Respiratory Disease, Centers for Disease Control and Prevention

Stephanie M. Walsh, MD, Assistant Professor, Department of Pediatrics, Emory University School of Medicine

II. Introductory Remarks

Randy E. Durbin, DO, MSPH, Altarum Institute

Dr. Durbin, Altarum’s Director of Medical Epidemiology and Health Informatics as well as the lead for the Institute’s work at CDC, welcomed everyone in attendance, both in person and by webcast. He noted that Altarum is heavily engaged in all the issues that will be discussed at this roundtable, including pediatric obesity, in which the Institute recently completed a 2-year Childhood Obesity Prevention Mission Project (CHOMP). Altarum is also involved with immunization information systems integration and assisting in the pilot BMI registries in Michigan.

Dr. Durbin explained that the policy roundtables serve three purposes: (1) to stimulate our thinking and inform the broader debate on key health topics, (2) to provide an opportunity for Altarum staff to learn from leading experts in our fields of research, and (3) to have an informal opportunity to connect with clients and meet with new colleagues. He charged the presentation panelists to be bold, agitate everyone’s thinking, prescribe better policy choices, be systems thinkers, and speak about how systems need to or will change to address these issues.

III. Summary of Roundtable Presentations

Therese Hoyle, Public Health Informatics Institute, Michigan Department of Public Health

Ms. Hoyle moderated the roundtable program. She has been working with Altarum for the past 2 years on adding height and weight to the immunization registry in the Michigan project.

Ms. Hoyle introduced the seven roundtable panelists, who included representatives from CDC, Kaiser Permanente Care Management, AAP, and Children’s Healthcare of Atlanta. Ms. Hoyle explained that the presentations would start with current efforts at the national level and progress downward to the private, local level.

National Level

Brook Belay, MD, MPH, CDC

Dr. Belay is from the Division of Nutrition, Physical Activity, & Obesity at the CDC National Center for Chronic Disease Prevention & Health Promotion. He and his colleague, Dr. Goodman, presented their perspectives on improving childhood BMI surveillance with IISs and the key issues that need to be addressed.

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Dr. Belay presented data from the National Health and Nutrition Examination Survey (NHANES) that looked at the obesity prevalence among children and adolescence from 1963 to 2008. Obesity prevalence was defined by a BMI greater than the 95th percentile for age and gender and was tracked for the last several decades. The data showed that obesity has more than tripled in children and youth ages 6–19 and doubled for those ages 2–5. This gives an overall obesity prevalence of about 17% across all children nationwide. This is of particular concern because of the increased comorbidities associated with obesity, such as Type 2 Diabetes, asthma, bone health issues, and mental health issues. As these children grow into adulthood, obese children tend to become obese adults and all of these comorbidities come to the forefront; health care costs continue as well. In 2005, childhood obesity was associated with an additional $1.8 billion in medical expenses for obese children compared to non-obese children.

Dr. Belay reviewed the current systems for conducting BMI surveillance in childhood. There are currently four systems in place, each with their own limitations:

(1) The Pediatric Nutrition Surveillance System captures height and weight on children at the state level. However, it is only for low-income children under the age of 6 years.

(2) NHANES captures BMI data, as presented earlier, but only on the national level.

(3) The National Survey of Children’s Health is a survey that looks at children from birth through age 17 years. It can provide some state-level estimates on BMI; however, these data are reported by parents and introduce measures of bias and errors.

(4) The Youth Risk Behavior Surveillance System captures information on adolescents and is self-reporting by the teen, thereby presenting bias and nonfactual information.

Adding height and weight information to existing immunization systems would make for an attractive addition, given that current BMI surveillance systems do not give a complete representation. The current movement now is to add a clinical module to existing immunization registry platforms that would add BMI data gathered in the clinical setting. This adding of a clinical module to immunization registries is appealing, but there are complications on several levels to making it become a reality.

Dr. Belay spoke about the Health Information Technology for Economic and Clinical Health (HITECH) Act, passed in 2009. It seeks to increase and improve clinical care, quality, and coordination and to link that care with existing public health systems and infrastructure. It gives incentives to health care providers to use electronic health records in a meaningful way. For providers to be eligible for these incentives, they must use a core set of requirements to look at health care, quality, and coordination from patient-level interactions and data monitoring to exchanging information with public health systems, including IISs. One of the core requirements is to include measured height and weight.

IISs are population-based, confidential, and computerized information systems that collect vaccine data on all children within a geographic region. They are state and federal partnerships. The CDC would provide the funding and guidance, and states would administer and manage the system. Data can come from health care providers, health plans, state agencies, and even schools. Data can be reported by direct entry or paper, electronic, vital record, or other tracking systems. Laws governing IISs would vary by state, which would affect mandated reporting and the ability to opt in or out at the parental level. The mean annual IIS cost per state from 1998 to 2002 was between $919,000 and $1.5 million. In 2008, states participating in an IIS covered 67%–94% of all children under age 6. Adding BMI data to these platforms would bring the data to a new level. The issues in doing this are of data quality, how and what types of data would be transmitted, and how to standardize this process.

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Alyson Goodman, MD, MPH, CDC

Dr. Goodman, also from the Division of Nutrition, Physical Activity & Obesity, continued the discussion of the proposed integration of BMI data into immunization information systems and its pros and cons.

Integrating BMI and IISs could significantly improve childhood BMI surveillance by tracking measured BMI at the local level. Many organizations and government entities invest millions of dollars into child obesity prevention and treatment, but there is no real ability to track measured BMI over time in these communities. Merging BMI and IISs would fill this gap.

The integration of BMI and IISs would provide nearly census-level data. Since primarily young children receive frequent vaccines and receive frequent well-child visits, getting their height and weight during these times would provide ongoing tracking data. Older children and adolescents also visit a provider frequently enough and could be used to assess the effectiveness of public health interventions. It could also become a basis for comparison among states to see how they stand with other states. Eventually, states could assess how their interventions are working over time, and measured data could be used to have a better assessment of how we are doing as a country.

The use of IISs for BMI has the potential to improve point-of-care quality. BMI data in an electronic health record could improve a physician’s care for that patient. IISs have already improved vaccination rates, and adding BMI could be advantageous in that by tracking it at the local level, it may work its way down to the health plan level, the community level, and eventually the physician practice level and really improve point-of-care quality.

BMI data already exist in provider charts, and getting those data out of a patient’s chart in a de-identified, respectful manner would be useful for general surveillance. The AAP guideline is that BMI should be plotted at least annually for every child seen in a clinical practice. A recent survey of AAP members reports that 99% of them record height and weight at child well-visits, so the data exist.

BMI is already included in Meaningful Use criteria in HITECH. Clinicians already using electronic health records are incentivized to use BMI. However, people who work on immunizations do not know much about obesity-related issues. Funding and education would be needed to work on that gap.

Data management systems are in place. IISs are in all 50 states, five cities, and the District of Columbia. Now we need to extract and assemble all the data. Privacy and confidentiality are a huge issue, and laws differ by state. There are also financial considerations, with limited funding and the current budget climate.

There are some issues in terms of data quality to consider as well, such as elements of data missing (e.g., race, ethnicity) in some IIS data. Duplicate data are also a huge issue from records coming in from multiple sources, as well as measurement errors in BMI. Also, there would be a chance of under- or overrepresentation of specific populations, such as children who do not get vaccinations because of parent refusal, children receiving vaccinations but not reported in the state IIS, or children receiving vaccines less often (e.g., adolescents).

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Issues and Next Steps

There is currently no messaging standard for BMI data. Data leave one electronic health record and go into another electronic data repository, such as an IIS, but it could be called a health information exchange (HIE) or any sort of data repository. There is not yet a national standard for how those data will be encrypted and how the actual message is constructed. There will be a need for a collective decision on which standard to use. An implementation guide to using that standard would need to be developed so that each state does the same thing.

Synchronization of IIS reporting is an important issue. Algorithms are a point of discussion. The type of information transmitted and how often would need to be considered. How many data points are needed to have a meaningful surveillance system? Lastly, the added value to providers needs to be considered. What incentives does a provider have for contributing to a system like this?

Gary Urquhart, MPH, Centers for Disease Control and Prevention

Mr. Urquhart, from the IIS Support Branch of the CDC National Center for Immunization and Respiratory Disease, had more recent data to share from the 2009 IIS Annual Report on the number of children, by age group, participating in IISs. In 2000, the participation rate for children less than 6 years of age and with two or more immunizations was 21% nationally. In 2009, it was 77%. Today it is more than 80%. That means more than 20 million children under the age of 6 are participating in IISs. In 2009, adolescents over the age of 10 constituted 46% of the groups. Adults (over age 18), at 30 million, represented 13% of immunization information in the registry. Most efforts focus on the pediatric population, but in more recent years, actions are also being taken to record human papilloma virus (HPV) vaccinations in adolescents and pneumococcal and flu vaccinations in adults.

Fifty-six grantees— the 50 states; Washington, DC; and five other cities—are CDC Immunization Program grantees implementing the ISS. A few states do not have registries or did not report.

For the adult population, numbers for participation in IISs are aged in and may not be reliable. Most of the adults are not followed, and the followed ones are measured by provider site participation. Also, the definitions of public versus private provider sites are not always clear and change, making the reported numbers “soft.” In 2000, about 38% of public provider sites provided immunizations; by 2009, 80% did. Mr. Urquhart asserts that the higher numbers in public sites early on are due to the fact that in the mid-1990s, immunizations were being delivered predominantly by public health sites. However, also in the mid-1990s, Medicaid managed care became more popular and more private practices started providing immunizations. With the rise of the internet in the early 2000s, more provider sites became involved.

Mr. Urquhart also indicated his discomfort with adult population participation numbers because of individual practice associations (IPAs) and health plans. He stated that data from health plans could represent 20 practice sites, so data from an IPA or health plan could be aggregating provider site data, which could indicate underreporting of actual individual provider sites.

HL7 Messaging Standards

Mr. Urquhart spoke of Health Level 7 (HL7). HL7 is a volunteer, nonprofit organization involved in the development of international health care informatics interoperability standards. These standards are a framework for the exchange, integration, sharing, and retrieval of electronic health information and are the most commonly used in the world. In the 2009 data, HL7 was the messaging standards being implemented by the CDC grantees. Compliance with the standards was at about 60% at that time. It is

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currently at 80%, and the CDC goal is to have it as close to 100% as possible. It is the preferred messaging standard choice, because it is in the Meaningful Use incentive rules and saves money.

Dr. Urquhart spoke on the CDC’s IIS Sentinel Sites. They are in eight states and have high participation rates for children provider sites, where they implement and test best-practice guidelines. They produce publications and peer-reviewed literature and give presentations so that grantees constantly look at how to improve data quality. An issue that they face is that every year, 37–40 million families move, 85% within state and 15% leaving the state or country. Thus, obtaining consistent, consolidated history for a child or patient is an issue.

CDC Work and Initiatives

CDC has decided to centralize some of the vaccine procurement and distribution activities. They decided to use registries capable of doing inventory management to track the vaccines for children. Many registries want to use their IIS to implement the CDC Vaccine Tracking System (VTrckS).

Most of what CDC works on with immunization systems is supporting immunization programs and policies, improving participation of all age groups and provider sites, improving accountability and data quality, enhancing interoperability, and supporting health IT initiatives such as Meaningful Use.

Other CDC work that relates to potential for doing BMI follows:

Collaboration with the American Immunization Registry Association and the Public Health Informatics Institute on developing best practices;

Modeling of Immunization Registry Operations Workgroup, another group that works with on best practices and the many intricacies of immunization program operations;

Registries as a potential supplement for the National Immunization Survey in the future;

Sentinel Sites working on addressing gaps in IIS literature, enhancing data for use for public health action, doing work around rotavirus or HPV, data quality improvement, and record level analysis;

IIS functionality to better support immunization program, VTrckS activity, and interoperability;

2D barcodes on vaccine vials for tracking immunizations and improving data quality on lot numbers and manufacturers; and

Funding grantees to implement electronic health records (EHR) and IIS interoperability to enhance it to make sure that HL7 is being used.

Some additional challenges follow:

Program ownership at the state level (systems are designed to support programs, and if programs are not invested, it will not go far);

No BMI messaging standards;

Administrative barriers, including privacy and confidentiality; and

Funding.

Akaki Lekiachvili, MD, MBA, CDC

Dr. Lekiachvili, from CDC’s Office of Informatics and Information Resources Management, gave an overview on the health IT landscape and current activities going on across the country.

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Health IT Overview

National Level

Policies: Meaningful Use, a CDC program that provides financial incentives to eligible providers for meaningful use of certified EHRs to meet health and efficiency objectives. It can ensure that data elements and information of interest are captured in a standardized format.

Standards: HL7 and Integrating for Health Care Enterprise (IHE). There are two groups of artifacts within HL7: the version 2.x messaging standard for exchanging information for clinical transitions and the Clinical Document Architecture (CDA) for exchanging clinical documents. Immunization registry currently uses the 2.x standard; the National Hospital Safety Network leverages CDA. Which standard will become de facto in the future remains to be seen, but most likely both will be standards.

IHE is an initiative by health care professionals and vendors. They identify a case, such as BMI reporting; look at available standards; and then define technical specifications that vendors can use to implement those communications or exchanges. Cancer registries and early hearing detection programs leverage IHE very heavily.

Framework: The National Health Information Network, which acts as a backbone for national health information infrastructure. It is a set of standards, policies, and services that enables local networks to exchange information.

State or Regional Level

There are many different kinds of networks: health information exchanges (HIE), integrated data networks, health care organizations, and regional health information organizations. Any or all of these can be part of a larger HIE.

No two HIEs are alike across the nation. The textbook definition is that an HIE provides information highway where providers, payers, labs, and pharmacies can plug in and exchange information for delivery and continuity of care.

Strategic Planning: SWOT

SWOT (Strength, Weaknesses, Opportunities, Threats) is widely used in business decisionmaking processes but applicable to any kind of venture. Dr. Lekiachvili presented a SWOT analysis for pediatric BMI surveillance:

Strengths o Recognized, controversy free, and

well defined o Other strengths adequately covered

in detail by the providers

Weaknesses o Multiple stakeholders with different

requirements

o Variations across states and communities

o Access to target populations o Existing policies and regulations

Opportunities o National and local initiatives that

can be leveraged o Technology maturity o Existing infrastructures

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o Focus on communities and interventions

o Focus on change through policy

Threats o Clearly defined requirements o Selecting and developing standards o Perceived confidentiality and

privacy issues o Provider engagement o EHR and HIE native functionalities

and being aware of requirements when defining them

o Distributed population queries—initiative to come up with new methods to remotely query separate electronic health systems and measures to come up with population-level measures

o Existing infrastructure o Uniform and meaningful adoption

of EHRs

Private Level

Trina Histon, PhD, Kaiser Permanente

Dr. Histon from the Kaiser Permanente Care Management Institute gave an overview of Kaiser. It is the country’s oldest and largest nonprofit integrated health care delivery and financing system. Headquartered in Oakland, California, it has nearly 9 million members, of whom 2 million are children. It operates in nine states and Washington, DC, with California having more than 6 million members.

The epidemic of overweight children is a large concern for Kaiser. It has a large member base that typically start out as babies, delivering about 94,000 babies a year. Kaiser’s current work on childhood obesity is called KP Health Connect. Over the past 6 years, Kaiser has implemented a $4–6 billion electronic medical record (EMR) into its system and built tools to address childhood obesity. Kaiser is looking at childhood obesity prevention from the moment of conception, starting with the pregnancy and taking mom and baby through pediatrics and that clinical pathway. It is also looking at how to do better community clinic integration, formalizing links with community partners and services and creating information and feedback loops.

So what is the clinical care delivery system’s responsibility in contributing to good health outcomes? The role of pediatricians and family practice doctors is significant in addressing childhood obesity. Pediatricians and doctors must raise awareness of child obesity among patients and their families. They calculate, review, and discuss BMI in the office; include evidence-based practices to prevention and treatment of obesity; engage in the conversation on obesity; and help to expand and improve pediatric obesity research.

Knowing the importance of capturing BMI, calculating it, and plotting it, Ms. Hinton stressed that we also need to know where to go from there. Kaiser’s EMR has built a referral mechanism and clinical evidence into the system.

Kaiser’s current work involves the following:

Defining roles and responsibilities in child obesity

Understanding our Health Employers Data Information Set (HEDIS) performance

Creating and promoting a BMI “Best Practice Alert” and “Physical Activity as a Vital Sign” in the EMR

Creating and enhancing pediatric weight SmartSets

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“T minus 9 to 2” exploratory work

Clinician communication tools—motivational interviewing

Developing and promoting multimedia programs and materials focusing on healthy shopping, prepping, and cooking

Clinic-community integration Kaiser is currently Number One in the country on the Healthcare Effectiveness Data and Information Set (HEDIS) pediatric measures:

Capture of BMI percentages

Counseling for nutrition

Counseling for physical activity o Percentage of members 2–17 years of age o Outpatient visits with the primary care provider or OB/GYN o Documentation using ICD and CPT codes o Alternative documentation with a “hybrid” method

Kaiser has enhanced electronic medical tools available in its system. When a child is seen by a pediatrician, the doctor is able to bring up the patient’s record and see the child’s BMI by age percentile. In this system, children over the 85th percentile have “best practice alerts” for doctors, who then have a cadre of clinical supports they can consider (e.g., lab tests, referral to a dietician, follow-up). The system has focused family messaging and built-in prompts that doctors can use to delve deeper into BMI surveillance or can turn off.

Another option in their system is SmartSet, a clinical template that contains everything that would need to happen in a well-child visit. The record has tests orders, immunizations, test results, patient goals, progress notes, medications, treatment and instructions for patients, and levels of service and follow-ups. The doctor has a range of diagnoses from which to choose. The system also has prevention reminders for previous prevention issues were not completed or addressed.

Thus Kaiser gives doctors many tools that build down and that doctors can actually edit. Many providers build their own SmartSets for best personal results. The system also has a questionnaire to help physicians learn what children eat on a regular basis and how often they exercise, watch TV, and so on. It also captures exercise and BMI for adults in the system, because exercise is a vital sign and becomes a journey of documentation throughout all the ages.

Kaiser’s next frontier is to look at kids and pregnancy, gestational weight gain, maternal smoking, breast feeding promotion, and more.

Christopher Bolling, MD, American Academy of Pediatrics

Dr. Bolling is a pediatrician and the national conference and exhibition chairperson for AAP. Speaking on what the medical community needs at this point from BMI registries, he emphasized that obesity management and prevention is a very young discipline. No one in pediatric weight management has ever professionally trained in it as a subspecialty. Doctors need to know whether what they are doing is useful.

Some blocks to developing a good BMI registry are problematic and unique (e.g., practitioners being penalized for using the diagnosis of obesity or overweight in a patient’s chart because it may affect insurance coverage, parental resistance to having a child labeled as overweight). Obesity and

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overweight management brings with it uncomfortable feelings and areas on both personal and legislative levels.

While thinking and talking about providers and having a part in collecting BMI data on children, Dr. Bolling mentions that we are not talking only about pediatricians but also about family medicine doctors, nurse practitioners, physician assistants, school nurses, dieticians, and public health advocates. All these people have input into creating and using immunization information systems and need to be part of the discussion of creating effective interventions and screening tools. Providers who are both imputers and utilizers of the data need to be acknowledged. AAP and pediatricians have a lot of interest in a BMI registry, because both are imputers and utilizers.

Imputers and utilizers need to see the benefits of entering the data. We expect to have data providers but often forget that we need to give them feedback on the results of our work. The success of immunization registries has been clear, as vaccines are curing preventable illnesses. For clinicians, the benefits of the work have to be seen, be an efficient process, and have feedback. Public health advocates need to have clear data that they can convey to elected officials.

There is a growing understanding of quality improvement as an important skill set for a medical provider, and the BMI registry will be critical to this. Dr. Bolling states that learning maintenance of certification and quality improvement techniques for dealing with obesity is a driver for their practices. There is a good opportunity for getting providers involved with screening for BMI percentiles and for providing the mandated nutrition and activity counseling. He stressed the need to be rigorous in measurement and strive for the very best measurements in datasets.

As a teacher and clinician, Dr. Bolling says he looks to the BMI registry to bring some organization in our understanding of what happens when we intervene with obesity and what is happening in our communities. He continued that we also need a broader understanding of what we are doing on a systems level and on a community level. As researchers and physicians, we require BMI surveillance tools that are clinically significant and validated, and there should be rigor in any BMI registry that we establish.

We need to think about where these BMI registries come from, where the information is being used and, what sorts of legal protections there will be for these data. BMI data are as important as a clinical indicator but not the be-all and end-all. Some individuals with high BMIs are truly muscular. However, BMI is a very useful measure, and maybe most of our data do not need to be linked. If we link immunization registries, we will have to figure out how those data come in as initially linked and then delinked as we talk about them on a community basis. Stephanie Walsh, MD, Children’s Healthcare of Atlanta Medical Center

Dr. Walsh spoke about the work in Georgia. Georgia started its own BMI surveillance with the Georgia Student Health and Physical Education (SHAPE) Initiative, now a Georgia law. It was piloted in five counties of the state and is now implemented in all the state’s schools systems. The law mandates annual fitness assessments in grades 1–12. It requires all schools to have certified PE teachers and meet minimum requirements for physical education by grade levels. The FitnessGram is the physical assessment being used to assess children. It involves a pacer or 1-mile run, curl-ups, push-ups, backsaver sit and reach, a one-leg routine, and height and weight assessment.

This program begins in elementary school, with children age 6 or 7 years, after the bulk of immunizations. Grades 1–3 are assessed with height and weight, but information does not have to be

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sent home; that is a limitation, because third-graders have a 24% obesity rate. After fourth and fifth grade, the numbers start to drop off, because PE is not required in middle and high school at all levels.

The FitnessGram does not use CDC body composition percentile standards, but it does use criterion reference standards. Georgia assesses risks for metabolic syndrome and also follows along the CDC BMI charts. The fitness zones fall in the 50th percentile, with the needs improvement risk at about 80% and the needs improvement high risk closer to the obesity range. General principles for using SHAPE and FitnessGram are that BMI alone and fitness assessments alone are not going to make children healthier, but everyone has personal responsibilities—parents, caregivers, schools, and businesses. All need to be stakeholders in this issue.

All data are kept within the FitnessGram data collection infrastructure. It is Family Education Rights and Privacy Act (FERPA)-certified, and the data are safe. The PE teachers conduct their tests and generate reports, and the school must figure out how to send the reports home. All children get a report that evaluates their body composition, aerobic capacity, muscle strength, and endurance, giving them a figure of which healthy zone they are in and whether they need improvement. The data are de-identified and available to the Department of Education, where a pediatrician sorts them out. Parents can bring it to their pediatricians.

Benefits to the students are that it lets them know their current health-related fitness level and helps them set any goals to improve their health. It is also a motivation to get and stay active for a lifetime. It provides the state with longitudinal data on the health-related fitness of Georgia students and helps them create policies, programs, and curricula for physical education in schools based on the objective data. Therese Hoyle, Michigan Department of Health

Ms. Hoyle wrapped up the discussion by summarizing work being done in Michigan and the Michigan Care Improvement Registry. In a recent obesity summit in Michigan, Governor Snyder spoke of his initiatives to have healthy Michigan citizens and said that obesity is the number-one initiative. He mentioned data collection and the immunization registry, and there was a mix of negative and positive press. Ms. Hoyle stressed the importance of communication. The words “track” and “tracking” are not good to use with immunizations, so we use the word “tool,” as in a tool to help in surveillance. We do monitor, but it helps providers, communities, parents, and patients.

Altarum recently put together the functional requirements for Michigan to build the height and weight module into the system. It started with an initiative from the Healthy Kids Healthy Michigan stakeholders appointed by the Governor. It was truly a stakeholder intervention that recognized that obesity in children was Michigan’s number-one problem.

The Michigan Care Improvement Registry is a tremendous tool. It has immunizations; newborn screenings; lead results; Early Periodic Screening, Diagnosis, and Treatment (EPSDT); and BMI growth charts (same as CDC’s). If you add children’s height and weight, it prompts the provider when they are overweight or overdue for an assessment. It displays counseling activities for HEDIS reporting, which was not available in the EHRs and thus was added to the registry. It is a history for a given child. Wherever they go in Michigan, the provider is a participant in it. It has the ability to streamline information to physician offices.

Following AAP recommendations, the registry has the most current data available at the practitioner’s fingertips regarding a child. If CDC or AAP issues updates, the provider can have immediate access to

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them in the registry. It is one-stop shopping for provider and clinical decision support and a great tool for parents with family support and counseling tools. In developing their registry, Michigan followed guiding principles, engaged stakeholders, planned for it physically, and planned for interoperability. It is currently waiting for administrative rules to pass. Michigan anticipates the first year to open the tool up to all providers who will participate voluntarily.

IV. Questions and Answers

Questions are fielded by moderator Therese Hoyle.

Question

Therese Hoyle, Moderator

The first question is for Brook and for CDC. We have dealt with this in Michigan and have come to a conclusion for our state, but how many data points do we capture? How many times do we capture height and weight on a child throughout the year to have effective data for surveillance? Do you know? Do you have an idea of what you would like to see in these systems?

Brook Belay, MD, MPH

Thank you for the question. So how frequently do we need to capture data for it to be effective or useful is my understanding. So I think Aly mentioned that repeatedly in the first year, it would be, for example, multiple measurements—each time a child came in. When you look at the first year of life, for example, having five or six different data points probably would not be what we are looking at across the board. I think what we would need to track—sorry, not track—what we need to use as a tool to follow BMI would be probably at least one data point throughout the course of the year. I would probably say not much more than that, at most two. And then, of course, the data points start to align more in early childhood and throughout childhood, and then we are going to come into a different problem later on in adolescence, where we are going to struggle to get one data point. So my answer would be one. I do not know if Aly wants to add anything.

Alyson Goodman, MD, MPH

We have been discussing this amongst our colleagues in research and surveillance at CDC, and that seems to be the relative consensus. An annual data point will add tremendously to what we have already. If we, for national surveillance, or even really for state surveillance—when we get into having so many data points, it becomes a surveillance system that is almost overburdened with too much data, and the process of weeding out a lot of that becomes very, very cumbersome. In past experiences with BMI surveillance, that has become quite problematic in terms of the time required to do that, so it could take multiple people—full-time jobs just to deal with that amount of data. So we are thinking along the annual lines. Of course, when we are talking about early childhood weight gain, people who are very interested in the first year of life—you do need multiple data points, and so I think that is something that we need to discuss continually to decide what is this really going to be used for in the future.

Therese Hoyle

Michigan has decided that same thing. The question the practitioners had for us as well: How much data do you want from us? And it really is just one a year, for each year of the child’s life, and that seems

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really not that much compared to the immunization data they send us today. So that really was a reasonable task of them.

Christopher Bolling, MD

When Trina and I were working on the NCQA guidelines, there was a lot of debate about “Does it have to be at a checkup? Does it have to be at anything else?” Our feelings were that it just needs to be at some point, whether that is an ill visit, a well visit, whatever—just very practical, however you can grab it, once a year.

Akaki Lekiachvili, MD, MBA

One more consideration that we discussed was, let’s say the child has been seen at 8 months since previous data points were sent. We do not know an 8-year-old child when he or she is going to be seen next, so can we afford to miss that data point at 8 months? Do we have an opportunity to go back and retrieve that data point? Because that is the closest to 1 year we are going to get, but we do not know that—when it was. So that is another consideration when designing the registry.

Question

Maeve Howett, Emory Nursing School

And I am a pediatric nurse practitioner and lactation consultant, so for the most part I would agree fewer data points would be great, except for that evidence about the acceleration of weight gain in the first year. I wonder if we couldn’t add a 6-month measure, just because that is when—going to change from exclusivity.

Comment

Bettylou Sherry, CDC

I take your point carefully, and I thought about it, and we are really talking about surveillance here. I think what you are talking about is more clinical care; it is practice, and we are honestly talking about surveillance.

Question

Neil Shulman, Emory Medical School Physician, Faculty

I have been involved in public health work as well. I think this has been an excellent series of presentations looking at defining the problem. I just want to take a minute or 2 to talk about potential ways of solving the problems, too, as far as interventions. And I know you will probably have other events where that is addressed, but there are a couple of areas. For instance, if you just look at the big picture culturally, if you are selling junk food, the more you sell, the more money you make, the more people you can hire to market your junk food. You guys are on the other side of the table, and you have to apply for grants—go through all sorts of things. You do not instantly get resources by being successful at getting people to eat less. I personally think that the food industry—you can learn from the junk food industry and how do they reach the younger population. For instance, gaming is a big thing, selective TV advertising and Internet advertising, and so forth. But you could do the same. You could have computer games where some character is grabbing for bad food and you shoot the bad food out of its hand, but if it puts

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the bad food in its mouth, then it gets bigger and bigger and it explodes. If it puts good food in its mouth, it gets more and more muscular. And I think there would be a lot of innovative ways to teach this stuff to adults and kids in an educational way.

The second thing is, I do not think we take advantage of the brainpower of the people who are obese, and I think if we get obese people against obesity and give them a voice instead of stigmatizing them, just like we did with cigarette smokers—I have been doing an independent little study. Most people who smoke cigarettes—I have not come across one who wants their kids to grow up and smoke cigarettes. So if you get obese people and you put them up front talking to kids about the problems of obesity, I think they are much more likely to hear them. I think a lot of those are very caring people and would be very good people to bring into the picture rather than excluding from the picture.

And then one other giant problem that I think has to be addressed: At Emory, we recently had a movie and a discussion among many of the faculty that the big picture of education in the country is more and more testing and more and more homework. And if I had to take the final exams that high school students have to take, I’m sure I would flunk them. Reading, writing, and arithmetic is important, but being alive is also important, and being healthy is important, and it is more important than memorizing a whole lot of stuff that you are going to forget later anyhow. And I think that is a challenge to go to the school system, but there are people within the school system who also feel strongly that it is more important, actually, that kids be healthy than they memorize physics formulas and math formulas, algebra—I don’t remember my algebra formulas. But I would much rather be alive, and I think the school system has to say what is more important: having healthy kids or this overload of testing and homework.

Therese Hoyle

I have two takeaways from what you just said, and one is a communication that I just showed you from media. I think you are right. If we could have parents and children who are obese say it is okay to have the doctors have this data to help us monitor this condition, that would help us a lot. But second—and I think I am going to refer to Stephanie on this—the school—your fit program is really excellent, but the data stops. And FERPA is our big barrier—the school privacy rights for parents for registries, but could a registry help you if we had the ability to capture that data at the school so you could see it in the office?

Stephanie Walsh, MD

To have the data would be fantastic. There is going to be something with the Department of Public Health and epidemiologists involved to make some of these data available on a bigger picture. I feel like the pediatrician is removed, but I am hoping that this is the beginning and that we will see the need for this and be able to use it in many other ways.

Therese Hoyle

Yes, because if they added one statement on their form and the parent says. “Yes, you can share these data,” then you can have it through an electronic system like a registry. So it would be just that parental consent and having the school attach to a registry to input it. So thank you. Yes, another question?

Question

Seema Csukas, MD – Georgia Department of Public Health

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Two comments. We are looking at how to capture these data from the SHAPE program through the epidemiologist at DoE. Right now we are looking at de-identified data so that we can do some targeted interventions, whether it is a school, county, school district, etc. So I think from that perspective, it becomes helpful not only for public health but also for the community themselves and for the pediatricians within that community to kind of work together to know, “Here is the data for your school system or your county or your district, and how can we use that information to target?” And what we might look at is how many grocery stores are in that community that might be at a higher BMI or how many convenience stores or how many farmers’ markets, and that might help us to target our interventions appropriately from that perspective.

The other thing: I just wanted to ask a question about immunization registries. How many states are actually capturing information data points other than immunizations on their immunization registry and BMI as well as other kinds of things? How much of a burden does that become for the primary care physician—actually their staff—in actually entering that information? Not everyone has an electronic system, and not everyone has an electronic system for all the data points that might want to be captured on an immunization registry. Currently in Georgia, all we capture is immunizations in our registry, and that is legislated, but as we look at different opportunities to capture information, that is something that we would like to look at.

Gary Urquhart, MPH

The number of states capturing other than immunization data I cannot tell you off the top of my head, but I can tell you that virtually every state captures more than just immunizations, whether it is information for HEDIS or whether it is newborn hearing assessment, metabolic screening, etc. Lead program is another one, etc. So in terms of burden on the physician, on the practice site, most kids come in for well-child visits, so they are not coming just for immunizations. They get immunizations as a part of well-child visits. There are some immunizations that are done independent of well-child visits, and those we do not get as good coverage for. So burden-wise, if they are already entering information as part of the well-child visit, it is probably not that much of a burden.

Therese Hoyle

And to expand on that, in Michigan, what we did is, the extra data we have—the EPSDT, the Medicaid data, the lab, newborn screening, newborn hearing—that is all pulled from the public health databases that we have to display to the physician the results. So there is no data entry. But BMI will be our first data entry, and that is where the physicians are saying, “Hey, let’s pull it like we do immunizations electronically.” So that is what we hope to do. Do we have any questions online?

Question

From participant - sent in through webcast

Last weekend, I tried to introduce a childhood obesity resolution at the Michigan Association of School Board. The resolution would have directed the association to work with state and national organizations to identify tools and programs for school districts to use to address the childhood obesity program. The resolution was defeated by a two-to-one margin, 100 for and 200 against, primarily because members reacted negatively to the use of the term “obese” and felt as though this would lead to segregating or stigmatizing a group of students. What are strategies to counteract this feeling by the membership?

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One of the things I was really glad to see about this particular conference is, we are talking about BMI surveillance, and I think using BMI is a great way around that. I was really encouraged and really was taking notes with your comments, Therese, about calling it a tool as opposed to a tracking system or dataset or anything else that sounds remotely nefarious. So using BMI surveillance, some of the stuff that Rudd Center put out recently on perceptions on how parents react—recently Rebecca Poole stuff has been very interesting. You are really talking about unhealthy weight status when even talking about obesity with parents, using that term instead. I did some focus groups in the past where parents say that if you use terms like “obese” and “overweight,” they prefer that to colloquial terms that are sort of where you are trying to make the term sound softer, but they really want objective data around it. If you say my child is overweight or obese, what are you using to say that? It is not an opinion of what they look like or an opinion about their lifestyle that it is really based on height and weight data, that this is more acceptable. But like I said, I think the stuff coming out of the Rudd Center more recently is even better, saying we really need to just keep the focus on healthy weight, BMI surveillance, and a tool.

Trina Histon, PhD

Chris, I just want to add a comment to that. I echo: The Rudd Center is a great place to get resources and language matters. When we think about the term “obesity,” we sort of use it in a clinical realm, but like many other clinical pieces of language, we also come up with sort of a layperson’s terminology as well, and I think this issue—because the stigma has to go and the judgment has to go, and if we all are afraid of using the word, then the stigma would persist. So I think trying to find a middle ground of using alternative language and empowering children and families—that it is really about health and getting people healthier and sort of using that framing, I think will be really important. I think our own providers try and come up with that sort of language about “It is about your health,” and it is the whole milieu of that person; it is not just their BMI or their numbers but where they are living, how active they are, how much fruit and vegetables they are getting. I think weight loss is not necessarily a behavior, but there are behaviors like being more active and eating healthy that should be part of the language that we use.

Alyson Goodman, MD, MPH

An advantage to talking about this kind of activity as surveillance, so to speak, or a tool for maintaining healthy weight—and we really are sort of walking the walk, in that we are talking about a system that would capture data on all children, not just children who were overweight or obese, so this is not a registry. I think when people think about registries, they kind of think about cancer patients or something like that, where just the ill people make it into the registry. What we are really trying to do is look at all children, and so this is a tool for helping children to maintain healthy weight so that we can study healthy kids and kids who are having issues with their weight.

Therese Hoyle

That is a very good point. There is one concern out there about using registries. What Gary was talking about, too, is the privacy and confidentiality, and that is to opt in versus the opt-out. And in Michigan, our registry is opt-out, so a parent can opt out their child if they do not want their immunizations in or the BMI. And we went round and round, because if you opt in for height and weight measurements what the parents will do is, give you all the healthy-weight children data, but then we do not have everybody’s data. So the opt-out is a much better approach to helping with data and making it a tool,

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and the parents have the option to opt out, and many do not. But the minute you put it in front of them to say, “Can we have this?”, then it scares them.

Gary Urquhart, MPH

Everything Therese said is true. Opt-in systems are much more resource intensive for parents and for public health and so on. So if you want opt out, it means you have statutory or some sort of law which puts everybody in a BMI registry or an EMR registry at birth and the parents/legislators understand how the data will be used and so on ahead of time. And all this requires a lot of investment on the part of state and local people to have a champion so that you do not sort of find out what is going to happen once the cameras are rolling and you are in a legislative meeting. So having local investment—local and state support for these things before you get going is really important.

Question

Maxine Hayes, MD, Pediatrician, State Health Office of Washington State

First of all, let me just thank Altarum and Emory for this wonderful roundtable today. Let’s get back to the surveillance as the primary tools in terms of determining what we can do to approach childhood obesity. And I would like to put on the table: One thing we have learned in Washington State about adolescence, the older kids, is that a very useful and very practical partner are the pharmacists. We know that the equivalent of the U.S .population passes through a pharmacist every 30 days, and pharmacies can actually electronically capture a lot of information. And I want us to remember them when we think about our immunization information systems. This is something we learned with the management of H1N1. And in our rural communities, the older kids—even though they may be in school, if we do not have that annual record of their BMI, the pharmacist is one place where—this might possibly be a place to get that information. So in information immunization technologies, I think we need to just think about how we can utilize them.

Brook Belay, MD, MPH

I think that is a great comment, especially with so many MinuteClinics and so forth available around the country, in and around pharmacies, for example, and Walgreen’s and so forth. I think it is a very important item to consider, especially when, for example, going back to Akaki’s comment, if you have a 14-year-old and they do not make it to the provider’s office, whoever that provider might be, but they do walk by the Walgreen’s and say, “I will get my flu shot today,” that might be your only chance to capture that patient—or that adolescent, rather. So I think it is a great idea, and it also serves to highlight the previous discussion that we really need to be careful about how we are communicating the whole purpose of this surveillance system, and you cannot have fliers or talking points for every touch point saying “registry” or “surveillance system.” It really has to be, “This is a tool to help your child, and you can learn more about how to help your child if need be or help other children by participating.”

Gary Urquhart, MPH

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The caller is right. After H1N1, we realized the importance of having pharmacists involved with immunization activities, and so we have had some meetings with the American Pharmacist Association in Washington, and pharmacists in general are very interested in participating and providing immunization. There are some turf issues here between the provider community and the pharmacy community, but with the assumption that those could get worked out in the interest of the patient, that is a very viable suggestion for both adolescence and adults.

Maxine Hayes, MD, Pediatrician and State Health Office of Washington State

And let me add that with the electronic health record, we would want the pharmacist to be able to provide that information to primary care providers. They are not the holders of it. So if it could get back to the medical record, we are still underscoring the importance of a medical home or a health home. But the point I was trying to make is, at least have another alternative for the older kids, who are not likely to be seen on a regular schedule as the younger kids are.

Question

Randy Durbin, DO, MSPH, Altarum Institute

A question for the panel and for anyone in the audience—and it is not a new one: How do we address the contrary incentives that school systems have in collecting BMI data versus the practical need to fund key extracurricular activities (for example, band) if they collect data that suggest that their system or school more specifically has a problem? Might they not be undermining their own ability to have this extra revenue stream to fund some of these activities? And the obvious culprit is vending machines as an example. How do we change the message and incent the school systems to collect data that might end up pointing the finger back them?

Trina Histon, PhD

I think Simone French, amongst others, has done really good research on the whole vending machine issue and replacing the content, even with water instead of soda, and looking at price point differences, because kids only have limited income that they bring to school, and if the water is cheaper than the soda, then they will buy the water. So it is really looking at sort of the school system and how you preserve the revenue stream if they are to continue to have vending machines, but really looking at the price points. And I think there is a good body of literature out there now that can point to how you do that, but it is sort of a perverse environment. And on one hand, you have the lack of physical activity and the food and nutrition environment in the school kind of directly going against what you are trying to do in terms of improving children’s health, and I think it is sort of not just the next battleground, but it is the current battleground—and how we engage parents in creating a healthy school environment with wellness policies that were federally mandated, and changing the culture from bake sales and cook out, and selling chocolate for revenue streams to doing something else that is healthier. I think it is a real culture shift that we need to bring in, and I think engaging the parents and actually exposing the kids to how they can be healthy and what they can do—because they often are not the ones bringing the food into the house, but it has to be on all fronts.


This is an area, too, Randy, where I think knowledge really is power, because you need those principals who have taken the leap and have done that and then had success, because the first few that started doing that really got a lot of pushback from other school principals in their district saying, “How can you

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cut your nose off to spite your face?” So I think it really is the job for those of us in the obesity community to get out there and help them understand that it is a temporary hit, but it is something that—their revenue comes back when they switch to a smart vending policy. And the fact of the matter is, kids just like to buy things, whether it is water or soda.

Question

Laurita Burley

I am Laurita Burley. I am a registered dietitian and an adjunct clinical assistant professor in family medicine. I worked with family medicine residency training programs, and one thing that I heard today (and I have heard from several) that—especially with Dr. Walsh’s comment about the parents bringing the report to the physician, and I remember Dr. Bolling speaking of the physician’s role. Having worked with residents in family medicine, when they are presented with these data, they are often overwhelmed and say, “What am I to do with this? Please come and help me.” I know we are talking surveillance, but in terms of interventions, where are we with medical education? Because in the course of the clinical visit, if the nurses, the physicians, the office staff are all addressing it and the parents are getting all of these messages about how to manage it, they are confused or they often do not come back for follow-up. Kaiser has an excellent system, but many of our facilities and institutions do not offer long-term follow-up that is necessary to intervene. Thank you.


Even one of the adages in medicine, of “First, do no harm,” is really important here, because in the state of Arkansas, the physicians were one of the groups that kind of knocked the stilts out from underneath BMI surveillance there to begin with. So the first step is to kind of get them out of the way and then to help them understand. And certainly, that is one of the functions that we try to do at the AAP. I don’t know; Stephanie, you may have some input on training physicians, too. But I think you just really identified a very, very important area for us to really address.

Stephanie Walsh, MD

We were just talking about this in the lunch line, so it is funny you should bring it up. But basically it is, yes, you do not really learn any of these counseling skills and the way to have these conversations with families in medical school. So we have had to go back and relearn them and use some techniques like motivational interviewing and trying to teach the residents early on “How do you start this conversation? How are you comfortable in yourself, and what are the tools you need to start?” That is key, because otherwise it is very overwhelming, and if you are overwhelmed as the provider, how do you expect the families to feel? So it is important that we do start there in the training years.

Therese Hoyle

That is a really valid point. And I had several physicians in Michigan who said this tool would be so helpful, Therese, because we don’t know what to say always, and we are saying, “Hey, we have this data; it came out of a state system; it is available for you,” so they use that as the first response—how they have the data, and is not that your child has health issues. As we have the data now, let’s talk about where it fits. So that is excellent in the training.

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Question

Neil Shulman, Emory Medical School Physician, Faculty

I have had the opportunity to do these kid spots on public TV that address some of these issues, where the kids are teaching me what to eat and how to behave and so forth. And I think that public television—they are called “What’s in a Doctor’s Bag?” and they play in Georgia. But I think public television is a great resource for doctors and health facilities—to work with public television and entertainers throughout the state to reach out to kids. You do not have to say in the middle of the spot, “Now turn off the television and go out. Why are you watching me?” But beyond that, I think that the public television stations throughout the country are very strong advocates for doing positive things for kids, and they are great to work with.

Therese Hoyle

I agree. I think that is a great point about public television, and I would like to wrap this up a minute with my thoughts, and then Randy is going to wrap it up. And I want to use what was stated today about the strength, weakness, opportunities, and threats. And the strengths truly are, we have these systems that are available; they just need a little tweaking. And the weaknesses: We do not have population-based data. We all know that; that is why we are here. And our opportunities really are the ability to have a tool for parents, for the community, for the provider, and we have the ability to measure a population. And the threat really just comes down to the communication part of it and how people perceive change. And if we manage everybody’s expectations, 5–10 years from now, we really could talk about this as an issue in the past. So thank you. I am going to turn this over to Randy. Thank you.

Randy Durbin, DO, MSPH, Altarum Institute

I will conclude by thanking our panelists individually and collectively. This has been an exciting first panel in Atlanta, and I think it sets the stage nicely for future opportunities in the near term to go not only from analyzing and identify what the problem is—how we figure out how to collect those data, and then what do we do with it? How do we engineer gentle interventions, and then how do we evaluate them and then circle back around in the cycle of improvement? Altarum Institute is certainly pleased to be one of the stakeholders. It is something we are very passionate about, and I look forward to engaging this group and others, both in the present and also on the Internet, as we go forward. So thank you again for the panelists.

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V. Appendices Appendix A: Altarum Institute Altarum Institute is a nonprofit health systems research and consulting organization serving government and private-sector clients. Altarum provides comprehensive research and tailored consulting services that help clients understand and solve complex systems problems that impact health and health care. Combining the analytical rigor of a research institution with the business agility of a consulting firm, the Institute is uniquely positioned to deliver practical, systems-based solutions to its clients and funders. Altarum’s nonprofit status ensures that the public interest is always preeminent in its work. Services and Offerings Altarum Institute is widely recognized for delivering research and solutions that are technically robust, pragmatic, and carefully aligned with the cultural norms of the populations being served. The Institute’s service offerings are grouped into the following six categories:

Health Research, Policy, and Analysis

Health Program Development, Management, and Evaluation

Health Care Planning, Finance, and Operations

Clinical Research Support and Pharmacovigilance

Strategic Communications and Digital Services

Conference and Meeting Services Areas of Expertise Altarum applies its service offerings across a wide array of domains in which it has developed deep expertise: • Behavioral Health • Community Health • Food Assistance and Nutrition • Geographic Information Systems and Geospatial Analysis • Health Disparities and Health Equity • Health Information Technology • HIV/AIDS • Lean Six Sigma • Military and Veterans Health • Obesity • Survey Research and Services • Women, Children, and Adolescents Altarum Institute Staff and Values With a history dating back more than 60 years, Altarum Institute offers unparalleled knowledge and practical expertise. Altarum’s more than 350 employees represent the best in health care policy, research, business and clinical process improvement, technical assistance, and program evaluation. The Institute’s staff is diverse in experience and background, but of one mind on its core values, including intellectual excellence, impeccable business ethics, and a commitment to client success. For more information, please visit http://www.altarum.org/.

http://www.altarum.org/

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Appendix B

Emory University Department of Pediatrics

At the Emory Department of Pediatrics we are committed to giving children a bright future. We provide

the highest quality state-of-the-art clinical care. What makes us different, however, is that we are also

committed to improving how we care for children through scientific research as well as training the next

generation of leaders in pediatrics. We are Georgia's largest multidisciplinary practice serving children

not only through the Emory Children's Center, but also through Emory's alliances with Children’s

Healthcare of Atlanta, Grady Memorial Hospital, Dekalb Medical Center at Hillandale and Emory

University Hospital Midtown .

For more information, please visit http://www.pediatrics.emory.edu/information/index.html

Children’s Healthcare of Atlanta

Enhancing the lives of children through excellence in patient care, research and education

At Children’s, we strive to enhance the lives of children through excellence in patient care, research and education. Whether treating an injured toddler in an emergency or supporting a teen through a series of chemotherapy treatments, we take our commitment to care for each and every child who comes through our doors very seriously. It’s through teamwork at every level of our organization and with you, the family, that we are able to achieve a high level of excellence in pediatric care.

Nearly 150 doctors at Children’s, more than any other hospital in Georgia, are included among the nation’s best doctors as listed by Best Doctors in America®. This is the world’s leading resource for patients, families and doctors seeking expert medical information and guidance to treat illnesses and injuries of all kinds. Children's is the pediatric physician teaching site for Emory University School of Medicine and Morehouse School of Medicine.

Mission, Vision and Values

Our mission at Children's is to enhance the lives of children through excellence in patient care, research

and education. We have a vision to transform pediatric healthcare and be the leading voice for the

health of Georgia's children.

Our key values:

Integrity—Being honest, ethical and committed to all we do. Respect —Appreciating all people, work and ideas Nurturing—Fostering the care, growth and development of the individual Excellence—Delivering the highest level of care and service Teamwork—Working together to achieve our goals

For more information, please visit http://www.choa.org/About-Childrens

http://www.emorychildrenscenter.org/

http://www.choa.org/

http://www.choa.org/

http://www.gradyhealthsystem.org/

http://www.dekalbmedical.org/Main/Home.aspx

http://www.emoryhealthcare.org/hospitals/euhm/

http://www.emoryhealthcare.org/hospitals/euhm/

http://www.pediatrics.emory.edu/information/index.html

http://www.med.emory.edu/

http://www.med.emory.edu/

http://www.msm.edu/HomePage.aspx

http://www.choa.org/About-Childrens

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Appendix C: Roundtable Attendee List

Name Affiliation

Brook Belay CDC, Obesity Prevention and Control Branch, Division of Nutrition, Physical Activity and Obesity

Kimberly Bellis Altarum Institute

Kevin Blocksom Altarum Institute

Christopher Bolling American Academy of Pediatrics Provisional Section on Obesity

Laurita Burley Morehouse School of Medicine

Tanesha Burley Altarum Institute

Larry Cobler Altarum Institute

Seema Csukas Georgia Department of Public Health

Ed Donaldson SuccessEHS

Randy Durbin Altarum Institute

Martelle Esposito National WIC Association

Alyson Goodman CDC, Division of Nutrition, Physical Activity & Obesity

Erica Griffin Altarum Institute

Janelle Hartman CDC

Maxine Hayes Washington State Department of Health

Patricia Heiler Michigan Department of Community Health

Trina Histon Kaiser Permanente Care Management Institute

Maeve Howett Emory University

Therese Hoyle Public Health Informatics Institute, Michigan Department of Community Health

Rick Keller Altarum Institute

Jim Lee Altarum Institute

Akaki Lekiachvili CDC, Office of Informatics and Information Resources Management

Sarah Lifsey Altarum Institute

Jennifer Mansour American Academy of Pediatrics

Jacqueline Marlette-Boras Maryland Department of Health and Mental Hygiene

Rachelle May-Gentile Altarum Institute

Ruth Morgan Altarum Institute

Zack Osgood Altarum Institute

Missy Page Georgia Department of Public Health

Heather Rindels Altarum Institute

Jennifer Roberts-Johnson Nebraska Department of Health and Human Services

Susan Salkowitz Salkowitz Associates, LLC

Amy Sheon Case Western Reserve University

Bettylou Sherry CDC

Neil Shulman Emory University

Laura Skaff Altarum Institute

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Nancy Smallwood Children’s Healthcare of Atlanta

Gary Urquhart CDC, Immunization Information Systems Support Branch, National Center for Immunization and Respiratory Disease

Stephanie Walsh Emory University School of Medicine, Department of Pediatrics

Arianne Weldon Georgia Department of Public Health

Learning How Pediatric BMI Surveillance Can Lead to Approaches to Combating …altarum.org/sites/default/files/uploaded-publication... · 2018. 10. 15. · blood cholesterol levels,

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