Joyce Lee, MD, MPH, is the Robert P. Kelch, MD, Research Professor of Pediatrics at the University of Michigan Medical School. Dr. Lee also serves as the Associate Chief Medical Information Officer for Pediatric Research, Associate Chair for Health Metrics and Learning Health Systems for the Department of Pediatrics, and Ambulatory Care Clinical Chief for Pediatric Subspecialties at the University of Michigan Medical Group.

Interview with Joyce Lee, MD, MPH

In this interview, Lee discusses her expertise in supporting people with type 1 diabetes (T1D) and working to improve patient care through the T1D Exchange Quality Improvement Collaborative (T1DX-QI).

The T1DX-QI was established in 2016 — with the support of The Leona M. and Harry B. Helmsley Charitable Trust — in an effort to refine best practices and improve daily life for people with type 1 diabetes (T1D). Growth has been tremendous, with 54 endocrine clinics from across the U.S. participating in the Collaborative. 

Fueled by top leaders in diabetes care, the T1DX-QI has become an engine of innovation and inspiration. By engaging with the shared, data-driven, and systematic methods of the T1DX-QI, clinics have seen unprecedented success in their approach to diabetes management.   

With members working closely together to identify gaps in care, discover and refine best practices, and share research — the process has become knowledge-sharing at its very best. While collated data gives clinics a clear sense of “where they are,” it also demonstrates “where they can be” by applying shared, evidence-based methods for improving care. 

Why pediatric endocrinology?

“My interest in endocrinology originally stemmed from a fascination with hormone pathways, fluids, and electrolytes,” said Lee. “Ironically, my clinical work is exclusively focused on diabetes, which theoretically is just one pathophysiology. But the multiple ways in which it manifests and impacts families is both challenging and exciting, which is why I love my focus as a diabetologist.”

Watching her patients adopt the advancements in diabetes technology fuels her admiration of them.

“I feel very lucky to be working in the type 1 diabetes area — it’s exciting because patients have done an incredible job integrating technology and digital health into daily medical management,” explained Lee.

“About six years ago, I made a shift towards quality improvement (QI) and informatics to have a broader impact on care and outcomes,” said Lee, who completed the Advanced Improvement Methods course at Cincinnati Children’s. She is a trained Epic Physician Builder with expertise in SQL and business analytics using Tableau.

System solutions

As a health services researcher, Lee thinks a lot about how the healthcare system delivers care and impacts clinical outcomes.

“Describing barriers and problems isn’t enough — we want to engineer solutions within the system. That’s why I made the move to QI,” explained Lee. “In order to change provider or system behavior, you have to change the technology that’s being used to deliver care.”

Measurement is a critical part of QI work, explained Lee.

“Unless we measure what is happening in the system, whether they are processes of care or outcomes, we can’t understand whether there are differences for particular populations.”

For example, while the adoption of CGMs technology is increasing, Lee said many patients and families continue to be denied access.

“With numbers in hand highlighting inequities in care, smart solutions can be formulated, tested, and applied inside the delivery system.”

T1DX-QI involvement

“I’ve been interacting with the T1DX-QI since 2014 in the initial design and planning phase,” explained Lee. “As T1DX-QI has evolved, it’s been exciting to see the growing number of participating centers, the structure that exists to deliver metrics and outcomes, and the teams that are involved in cross-institutional collaboration. I just think it’s really incredible how much has been achieved.”

Lee sees the strength of both data and metrics — at a national level — through her work in the collaborative.

“The T1DX collaboration allows us to pay careful and systematic attention to real-world healthcare problems faced by one of the largest cohorts of type 1 diabetes patients in the US,” explained Lee.

Six Habits

A recent publication by Lee, et al: Feasibility of Electronic Health Record Assessment of 6 Pediatric Type 1 Diabetes Self-management Habits and Their Association With Glycemic Outcomes is work that originated within the T1DX-QI and is bringing Lee’s vision of patient-centered care and design to life.

“With this discovery, we explored the evidence for what matters most in terms of diabetes outcomes,” she explained. “By formulating this work into six simple habits that are asked at every visit, we can see a positive correlation with time in range and A1c.”

Lee has created a low-burden, electronic health record workflow to record habits at the point of care.

“The Electronic Health Record is a critical tool for delivering high-quality, reliable, and consistent care,” she explained. “As a result, we need to think about the optimal design of the EHR for patients, providers, and for supporting learning in the system.”

Psychosocial Measurements

“The T1DX-QI has been doing a lot of work in terms of psychosocial measurements,” explained Lee. “We’ve all been involved with depression screening — capturing it and collecting data about it, as well as diabetes distress for those above the age of 12. This has been very helpful, beyond habit information and A1c values; by pinpointing where there’s distress, we can better understand how to help our patients.”

Lee now leads a QI project on psycho-social measurement in T1D, in conjunction with a JDRF Center of Excellence Grant at Michigan Medicine.

“We see the psychosocial measurement, and integration of it into the clinical workflow, as an important opportunity for the care team to really understand the whole picture of diabetes,” said Lee, “not just the standard glycemic outcomes that endocrinologists tend to focus on.”

Patient-centered data

What stems from Habits Five and Six is learning about the patient-centric practices of data engagement.

“While I’m very interested in data and helping to improve the system for patients, I also work directly with patients and families, learning how they interact with their data,” said Lee. “This is a quality project that we’ve been working on for some time.”

“I want to know if diabetes data has been looked at since we last met,” said Lee. And by this, she means not just looking at numbers but summaries and trends through diabetes apps such as Clarity or Tandem — and discovering if this led to a change in insulin management.

“We developed the D3 curriculum (Data, Devices, and Diabetes) to teach patients and families how to make sense of diabetes data and make adjustments in their diabetes management and insulin doses to address patterns of high and low blood sugars,” explained Lee.

“This is a skill that is critical for success with T1D management. Families who engage with the data themselves have greater confidence and improved glycemic outcomes.”

Doctor as Designer

As a physician, researcher, designer, and professor, Lee has been interested in leveraging health information technology (HIT) to transform clinical system functionality and improve quality of care and outcomes. As a trained Epic (electronic health record) Physician Builder, she has skills to create point-of-care tools for patients, such as portal questionnaires before visits, and for providers, to capture data about patient encounters.

“I’m interested in data, patient engagement, and helping patients to become independent to the point that they hardly need us because they’re so smart and so expert in what they do,” said Lee.

She also serves as the Institute’s Associate Director for Informatics and Clinical Research Innovation.

“At Michigan Medicine, we’re lucky to have the Elizabeth Weiser Caswell Diabetes Institute, which was a gift from a family touched by T1D, the Weiser family,” she explained.

“We’re working on leveraging health information technology for researchers, capturing data from the EHR — whether that’s device data or data from the portal — and exploring how to make that data useful and actionable for the system.”

What’s next?

“My general overarching vision for healthcare is focused on learning health systems (LHS), in which the right care is provided for the right patient at the right time. Typically the clinicians, the improvers, and the researchers work in silos. My goal is to have a more collaborative approach. This is, in essence, how T1D Exchange supports innovation in T1D.”

The LHS framework provides health information technology tools to clinicians and patients at the point of care, delivers dashboards that allow clinicians to learn what matters for achieving better outcomes in their patient population, and supports interventions to improve outcomes.

“Ultimately,” said Lee, “that is my goal as a provider that’s engaged in quality and health IT.”

Outside of work, Dr. Lee enjoys watching masterpiece theater, spending time with family, and building Tableau dashboards for fun – haha!