So, next up, we have Dennis Yang, who's going to speak to us about the do's and don'ts of setting up a poem practice. He's going to share this session with Mingming Zhu from Kaiser, and they're going to talk about East Coast, West Coast, you know, what the differences are. All right, thanks, Aziz, and thank you for having me on this course. This is probably the only talk you're going to have today that is not evidence-based pretty much at all, and it's all based on my personal experience, so we're going to talk about setting up a poem program. I'm going to go over some key points during this process, from obtaining institutional support, training, developing a team, how to get started when you're trying to get your referrals, setting up your endoscopy unit, following up your patient, and throughout the talk, some tips of do's and don'ts. So, just in terms of background, I work in a private hospital. It's a university-affiliated tertiary care center of approximately 1,500 beds. I'm working exclusively in interventional endoscopy unit that serves as the main interventional endoscopy unit for 14 hospitals around me. So, why is background important? Because you want to take this into context in what I'm saying and then tailor it accordingly to your own practice. So, the first thing when setting up your poem programs, you want to identify, or in better words, demonstrate the need of poem at your institution or your endoscopy unit whatsoever. So, the first thing you want to convey is the complexity of these patients that we've already heard about. These patients require a slew of diagnostic and therapeutic tests, and you want to highlight that poem is no longer an experimental procedure. In 2022, poem is standard of care in the management of many of these patients, and an important cogwheel in terms of establishing a multidisciplinary program. So, the better you can do in conveying this is going to allow you to obtain the administrative support that you need to get launched on your program. So, why is this important? Because administrative support is necessary throughout various fronts. Somebody can obtain protected time or expenses for training and resources, including animal lab sessions. You may need to make changes to your infrastructure. You certainly are going to need expenses when it comes to equipment and devices. So, obtaining this admin support is crucial, and obviously, don't underestimate the importance of marketing as well. So, if you haven't already gotten to the stage of training, well, this is going to be obviously necessary as you're establishing your program. There's no standardized criteria for training in poem, but the ASG did put out a nice core curriculum within the past two years highlighting some cognitive and important technical aspects of the procedure, highlighting hands-on training as well on animal and human cases. We actually published a paper last year kind of outlining a blueprint for poem training among advanced endoscopy fellows that follows a similar pathway in terms of focusing on mainly didactic training in the initial phase. That cognitive component is very, very important. And then the intermediate phases, you start doing more animal models, assist on procedures, and then the last phase, start doing cases, particularly with proctorship. In this entire process, one of the dos that you want to do is to keep very good track of all your training records, of all your certificates, any procedural logs. And why is that important? It becomes very important in the step of credentialing and privileging at your institution. So, credentialing is a process in which they assess competence, privileging is the process in which they authorize you to do that procedure. So, this can vary significantly between everybody's institutions, but it generally involves them contacting previous employers, asking you to provide reference letters, and here's where those training attendance certificates are going to be key in order to back up your training and your competence during this process. If you have already been doing poem procedures, again, make sure you keep track of that. And one of my recommendations is during this process, try to be an asset. So, many hospitals, they do not have any established criteria for poem credentialing and privileging, so you can actually contribute and establish this with them and say, hey, you know, I think this is what we should do, and be an asset in this process. It may actually speed up your credentialing and privileging in your favor. So, now that you know how to do poem, you've been credentialed and privileged, should you start doing the procedures? You probably can, but I probably recommend you not to immediately. You don't want to operate on an island and then run into a problem and know that you're by yourself. So, the first thing you want to do is establish a team, have a buy-in from your colleagues. Why is this important? Because these colleagues are going to work very closely with you, including the surgeons. Many of us think that the surgeons are trying to oppose poem, but no, they are going to be referring these difficult post-heldomyotomy patients to you. So, you want to work as a team with them, especially if you run into issues. And establishing a team, not only does it provide a more comprehensive poem program, but it establishes a very strong network for referrals of patients. So, again, don't start on your own, never work by yourself. And then establishing that network is going to be key when you're trying to establish a referral system at your institution, right? So, you know, common things being common, you want to introduce yourself to your local doctors through all different means. But before you even do that, you want to have a referring physician system established. So, you don't want to reach out to your referring doctors and tell them, yes, I can start doing poems, and they start referring patients, and you have no way of handling that. That's the last thing you want to do. You want to make that process easy and have adequate support for the referral volume to take care of these patients promptly. And then you want to be available to your physician and let them understand you're not just here to do a procedure. You're here to help them before the procedure and after the procedure. So, how does it work at my institution? Whenever we get a referral for a poem, we have a checklist of items that we want to have, including esophagrams, endoscopy, manometry, and so forth. We review the cases. If any of these things are missing, we'll try to find them. If they have not been done, we try to arrange them so we have that information. Following that, I also like to see all my patients in clinic. Why is this very important? Because it gives you an opportunity to establish a report with your patient. You want to review the appropriateness of the procedure. So not all referrals are very straightforward, and some patients may not benefit from poem. So having that face-to-face contact is important. You want to use this opportunity to discuss alternatives, expectations, and long-term follow-up. Now, sometimes I'm not able to do so, so sometimes I have to do the procedure because my unit is an open-access interventional endoscopy unit. So I only do so for very straightforward procedures, and I spend the time talking to them pre-procedurally. We have made up pamphlets for our patients in which we discuss with them their expectations prior to the procedure regarding diet and also post-procedural care. Many instances, I tell my patients, you may expect to be admitted. You don't want to tell them the day they show up for the procedure and then realize they have not made any arrangements to take care of their dog or their farm animal, et cetera. So they're going to be very pissed off at you. So let them know in advance they may get admitted. And then billing and coding. Obviously, it's going to be an important component of this process. You want to anticipate these billing and coding problems. Payers are generally going to be reluctant to pay any quote-unquote experimental procedures. This used to be more of an issue when we didn't have a dedicated code. But regardless, what you see here is a letter that we have prepared at our institution that we send to all payers outlining the benefits of POAM and with data how it compares to other standard of care. By sending this letter, you oftentimes preemptively triage a lot of these patients and are able to obtain authorization. Hopefully this will be less of an issue now with dedicated CPT codes. Okay, moving on. Obviously, you want to set up your endoscopy unit. Talking to anesthesiologists and anesthesia team is crucial because if they're not familiar how to take care of these patients, every single time you do a procedure, your room turnover time is going to be extremely slow. So you want to develop a standardized protocol. Talk to them about what are the things that you're watching. And this will reduce variability if you have multiple providers. You want to have a dedicated team with your nurse and your tech, know what they're doing, know what to monitor intra-procedurally like we talked about. If the abdomen is getting distended, they may need a tap with a needle. Having a checklist is always very helpful in these scenarios. And never underestimate the importance of talking to the post-op team. That includes the nurses that are taking care of your patient in the recovery area, but also to your hospital team that may be admitting the patient. Especially nowadays in July, we have new interns, new hospitals, and so forth. In the middle of the night, you don't want them to send the patient with pneumomyelitis steinin who's asymptomatic to the cardiothoracic surgeon. So it's very, very important. So lastly, in terms of follow-up, again, I cannot stress this enough. They need a post-care. If you discharge the patient, you want to make sure that they're doing okay. Assess their symptoms. Assess for any adverse events. Educating all your referring doctors. So you may be familiar with POM. You may be familiar with what to do. But maybe not your local general GI doctor or their office. A lot of times the patients call their office, they don't even get to talk to a doctor. So you want to talk to their office of how to triage these patients, what questions they may have, and be an asset during that process. Clinical follow-up. Again, you want to make sure that the patient is enrolled in some type of surveillance for all the reasons we've already heard about. In my institution, all our POM patients participate in our RIB prospective registry. Even if you're not doing this, it may be good for you to keep track of these patients to monitor quality metrics. So again, in summary, what are the things you want to think about? You want to do this together. You cannot establish a POM referral service by yourself. You want to make it as easy as you can to referring doctors. And then a key thing is to show that you're going to be involved in the pre- and post-procedural care of your patients. This will subsequently lead to higher quality of care, patient satisfaction, as well as doctor satisfaction. And this will turn result in more institutional support for you in what you want to do for POM and other procedures. All right. Thank you very much. Questions? Any questions? Yes. Do you need to do the motility test? Do most POM providers do their own motility readings? It's half and half. A lot of patients, if they've not had motility, like I was showing you on that algorithm, so some of them may have not had any motility tests, and they had an endoscopy or an esophogram. It looks like achalasia. If they don't have the local resources and it's convenient for the patient referring doc, we'll do the test for them. Sometimes if it's a case where I reviewed it, but I get the black and white copies of the manometry, it's difficult to interpret, I may discuss these cases with my local motility doctors, especially if it's a complex scenario. I would highly recommend partnering with an expert in motility, because I tell patients I'm not making these decisions about what treatment that they should get as to avoid any bias, especially patients who may not have complete resolution of their symptoms, they're maybe not a super straightforward case. You really want that partnership, because if they have ongoing symptoms afterwards, you have some help in management. It doesn't mean that you do the procedure and then you walk away from the case. For example, I always see the patients myself a month after. I'll do the follow-up studies myself, and then have them go back and see the esophagologist. Good afternoon, everyone. I'm Ming-Xu, it's a privilege to be here today. I'm going to take you guys through how we set up our practice at a slightly different institution. I work at Kaiser Permanente in West Los Angeles. I have no disclosures. I wanted to introduce a little bit about what Kaiser Permanente's setup is. Many of you probably are familiar already and are aware, but it is one of the largest healthcare and maintenance organizations. The entire organization services about 12.6 million patients. Its concept is that it's a prepaid membership-based integrated healthcare system, where there's really no separation between the insurance provider, which is Kaiser Permanente Foundation Health Plan, and then the physician providers, which are the Permanente physicians. It's divided into geographic regions of coverage, which function very much independently under the Kaiser umbrella. The regions are Southern California, Northern California, Washington, Colorado, Hawaii, Georgia, Mid-Atlantic, and the Northwest. Then within these large regional centers, it's then further subdivided into the local medical centers. If you live in West Los Angeles, you go to Kaiser West Los Angeles. In Southern California, there's about 12 local medical centers that sees patients. Our referral base at West LA is essentially the entire encapsulated patients within Southern California KP. There's some unique advantages working within this system in terms of setting up a POEM program. Having an integrated healthcare system means that there's really no need for any preapproval or preauthorization. There's really no billing component to it because we are essentially billing ourselves. We are the insurance company. We are also the healthcare provider. We don't deal with CPT codes, the issues that come with billing for that, the way that Dennis has described with other challenges. We have an automatic built-in, very large referral base of the entire regional medical system, which covers about 4.6 million patients within Southern California. So it's a huge encashment area of patients, which is what's helpful in terms of getting that volume of referrals and that steady case volume, because it's a very rare disease to have achalasia with an incidence of 1 in 100,000. And so we need that huge encashment area to get a good volume of patients to our POEM Center. It's also an advantage in the sense that we all share the same electronic health medical record. And so the workup is extremely streamlined. It's essentially totally seamless. The prior workup in terms of the endoscopy, imaging, manometry, all of that is readily available within the electronic health record. And so there's really no faxing of information back and forth from the referring provider. And communication between us and the referring is seamless. But there are also challenges. As Dennis has referenced, there's many, many hoops to jump through in terms of building a new POEM program anywhere, and Kaiser is no exception. The first step, really, as he mentioned, is building a business case for integrating POEM internally within your institution. If you cannot make that business case to your administrative staff, your administrative leadership, the program is a nonstarter. So making sure that we presented our business case in terms of the cost to the system, to the KP system, when we were referring these patients out, when they were requesting to have POEM done inside of the Heller myotomy, and kind of literally showing them the money, the revenue that we were losing, is a huge part of our business case. And then there's capital expenditure when you're starting a POEM program. You have to consider that in terms of just the cost of the actual equipment, the electrical surgical unit that you're going to be buying, the devices that you're going to be paying for, the knives and all of that. There's capital equipment that you have to set aside money for. And then the credentialing and privileging. I echo what Dennis said 100%, which is that you cannot start a POEM program without understanding the exact details of the C&P process, because it's highly variable institution to institution. And I also echo exactly what he said, which is that you need to be at the front line of developing the credentialing criteria for POEM, because nobody at your institution will know what POEM is more than you. So if you are the one who literally, we developed the language for our credentialing and privileging. And they literally copy and pasted the language that we provided them. And so because of that, it made the process very smooth and easy for us, because we provided the language that they need to use to put their stamp of approval on the C&P process. And then the last step is probably the most enjoyable step, which is doing a roadshow to basically get buy-in from your colleagues, your referrings. So we went to the regional GI chiefs meeting, the surgical chiefs meeting, to present POEM and to make sure that our colleagues, our physician referring providers understood why we were starting this program. A huge part of our experience that led to our success is limiting the volume of referring to one center. So we established ourselves as the POEM Center. So all 12 medical centers within Southern California, as we were starting the program from the ground up, were referring their Achalasia patients to us. So we literally funneled the entire 4.6 million patient population and anyone who had Achalasia to one center. So I just want to take you a little bit through the timeline of how we set up our program. We decided to start within the context of an IRB, simply because it's a nice way to introduce the idea of a POEM program. And it just naturally integrates a lot of the components of the process within the IRB process. So privileging is included within the IRB process. We outlined the referral process that we expected. And we presented it at the technology committees and the regional chiefs committees as part of introducing this IRB process. And we started the IRB in June of 2016. Our initial goal was to recruit about 50 patients from all around Southern California to West LA. And concurrently with starting the paperwork and the administrative work, we also started doing hands-on experience, animal lab. I was lucky enough that I actually had been training POEM during my fourth year advanced endoscopy training. So I was already performing POEM after doing my fourth year training. I think that's not true of the majority of people. And so my other colleagues who do POEM had to go out to do labs like this to get that hands-on experience, which is absolutely critical. And then proctoring of initial cases. So you have to think about as you're getting your hands on, as you're getting more comfortable with your skillset, how are you gonna establish a proctor, reach out to your mentors to make sure that you have someone who can proctor your initial cases. And then ultimately we did our first live patient case in February of 2018. So the whole thing, the whole timeline took about a year and a half to go through. So the way that we set up our program is the centerpiece of that is a foregut clinic. So essentially there's three components for our foregut clinic. We have a very active motility lab where we do endoflip manometry. We have the full service of a modern motility lab. And then we have a case manager who essentially shepherds the patients from the point of referral to make sure that they had all the appropriate workup complete before they're seen in the office to the appointment, to the follow-up, to post-op recovery. So she really just manages all the administrative stuff that we don't wanna deal with in terms of taking the patient through the whole process. In terms of the physician group, there's three gastroenterologists as part of the foregut clinic. We have one motility specialist and then two advanced endoscopists, myself and Dr. Kim. And then we have a thoracic surgeon who is, it's mostly just a relationship. He's not actually in the clinic with us, but he's well invested in our program. And he's there as a backup. We've never needed him, but he's very supportive of our program. And then really we have a minimally invasive foregut surgeon who does work very closely with us because he used to do the laparoscopic killers before we actually kind of brought him into the program. So as far as our clinic workflow, as I said, our case manager essentially screens all of the referrals to make sure that the complete workup has been done before we see the patient in the consult. And she's gotten so good at it that she also prioritizes which patients get seen because we sometimes do build up a bit of a backlog where we can't see the patients and they're still very symptomatic. And she'll push those patients who are losing weight or who have a very high ECHR score to the top of the clinic list so that we see those patients earlier and do their cases sooner. All patients do an ECHR score intake form when we see them for the consult. They are also given a patient information sheet which has the pre-pone diet, the post-procedural expectations, what the recovery process will be like, what the follow-up will be like. It's kind of like a comprehensive packet that we give the patient for their information. And then the patients are seen by us, the multidisciplinary team, which includes usually one GI and one surgeon, the minimally invasive surgeon. And we actually see the patients together in the clinic. It's a true multidisciplinary clinic. And the reason we did that is because patients do have questions sometimes when they come from outside centers. They may not be fully bought in into the POEM and they wanna get a surgical perspective and he's able to be there to provide that surgical perspective. And most of the time, because we've established a good working relationship, he really actually supports POEM, pushes the patients towards POEM. And he's also a good person to have because when we have these very complex post-surgical cases, I've had a few patients, believe it or not, come to me for POEM after a prior Roux-en-Y gastric bypass. And did not realize until after their Roux-en-Y gastric bypass, they actually had achalasia as well, which was extremely odd kind of case to even have to deal with. But it was very helpful to have his perspective to say, is this somebody we can even consider doing a successful POEM on because the gastric pouch is so small, the residual pouch from the Roux-en-Y. So again, having him there is invaluable in terms of reviewing these complex cases. And then we do do a virtual follow-up for patients who live far away, who can't physically make it to West Los Angeles, or an in-person follow-up one to two weeks post-POEM. And then every six months, we try to follow these patients in our clinic. So I was asked to give a brief list of kind of do's and don'ts. A lot of this overlaps with what Dennis has already spoken to you about. I 100% agree to have a referral checklist. So our checklist is essentially an esophagram within one year. We require an EGD within one year, a diagnostic manometry, and then a gastric emptying study for patients referred for gastric POEM. And we make sure that our case manager essentially makes sure that these things are all done before the patient is seen. And if they're not, then she sends a message to the referring to get these things done before the patient's scheduled to see us. So it's a very nice streamlined process so that when we see the patient, we have all the information available. I highly recommend when you're starting a POEM program to limit your initial cases to treatment-naive patients for obvious reasons. They're gonna be less complex than the prior Botox or the prior helomyotomy patients. And having as much animal lab and hands-on experience as possible is absolutely critical, especially if you didn't get exposed to this in your traditional advanced endoscopy training. I was lucky enough to have that, but not everybody does. And if you don't have the skillset to do POEM, obviously you can't start a program. And then another critical piece is obviously developing the proctoring and the mentor relationships because you will need somebody to proctor your first cases. You also need someone to bounce ideas off of when you run into complications or post-op results that you're not too sure what to deal with. In terms of the don'ts, this was a hard one for me to think about. I don't think there's a whole lot that's not obvious, but I would say that don't antagonize your thoracic or your surgical colleagues. They're actually an ally to you. They will refer patients to you. We get referrals from them all the time of post-Heller patients or other complex patients that they want us to try a POEM on. So don't, you know, it's not a, you know, they should not be an antagonistic relationship. It's, they should really be your ally. Definitely when you're starting a program, do not start with any kind of borderline indications like EGJ outflow or the spastic esophageal disorders. Start with the classic, very straightforward patients because you want to demonstrate to your institution that your initial patients are a wild success. You really, for the marketing aspect of it, you want to have really good success stories initially. And then afterwards you can kind of, you know, expand the criteria, but initially, definitely start with the straight and narrow. And then the last thing I would say is, is don't underestimate the learning curve. I think that, you know, there's some published data that the learning curve for POEM is about 50 to achieve competency. Based on my experience at this point, we've done probably close to 150, 160 POEMs. And I will say that we're still learning. We still are getting better. There's small, subtle things that we're learning in terms of clip closure and how to prevent invagination of the closure and things like that, that we're still getting better at, even 160 cases in. So I think that the learning curve is not a smooth, just after 50, you're going to be like right up here and it's going to plateau. I think it's definitely an ongoing process. And then just a few more kind of what I thought, the lessons that I can share with you. I do think that it's, we've seen a lot of kind of confusion from referring GIs, from PCPs about, you know, patients initially presenting with real achalasia who are thought to have reflux. And patients who are told before they were diagnosed with achalasia, they actually have acid reflux and their esophagitis, the sensation that they're feeling is all related to reflux. So I think just educating your referring MDs about what, how achalasia can present, you know, the fact that they can have similar symptoms, but really it's a motility issue and it needs to be diagnosed by manometry is important. Because I think if people are not aware of achalasia as a disease and the diagnostic workup for it, they're missing these patients. And you're not finding this diagnosis in the appropriate patient population. I also, many people have mentioned this already, but I think it's also important to discuss the post-POM kind of expectations of what the recovery process is and what the realistic, you know, symptom relief they will get after POM, especially in patients who have really end-stage disease. You know, there are patients who have end-stage achalasia who will not get significantly better even after an adequate myotomy because what's driving their disease is the aparistalsis and the massive dilation of the esophagus and this huge reservoir effect. And despite doing an adequate myotomy and decreasing the tightness across the LES, you know, what's really driving their symptoms is the aparistalsis. And so those patients, we really need to educate them ahead of time so that they don't have these unrealistic expectations. We show all the patients their esophogram in the consult room before POM to show them kind of what the status of their esophagus looks like. And then we also talk about the realistic diet post-POM that, you know, we're not curing their achalasia with POM, that we're just improving their symptoms, but it's not a curable disease and they still need to change their diet in accordance with that. And then again, a multidisciplinary approach, making sure you're working with your surgical colleagues. I think a key aspect of our success story really is funneling the referrals to one center and being the one center within Southern California KP that does POM to build our volume. There's no way that we could have done 160 cases without limiting all the referrals to one center. And then again, understanding your institutional process for credentialing and privileging before you begin and then being an active part of that process so that, you know, it goes smoothly for you and successfully for you. And then lastly is to support your motility program. We are very lucky in that we've had excellent motility physicians with us. They send us patients, you know, there are people that you're gonna have to rely on when these post-POM patients come back with recurrent dysphagia and need further workup. They need esophilic dilation or whatever else. So you definitely need to have an active motility program in order to support that. And that's our team. On the left here is Dr. Hibbert. He's our minimally invasive surgeon who works with us. That's myself and then these are our staff. This is Dr. Kim. He's here today as well. And myself and then Dr. Hibbert again. All right. Thank you so much. Any questions? Any questions? Any questions before we move on? Yeah, go ahead. So your practice is advanced endoscopy but it's not just POM. Yeah. So do you limit your POM patients to one day a week, one day every two weeks or once a month? Yeah, so we currently have enough volume to do POM, like we do one POM day every two weeks and we try to do about two patients per day. So we do about four cases per month or so and we do them back to back in the same day so that everybody's just, the turnover is better, it's a smoother process. What about in the office when you see them ahead of time? So we do foregut clinic where we try to squeeze as many referrals. Once a week or once a month? Once a month. Once a month. Once a month, yeah. Thank you.

POEM practice

institutional support

training

team development

referrals

endoscopy unit setup

patient follow-up