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All these sports seem to have data analytics and data analysts and like, what do we have? What are we doing? How are we improving what we do on a daily basis? And so I think in every part of healthcare, in every specialty we're seeing this, right. It doesn't matter whether it's surgical procedures or surgical subspecialties or medical sub specialties. That's the reality of today. Everyone's trying to figure out how do they do more with less.

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Allright it's Newsday today. We're joined by Dr. Joshua Reischer, CEO and Founder of Healthnote. Part of the Cedars-Sinai accelerator. Joshua, welcome. Welcome to the show.

Thank you, bill. Thanks for having me.

I'm looking forward to the conversation. I love talking to the accelerator companies. There's so many really cool things going on down there and Cedars. But before we get there, what's your area of practice in medicine?

Yeah, so my background is in internal medicine. I focused mostly on geriatric patients, but trainings and internal medicine and a fellowship in bio-design innovation, which is not a common one.

Bio design and innovation. Give me an idea of what that entails. What's that.

Yeah, there's, there's a few programs throughout the country. There's one Stanford one and UCLA. I did mine at Texas medical center and especially essentially there there's a year long program where they take physicians folks who have a background in business and folks who have a background in engineering, whether it's computer science or material, et cetera, engineering. They put them together for a year and they, they end up working on different areas of focus that the health system wants to improve upon. And the idea is actually to start a company. So it's a fellowship to actually start a company to improve some area of healthcare.

Is that where Healthnote came from?

It's not. Actually started a different company while I was there and that's still going. One of my colleagues is still working on that. It's called Lena health but actually started Healthnote right before going there. And then launched and then left that program after a couple of well after 10 months and then actually came to Cedars-Sinai and then really kind of launched it from.

Give us the quick snapshot. What is health note doing? What problem is it solving?

Yeah, so my background again, internal medicine, I was loving seeing patients, but I spent most of my time collecting, organizing, and documenting data, and I wanted a better way to collect all the relevant information I needed from patients before they would show. And have all that information documented where, and when I needed it in the chart. So essentially we ask all the questions the doctor would normally ask. We do this before a visit, we text message a patient, ask them all these questions. And then we automate note writing that goes directly into the EHR.

So everything is pre-populated before the patient even walks through the door. So. We started in late 2018. Last year, we helped see over a million patient visits on track to do over 5 million patient visits this year. And really just helping optimize the way clinics and organizations work.

And that's fascinating. And it's interesting because we have five stories. And I think three of them are going to lend themselves towards this. Not that we pick them out for this reason, but they are about staffing shortages. They're about automation and it really is about making those people more productive. And that's that, that space right now that everybody's looking at saying, all right, how can we add automation? How can we streamline this process? Reduce the friction. But I love the aspect of what you just said that I really like is. Getting it into the EHR at the point, it needs to be, it's one thing to collect all that information and put it in a form, put it in a separate table. It's another thing to funnel that to where it needs to be for the clinician to interact with it.

Yeah. So exactly like what you're saying, most of the folks that we talk to and that I talk to on a daily basis, they're trying to figure out how do they enable multiple different clinicians to practice at the top of their license, whether it's physicians, nurse practitioners, PAs nurses, medical assistants, whoever, how do they decrease the amount of manual tasks and enable them to do what they did, their schooling and training to do. So I think that ends up being really, really important in this day and age, when it's really hard to staff, you're trying to keep people happy. How do you enable them to do really what they set out to do and not tasks that essentially a computer could do.

Yep. All right. So let's, let's happen to the first story, a hospital CEOs say work force shortages were more challenging than financials in 2021. So this is from an ashy study, American college of healthcare executives. And they went out and talked to I think 300 hospitals CEOs. And for, for the first time in quite some time, Staffing shortages came in at number one. And not that they haven't been top of mine, they were number three in 2018, number two in 2019.

So it has been steadily growing, but now it's it's right up there at number one for for CEOs. And they closed the article with this statement longer-term solutions, including increasing the pipeline of staff to these positions, as well as. Organization level efforts to increase staff retention bowan added in a statement, more immediate solutions, including supporting and developing all staff, building staff resilience and exploring alternative models of care. So, I mean, we're hearing that. All over the place. I mean, how does, what does this look like in the hospital when there's not enough people?

Is it just essentially, Hey, they're going to go out and get traveling nurses. They're going to get out to go out and find people, or is it a situation where there's, there's just gaps right now. There's just not enough people to do.

It's all of the above, right? So one, the people who are there on a daily basis end up getting stressed, right. Cause they have to pick up wherever there's slack. And that leads to what we hear about on a daily basis, the burnout frustration with the job. And sometimes it ends up impacting patient care, as I'm sure you've seen and heard about where there's only so much that one person can do and take care of it and if the ratios for whether it's nursing or physicians are not where they need to be that of course has the potential to impact patient care because you, you can't be on top of everything all at once. And so if you can't get the right people in at the right time, obviously that significantly affects folks.

And in healthcare, it's not like you can train most people for just a few months and we have them right. Depending on the position, it can take many years. So when there's a shortage people, project shortages for multiple years, some people say you can five or 10 years, they project a shortage for it because that needs are continuously increasing.

People are being poached away for multiple other sort of jobs, even if it's in health care There are better conditions sometimes when you can work remotely or from home or wherever and working in hospitals, not easy. Right. It's very rewarding, but it's not necessarily the easiest job.

So it's a challenge for getting the right people there. Getting them trained up, getting them ready, and then also keeping them as they're saying. So honestly, a lot of, it's not really surprising and it's a reflection of, I think what every industry is seeing, but it's magnified here because it's so hard to get people back.

No. It's interesting because that next article we talked about, so the government's trying to weigh in, right? So Congress is mulling fixes to the current staffing woes. I just get a little what can they possibly do while it's in the policy area for the most part, but they had some hearings.

And it was interesting because I, so Senate committee on health education, labor, and pensions hearing on Thursday, Senator Tommy Tuberville, Tuberville from Alabama has a witness about traveling nurse rates and whether agencies are taking advantage of the situation. So this was a common theme in this article was.

Hey, you know what these, these rates seem to be getting out of hand here. And so they had this hearing, he asked that question and the response was nurses who are leaving their permanent roles for traveling jobs do so for a number of reasons beyond higher pay Margaret Flint or senior vice-chair. And clinical director at community health center said during the hearing, I don't think people are likely giving up a satisfying practice as a nurse to do traveling nursing splinter said, and I think that's the misnomer we think, oh, these people are leaving just for more money. But the reality is it's, it's a bunch of different things but you know, we, we talk a lot about technology.

And if you're rewind three or four years, the talk of the town was the EHR is so hard to use that literally physicians were were saying, I don't want to work there anymore because the technology is so bad. I want to go work somewhere where the technology's at least acceptable. That's what we were talking about fi is that still the case, or have we sort of gotten, gotten better at least on the EHR for. Or the technology front for most health systems are, is there still a significant gap from system to system on, on the technology?

I think as people have gotten used to. The top EHR is everyone's sort of some people say it's the great digitize, everything you can look up your records. And as you're probably well aware of people have lots and lots of complaints, about many more clicks, many more steps, cumbersome gets in the way of care. And so there's lots of debate and that's not going to end anytime soon. In terms of. Of traveling and having the ability to move. I think for some people they felt like they were underpaid under appreciated.

And now they're, I wouldn't say taking advantage it's in any other industry, people would understand it and say, Hey that's okay. They're, they're doing what they want to do. In healthcare while of course there's there's altruism, but bottom line is people want to provide for themselves and their families and everything else, right. With cost of living going up, whether it's just wages or the ability to work in different places and try new places, right. People are interested in that these days. There's there's a trend, not just be healthcare with every industry. I think people are doing that today. So again, not that surprising that it's all happening.

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This is the second week in a row on this show. I'm going to mention this, but it was just funny. I saw it. I saw the cartoon. Where the nurse is asking for something she's asking for a pay increase or something. And they said, yeah, no, we can't give you a pay increase. We just can't do that.

And so she, the next little thing, you see her leave and she signs on with a traveling agency and then she comes back to the same place. And she's charging almost twice as much. To do the same work that she was doing before she left. That's the cartoon. The reality is there's a certain amount of truth in that cartoon because this article talks about the rates in some house systems, they're seeing a 30, 40, 50% increase in at least their traveling rates, if not more than that, which is increasing the overall wage that is required to run a hospital or a health system at this point. So we're seeing a significant wage inflation. At the hospital level. And then the question becomes, what can the government do about it? And they have some things in here, but also what can the health system do about that wage inflation?

And I think that's where our conversation from earlier comes into place, which is you, you want people to be as effective as possible. And so how do we make them as effective as possible? And I think. Your door and other people's stores and saying, Hey in other industries we've seen. Really take a Lyft here. And can we do that? Are we seeing an acceleration in healthcare now around automation, around things that we used to have a lot of pushback on because of this inflation, that's going on

A hundred percent. I think it became clearly needed to a burning need, especially since COVID and now as things even get better. I constantly hear I was at an orthopedic conference about a month and a half ago, and typically at an orthopedic conference you'd I would have expected to hear a lot about medical devices and do surgical procedures, things like that. All I heard really was about how do we automate, how do we use technology to do things better constantly for almost three days, right? In orthopedics, they often think about it and talk about things in sort of sports analogies and they were talking about, Hey, all these sports seem to have data analytics and data analysts and like, what do we have? What are we doing? Right. How are we improving what we do on a daily basis? And so I think in every part of healthcare in every specialty we're seeing this, right. It doesn't matter whether it's surgical procedures or surgical subspecialties or medical sub specialties. That's just, that's the reality of today. Everyone's trying to figure out how do they do more with less, right?

Because there is a lot of waste and inefficiency in the system. And so I think technology has the capability to help with that. Right. It's not like we're going to automate away everyone's job. I don't believe in that at all, but I think there is a lot of room for opportunity for both patients and providers. Ultimately it comes down to how do we better take care of patients? How do we do it at costs that other countries and places are doing it right. And how do we continue to sort of Maintain or improve the level of service and care that we, that we give to patients. And I think technology has the opportunity and room to help there.

right. We're going to talk about automation in the next article. so I hit this list that came from the AHA submitted a statement to the Health subcommittee with some policies that may help address the shortages. And so I'm just going to read the list and we'll, we'll go back and forth a little bit on it.

I can't really weigh into too much of this, but I just wanted to give people the. So number one, unless was lifting the cap on Medicare funded physician. Residency's number two, boosting support for nursing school and faculty number three, providing scholarships and loan forgiveness. Number four, expediting visas for highly trained foreign healthcare workers.

Five was dispersing any remaining funds in the provider relief fund, as well as replenishing the fund to help providers cope with increased staffing costs. Next one is investigating reports of anti-competitive behavior from nurse staffing agencies during the pandemic. That is further exacerbating critical workforce shortages.

Next was pursuing these a relief for foreign trained nurses. And then the final one was supporting the health of physician nurses and others. So they can deliver safe and high quality care by providing additional funding and flexibility to address behavioral health needs and funding for best practices to prevent burnout. It's pretty exhaustive less than any. Any of those jump out at you.

Yeah, a number of them. I mean, even starting from the top, increasing the number of residency spots. So sometimes folks don't understand how the whole system works, but actually the government helps fund spots for physicians to get their training. Right. And there's a cap on that. I think there's a whole interesting sort of side conversation of how all of that works, but Increasing the number of spots for training will definitely help. It's still going to take years, right? You open up a spot and you're still talking three to eight years, depending on the specialty.

Right? So none of these are going to be magic fixes, right? These are longterm strategies that I think everyone has been aware of that have need needed to improve. So I think that it makes sense that it's going to help, but they're not, you're not going to waive a. A magic wand here and it's not going to be fixed next year.

I do think technology does have the ability to help in the next one to three years where these are longer-term strategies, getting more folks in the right places, over a period of time the. The number of hoops that people need to jump through to become a provider is huge, right? There's so many other industries that people end up going into, right.

People go into healthcare very often at first for a myriad of reasons, including the altruistic reason. Hey, they want to help people in that way, as I'm sure everyone listening today knows there's many different ways. Help people and to be involved and to feel satisfied in your work. And I think a lot of healthcare providers go into it for that.

I know that's why I went into it. But you do have to jump through a lot of hoops and you delay your life. Right. And so very often physicians and other advanced practitioners don't really. Get their life started, but until they're in their thirties, right. And working super hard and then they get more and more sort of blockades put in front of them.

And so we talk about provider shortage and then like, we don't actually make it easy for people to become providers. We actually make it really difficult, which there's good reasons to make it difficult, but then there's some unreasonable things about it as well. And so I think the list that you. Mentioned starts to address some of those maybe unreasonable hoops and things that people need to jump through. So I think that they're all necessary, but they're not going to immediately release all of the sort of steam, if you will, to

I look at two of these expediting visas for highly trained foreign healthcare workers and pursuing visa relief for foreign trained nurses. My question is, is this staffing just the U S phenomenon or is this a world wide phenomenon? And I'd be surprised if it's just the US thing.

Yeah, I think it's global, but even having visas for folks, they often. That can help with our training, but there's still a limited number of spots, right? Like I know a number of folks from around the world, whether it's Europe, middle east, and other places where they have to jump through even more hoops than, than folks who are here. And they have more opportunities here and there's some really fantastic training opportunities. That's why people end up coming here and that helps them. But again, there's that cap. So actually the first one that you mentioned kind of is that a stop gap, right? Because you have visas. That's nice.

But actually, if you don't have a residency training spot, you can't practice here. It doesn't matter if you've been a practicing cardiothoracic surgeon for 20 years, you can't just come here and practice them. Fortunately, there's a lot of other sort of hoops that you need to jump through to practice.

All right. Next article. We're going to talk about automation. We're just making people as happy as we can be at this point, because when you hear automation, it's one of those things I think has a lot of misnomers to it. I think people believe. That automation is gonna take my job and those kinds of things.

And I thought there was an interesting they referenced the McKinsey study. So I pulled that up and I was reading some of it. And they had this, this statement, which I think encapsulates a lot of this, almost half of the activities, people are paid to almost $16 trillion in wages to do in a global economy, have the potential to be automated by adapting currently demonstrated technology according to our analysis of more than 2000 work activities across 800 occupations, while less than 5% of all occupations can be automated entirely. And I think that's an important point using demonstrated technologies about 60% of all occupations have at least 30% of a constituent activities that could be automated.

More occupations will change, then we'll be automated away. And that's, that's really the essence of this whole article, which is there's an aspect of healthcare and the way it's delivered today, where automation can come alongside, like can, can help and maybe even take away 10, 15, 20% of the job. That's not to say that that is going away. It's to say that you're going to replace that 10, 15, 20, 30% of the job with other activities and hopefully more meaningful and satisfying activities as.

Yeah, I think automation has the ability to deliver better care to patients because you get rid of the parts of the job that honestly, nobody wants to do. It's not going to take away the job itself any time soon from my perspective, but it does take away the parts that people are like, Hey, I didn't know I was signing up for this. Right. I didn't know. I was signing up to. Right prior authorizations for hours a week, right? Or manually enter information four hours a day because some of those things are regulatory.

Some of those things are just necessary for patient care, but there is to, to your point, just a huge opportunity to improve. Current operations. Right. And to me, I think that's the sooner and better opportunity than hiring 20% more people it's actually enabling people to do more of the things that matter for patients. Right. So.

I talked to two different organizations about their AI efforts and both of them pointed to prior authorizations and real-time prior authorizations. Oh, my gosh. Real-time prior authorizations. You mean like put the information in and boom right back to you and they're like, yeah, absolutely. All right. That's a game changer. I mean, it's that kind of application of technology that I don't think anyone's sitting there going I, I don't like that somebody may have lost their job on this end of it because there's so much friction and dissatisfaction with health care around the prior auth process that I think we'll find something else for those people to do. They don't have to and by the way, that won't be a hundred percent of the prior auths. That'll be what if it's 70% real time prior authorizations, think the physicians would be pretty happy with.

For sure. And it's the prior authorizations, but it's also, how do you gather the right information to know this is an appropriate authorization, right? So even automating the pre-steps that's honestly a lot of what we focus on is figuring out, Hey, what's going on with the patient? What are their complaints? What are their needs? Getting that right information in front of the provider, having that already digitized so that the provider can, again, just take care of the person who's sitting or standing in front of them and not have to spend time on the phone, doing data entry, et cetera, et cetera. So, yeah, couldn't agree more.

How do we prioritize what stuff gets gets automated? I mean, if you're looking at a system, is it based on return on the number of hours, time productivity money? how do you prioritize it?

in my experience, I'm not the one making those decisions typically, but from what I see from having many, many conversations with different folks, they are looking for, Hey, what's the highest ROI. And the return on investment can be, like you said, it could be hours saved.

It could be satisfaction. And sometimes it is new revenue generation or a mix of all three, right. Where, where does this help them in sort of a multi-pronged approach to make it make sense, right. It also enables them to get through the various committees that they need to get through. Right. How do they sort of show different stakeholders in a system that, Hey, this just kind of makes sense. And this is a no brainer to start with. And I think you have to start somewhere and it's reasonable to start where there's a, again, an opportunity to save time and money to sometimes. Generate new revenue and also where there's allowed constituency, whether it's physicians, nurses, or others in the system who say, gosh, if I have to do one more day of XYZ, I'm out of here.

Right. And come back to the earlier article that you were referencing. It's like, how do you keep these people happy? Right. And so some of it is automating away the things that they hate, right? It's they didn't go to school for this. They didn't sign up for this. They didn't know that this was a big piece of their job. So I think those are some clear opportunities and places to automate.

So they've a really forward-leaning statement in here. And I'm going to pull it out and read it, and I'd love to get your thoughts on it. So it goes but healthcare will be different by then. And yes, dramatically better. Diagnosis will be, will become increasingly automated and driven by massive amounts of patient data. These big data sets will be captured, stored, analyzed, and interpreted in real time. As a result of do it yourself diagnostics done in the home. With the aid of discrete self-monitoring devices will become common. Now we've all seen the futuristic I think it was the movie alien where the person actually lays down in a bed and it does all the surgery on the person and that kind of stuff. How futuristic is that statement? Is that a, yeah, maybe next decade kind of thing, or is that a no, we could see it.

I don't see it this decade, to be honest, I do see technology eating in diagnosis and playing a big role. Right. So for example when someone is reading an EKG strip, right, it's a series of lines. Does a human really need to read that? Is there any reason that a computer can't understand that can't understand the anomalies, like us reading ones and zeroes today? Why would we be doing that? Right. Like we're looking at it, the different kinds of interface. So I think there is the ability to have better, faster diagnosis, but humans are complex.

Health is complex, things are constantly changing. And so, yeah, I don't see. Honestly this decade that happening automatically. But I do see us starting the foundation for something like that. Right. I think that in 10 or 20 years, yeah, maybe more and more of these components are automated and we're all working on it right now.

Right? Like we're trying to figure that out, but it, it is critically important that healthcare information is. Intertwined right. And better connectivity is coming in. and It is in some senses here, but it's also filtering out the junk data, right. There's just a ton of junk information in the medical record systems and putting it all together as not a simple or easy feat.

So I think I think we're all. Trying to work towards there, but honestly, I don't see that in 2020 is just automatically diagnosing patients, maybe for some basic things. It's sure it's possible, but the more complex. You get the harder it is.

No, I'd love to jump into this article on clinical variation, but I have a feeling this is a bigger topic than a two minute close on, on this topic. So let me ask you this. What's what's next for Healthnote?

We're just continuing to expand in what we do. We just raised another round of capital that we haven't announced anywhere yet, but we're expanding our team size what we do right now, again, as I mentioned, we collect data from patients. We automate different processes within the EHR, so we're. Strengthening and deepening our integrations into the EHR is that we're in expanding to new HRS and expanding the functionality and automation capabilities that we're talking about here to really ultimately. Help providers serve their patients, right?

How do they do it better? How do they practice at the top of their license and enable patients to really tell their story of what's going on before they show up and enable them to be prepared? To receive better care. So just expanding on multiple fronts there.

Fantastic. I want to thank for your time. Great conversation. I always enjoy talking to the entrepreneurs of the world who are looking at these problems a little differently and trying to solve so Joshua, thank you. Thank you again for your time. Really appreciate it.

Thanks so much for the opportunity Bill.

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