A Smart, Small, Familial Approach to Population Health

Alec Bojalad
JUNE 07, 2018
This is a feature story from our June 2018 issue. Our bimonthly print magazines are available for free at this link.


Andy Dunn, MD, says the features that make Wyoming beautiful also cause healthcare issues. But the state has a high-tech solution.

“I’ve seen a patient who had maggots in his face,” Andy Dunn, MD, says at the end of a long Monday.

He didn’t see that patient that particular day, mind you. He has simply seen the unfortunate situation before. Dunn is a family practice physician and the chief of staff at the Wyoming Medical Center in Casper, the second-biggest city in a state that is anything but cosmopolitan. He’s the medical director for 2 primary care centers, 2 associated urgent care centers, and the continuing education unit, an observation-and-training arm of the hospital.

Dunn played baseball in college and briefly in the minor leagues. You can tell because he litters his dialogue with coach-speak like “stay after it.” He takes what he calls a Norman Rockwell approach to medicine, referencing the artist’s painting of a doctor listening to the “heartbeat” of a young girl’s doll. Dunn is upbeat and energetic. Even when talking about the maggots.

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“The guy was a rancher, and he had maggots in his face for weeks and just wouldn’t come to the doctor,” he says. “Finally, his family made him, and I can’t even describe it. I thought someone was playing a trick on me. His skin was waxy and looked like waves. Grossest thing I’ve ever seen. I just took tweezers and was trying to pull all these maggots out. I know I didn’t get all the maggots before he went to hospice. It was amazing.”

Dunn tells the maggot story not for shock value. Rather, it’s an example of a challenge facing healthcare professionals in the state of Wyoming. He describes this “cowboy mentality,” which essentially means that citizens just don’t want to go to the doctor. That’s a problem for population health because it can be hard to track and maintain in a populace too busy or disinterested to see a physician. An even bigger challenge for population health, however, is that there isn’t much of a population in Wyoming to begin with.

Wyoming is the 10th-largest state by size and the smallest by population. The US Census Bureau estimated in July 2017 that the state was inhabited by 579,315 people, down from 585,501 in July 2016. That sparse population, spread out over a vast land area, creates a unique circumstance for the effective application of population health studies. It might be true that Wyoming has a rancher or cowboy mentality that discourages going to the doctor. But even for those who want to go, doing so can be a difficult proposition.

“It’s very sparse out here,” Dunn says. “Communication is a lot harder than you think it should be. When you spread out the population, it’s really hard to get consistent preventive screenings. Primary care is like you’re the ringmaster of a 3-ring circus or are trying to herd cats. We have triple-bypass patients who live 2 to 3 hours away. They have to travel back for follow-up appointments or face complications.”

Distance and time have always been concerns in Wyoming healthcare. In the modern biotech era, however, the Wyoming Department of Health is developing new tools to mitigate those concerns.

James Bush, MD, is the Medicaid medical director at the Wyoming Department of Health. He first got the idea to modernize how Wyoming citizens track their own healthcare at a community theater, of all places. He was playing R. H. Macy in a production of Miracle on 34th Street when he noticed how attached some of his young costars were to their phones.

“People would come offstage and start immediately looking and playing with apps. Then they’d go back onstage. They couldn’t be away from their app for half a minute. Basically, I have been of the opinion that kids or younger people these days live and die on these apps,” Bush says.

The Wyoming Department of Health had long maintained several websites and would send out periodic surveys to citizens on a mailing list to help build a fuller population health program. Bush had his doubts that those efforts were having the desired effects, so he sought a partner who could help develop a healthcare app for the state of Wyoming.

He decided to focus on a simple, easy-to-measure goal first: prenatal development. He passed that idea along to one of the department’s recruitment vendors, who came back with a Bay Area start-up called Wildflower.


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