May 30, 2022: Dr Colin Banas, Chief Medical Officer for DrFirst joins Bill for the news today. What went on at the AMIA 2022 Clinical Informatics Conference? What areas of healthcare are most in need of disruption and digital transformation today? If we don't continue to invest in virtual care, we could lose the coordination of a significant volume of patients. How do we make the delivery of care better? What happens when COVID-19 emergency declarations end? What are the implications for Coverage, Costs and Access? The future of medicine is not better appointment scheduling or more convenient telemedicine. The future of medicine is asynchronous.
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Price transparency. If you look at the tail end of that one, I think the secret shoppers are out and about and maybe 15% of hospitals are actually compliant with this notion of being fully transparent with costs. I don't think we spend enough time talking about the reimbursement model or the reason that we got the way we got in terms of fragmentation.
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All right. It is Newsday. And we have Collin Banas with Dr. First with us and he is in Houston at the AMIA conference Collin, welcome back to the show.
Thanks for having me bill love it.
Has the conference started yet or is it, is it coming up?
It actually kicked off in earnest this morning. So this is actually, I ducked away from one of the sessions to to spend some time with you, but it should be interesting. It's the 2022 clinical informatics conference by AMIA so.
What are the topics du jour to shore of this conference?
Yeah, a lot of workshops. So this morning there, the work and these workshops are four hours at a run. It's usually very academic if you've ever been to AMIA before And a lot of it is focused on policy and regulatory topics. And then there's some practical stuff. I think there's some fire sessions.
So you know, the evolution of fire and interoperability, things like that. And then there's there's career sessions how to negotiate or things to expect in a new CMIO role, et cetera. So it's pretty wide range of time.
Cool. Hey, you send me over some cool stories. I want to start with this though. Daniel Barchi chief information officer for New York Presbyterian wrote this on LinkedIn yesterday. It's gotten a fair number of responses. And since you're a clinician, you're the first one I'm talking to about this. I wanted to go back and forth a little bit on it. He wrote the future of medicine is not better appointment scheduling or more convenient telemedicine.
The future of medicine is asynchronous. Patients with symptoms will initiate care with a secure text chat with their physician or care coordinator over the course of a few hours, the appropriate labs imaging tests will be arranged over a few days. A series of messages, the clinician and the patient will get the results, answer questions, and decide on a course of care.
All of this will happen in a timeframe shorter than symptom to initial visit happens today. And I like this. I like this for a couple of reasons. One is it shows leadership, Daniel putting it out there for discussion. And as you would imagine, some of the responses were absolutely. This makes sense.
We're doing something like this. This is going to ruin healthcare it's, you have the visceral response, you have the positive response. I'm curious, when you, when you hear this idea of asynchronous medicine, what goes on in, in your mind?
You know, I like it. And if you've ever heard Daniel speak before, he's famous for telling stories about going faster. He has a military background and he used to command ships actually. And apparently the faster you go, the harder it is to to get hit. And so I like his vision I, he put it out there and it's actually something that we can all wrap our heads around.
I think it seems very similar to. The consumer experience that we've come to expect in aviation banking, shopping, et cetera. I think it has its limits. So I think there are certain things that asynchronous medicine is perfectly suited for. And in fact, you've seen a lot of health it vendors pop up in these spaces, whether it's.
Oh, I have an issue with hair loss. Oh, I think I have a cold. Oh I need rapid testing for whatever it is. There are certain things that certainly lend themselves to that kind of medicine in that back and forth. And it the corollary is a tele-health right. Not, we are able to do a lot of things in a video format, but we can't do everything. There are things that just will not work asynchronous or from afar And so I love it though. he's clearly pitched a vision and, you know, I can get behind that.
that's what I like about it. it's a vision and you can start to, plan around it and medicine isn't going to become all telemedicine, just like all medicine is going to become asynchronous medicine, but it's, a different tools in the tool belt. Right? So if you're going to do asynchronous, you need to have AI. You need to have bots. You need to have quality data. You need to have a communication platform, either texting or some other aspect of it. You need to have those things in place, which happened to be pretty common across most.
Digital health delivery mechanisms. So I like it for a couple of reasons. One is it gets the conversation started second, is it? It can inform the kinds of systems you're standing up within your health system. And I just think it's strong in a time where we hear so many cliches over and over and over again. I'm in one of those cynical moves where I'm tired of people saying, Hey they do this and Amazon, we should be able to do it here. What I'd rather start hearing from health systems is, Hey, they're doing that in Amazon and we're doing this over here. Not, we should be, we've been saying we should be for like eight years.
it would be nice to have a few examples of, Hey, Amazon's able to collect a bunch of information that we think is relevant for you around books. And Hey, our health system is now able to collect a bunch of information that's relevant to you around your health and deliver that in a way that you actually consume it.
I don't know. I just, just a. cynical side might come through today. So I apologize ahead of time for that. All right. Let's get some of these stories. him CIO round table recap. We have Becker's where tech innovation is needed. Most in healthcare we have the Kaiser family foundation.
What happens when the COVID-19 emergency declaration ends, which should be interesting. And then we have a. Becker's wrote a synopsis companies should brace for a culture of quitting to give it it's true. Byline actually, Gardner wrote that and then Becker's did a summary of that idea of a culture of quitting. I'll give you first story, which one would you like to talk about?
Which one was the most fascinating to me was actually the Kaiser family foundation summary on when the PHE ends.
yeah, I agree. Great charts in here. Very very well thought out. The synopsis of what goes on, what strikes you about when the emergency ends that is going to impact healthcare, the most.
I think if you've not stayed on top of this or hadn't had a reason, or perhaps you're just too busy, actually caring for the COVID patients, you don't realize some of the things that are tied up in the PHE just from a hospitalist perspective there's extra reimbursement that was tied to every COVID admission and discharge.
It was a lot of dollars there that will sort of go away once the PAG, And there was there's a three-day requirement and inpatient requirement to get Medicare patients into snips. That we're all used to on the inpatient side of the house that is currently suspended. And so we used to finagle all sorts of reasons to admit patients, to try to get them into a nursing facility.
And right now that's sort of that friction is gone, but will resume. The second, the epidemic is declared over and then there's all sorts of things in terms of easement or the easing of regulations on tele-health. Reciprocity across state lines, things like that, that would certainly evaporate once this is over unless, and some states have done this unless states have enacted their own new legislation to sort of keep the momentum going.
But there is a lot of dollars that are tied up in the PHE right now. And I agree that the graphs and the explanations were fascinating and really easy to follow. It's a good read for anyone.
Yeah. it really is. What's interesting to me is with all those extra dollars we just had a horrible earnings season in healthcare, we had Kaiser healthcare with almost a billion dollar loss. We had a common spirit with half billion Providence with a half billion. And these are operating losses too, by the way. I mean, if they reported their total losses with market. Which they usually do when the market's up and they're operating it's down, they usually report the total.
And now they're reporting just the operating, but anyway, half billion, they're half a million there advocate negative, a quarter billion and very few systems buck that trend, I think Mayo day. And Trinity may have as well buck that trend, but at the end of the day, they've cited two things common with the negative earnings.
One is the rising cost of wages and wage inflation, but the other is the decline in COVID paid. At least in the first quarter of the declining COVID patients led to less revenues, more costs leads to those kinds of numbers. Let me go through some of this stuff real quick.
So the chart starts with testing and they're saying, Hey, testing is covered under the public health emergency, and it won't be coming out of the public health emergency and Unit tests have become pretty, pretty prevalent. I mean, you can go into most drug stores now and get a, get a test, but gonna, you're going to have to pay for those.
I think this is one of those things that the federal healthcare system can look at and say is there another way to pick this up maybe through some other programs, some Medicaid program or something, and continue to to offer testing. I don't think that's going to impact the health systems that much Medicaid coverage.
So Medicaid is covering a bunch of things now that it wasn't covering before. And so those could potentially go away and if they go away, then states could have tight budgets around this and that anytime the states have tight budgets around their healthcare spending. Things get interesting and then they go into tele-health.
And I agree with you. I think telehealth telehealth is probably the thing that gets impacted the most because they, reduce the security requirements, which I think they have since upped If I'm not mistaken, but they reduced them during the public health emergency, they allowed across state lines and some of that stuff will go back Into effect and the compact between states, I think only covers about 35 states. Then there's a whole bunch of others that still don't have a compact. So if you are going to practice telemedicine in multiple states, you have to be licensed in multiple states. And those are those. And then there's, there's reimbursement for certain categories.
But I think CMS is actually going through those categories right now and determining. Which one's actually added value, and they're going to try to include those in their overall funding and which ones didn't add value. And they're going to try to, and they're probably just going to let those lapse I think is how they're thinking about that. So I think telehealth aspect to me is the, one I would, I would keep an eye on.
Yeah. site of service was, was the biggie. the way they eased up on where the patient needed to physically be to allow them to be at home and I don't truthfully, I don't see them doing away with that, but technically it could go away everyone who said the toothpaste is out of the tube on tele-health.
If you listen to folks like Mari Savikis from chime, she wants to say, oh, absolutely. It is not out of the tube. A lot of this stuff could easily go right back to the way it was. If legislation isn't changed.
Yeah. From a funding standpoint, I agree with you. It could really go back to the way it was. yeah, it'll be interesting. Somebody sent me a story yesterday. it was the story on Walmart Walmart bought a company I only bring this up because to a certain extent, some sometimes in healthcare, we get caught up into thinking, how do we make this better?
Instead of thinking, how do we make it better? How do we make the delivery of care better? And a Walmart bought me MD. And they have now rebranded at Walmart virtual care. And let's see May, 2021, the deal expanded the retailers healthcare services to urgent behavioral and primary care nationwide to be a telehealth company recently launched the Walmart health virtual care diabetes program, the virtual program to help patients with type one or type two diabetes to assist employers and other institutions.
And the next evolution of BMD, we are excited to begin officially delivering services as Walmart health, virtual care. we're worried about virtual going away and not being funded and other people are. People are now familiar with virtual care, they're comfortable with virtual care, and that is going to be our, our highway into disrupting healthcare.
And when I read that story, that's what I thought. I thought it might be a defensive mechanism, now, if we don't continue to invest in virtual care, we could lose the coordination of some significant volume of patients.
I agree. The interesting thing is how the the number of visits that were virtual really dipped way back down once, once we started to open back up and I would like to see that momentum kept somehow obviously 50% at the height of the pandemic, but I think the numbers I've seen lately are below 20, if not below 15%.
Yep. Yep. Yeah, definitely. They're definitely done. And 15 might be, might be generous these days. they kept trending down. And I think some of that is some of that's reimbursement models, some of that's comfort, some of that is old habits die hard. They say that the number one predictor of if somebody is gonna use tele-health is the physician's recommendation. Right?
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Him CIO round table a bunch of CIO sat down. Ed marks chief digital officer tech. Mahindra is no longer there. He's now with a diversion, I think Nasser Nezami CIO, Jefferson health, Alan Wise, CMIO bay care.
Elbridge lock layer, CIO Summa health, JD Whitlock, CIO, Dayton hospital, and Charles van Dyne Mio U S M D gathered to address healthcare shortcomings. And they talk about those same things. Imaging imagine visiting a supermarket and having to pay for each item separately. One debit card, swipe for your bananas.
Another for cereal. And more swipes for milk, bread, and other goodies inconvenient, right? The healthcare industry faces similar challenges due to fragmented care ecosystem. It's a pain point that has led to unsustainable costs, increases poor quality inequalities and impersonal communication and transactions.
All right. So they go into that. They sat down ad has been consistent in saying we have platforms. For the medical record, we have platforms for the financial transactions and other things with the ERP that we need to have a a digital platform that supports all the various. Ways that we are going to deliver care through digital means and having the communication mechanism and all that stuff.
Sorta coordinated by a single ecosystem, all the messages we send out, all the appointments, we send out all the devices that we're going to potentially put in the home and collect data and have that single. Point of entry into our health system and to to track that rather than going through with what these guys said, which would be interesting.
they commented on a bunch of things, artificial intelligence, interoperability system overload, power of information, rises, smart hospital, hospital, and home price transparency. They, so they commented on all these things. Start with you, pick a topic. You pick one of those topics, AI interoperability, system overload, power of information, rise of the smart hospital. Where do you think it's going? What's what are your thoughts?
What I think is interesting is price transparency. If you look at the tail end of that one, I think the secret shoppers are out and about, and maybe 15% of hospitals are actually compliant with this, this notion of being fully transparent with costs. And you go all the way back to Ed's comment about we have ERP systems and DHRs, and why can't there be one unifying glue or platform for all of this.
I always remind myself. I don't think we spend enough time talking about the reimbursement model or the reason that we got the way we got in terms of fragmentation. And so I think there's lots of ways to unify the care delivery platforms, but you know, the reason the things are the way they are right now is because hospitals, doctors, et cetera, care practitioners, they need to get reimbursed. And there is a lot of friction and a lot of nuance into the way that you have to do things in order to get reimbursed. So I it's all America and apple pie talking about a unifying platform, but I do think we really need to also have a conversation about the mechanics.
Of the finances the way healthcare is reimbursed. So that's just my, my soapbox for that. The other topic if I, if I can pick two, sorry, bill was the interoperability, cause I think there was a nod towards the DaVinci project and the hopes and dreams of fire and interrupt, but there was a a cautionary tale and then from one of the round table participants. And that was be careful what you asked for in terms of overwhelming the amount of the data that's coming in. And so there's this fine line. We need to walk in terms of usability or good. How does the saying go data becomes information and information becomes knowledge knowledge becomes wisdom. I don't, I don't think the doctors want data. They want information if not knowledge. So it's one thing to open the pipe and throw a whole bunch of data at folks, which is probably not going to be super helpful. So it's that fine line of making sure that it's usable. Coming and going
amen. You're preaching to the choir. I couldn't agree with you more on the, data side, the next story we're going to talk about, it's going to focus in on data data is the foundation for the advent of, digital care when I was at St. Joe's, we brought in all this data and the doctors just looked at me and said, I don't want that. I don't want that. I don't want that. I don't, they just kept going through it. And I was like okay, so what do you want? And they're like, we want we want some analysis being done on that.
And to essentially give us something we can, we can act on. I don't want to see if the person stepped on a scale, 50 times in the last a hundred days, I don't need to see that they stepped on the scale and what each data point is. I need to see if they're gaining weight or losing weight in an interval that that really matters to me.
I mean, that's the easy example, but as we put more and more devices out there and collect more and more data, we can, we can inundate already overworked clinicians with data. That's not going to be of value. So the question becomes, how do we create that value? And then it becomes. Do we have a mechanism for creating algorithms or a platform for creating algorithms that the clinicians are that that's easy for the clinicians to do.
When I say algorithms, you immediately think data scientists or data analysts or those kinds of things. And really what I want is a platform where clinicians can play around with the data and play around with the the graphical Representation of that data to say, yeah, that's, that's what we're looking for.
And a group of physicians can say, yeah, if we could put this in front of, of everybody of this specialty this is really going to help our outcomes and overall, and I think if we can put those kinds of things in place, the the promise of interoperable. The what we're actually after, which is the information and the and the knowledge to, to make sound decisions is really there.
And by the way, I really agree with you on the other comment. I hate to agree with you this much, man, should it doesn't make for a good show. People like like tuning in when it's like the ultimate fighting or something, or go back. But I found when I came into healthcare that I I looked at it, I'm like, oh, all these things are broken.
These things are easily fixed. And to a certain extent, a lot of them are easily fixed. they really are. You just have to redo the business model and whatever, and that's where you get into problems. It's like, Hey, this is how this gets paid, oh, well, if that's how that gets paid, then we, we can't do this as easily as I thought of price transparency, being a great example of that when they say, well just, just put your prices.
Okay. If you, if you understood the complexity of putting that bill together, you would know that just putting our costs out there in a spreadsheet doesn't work. So we have to come up with another mechanism for determining what you're actually having done. And and providing those costs, which by the way, I'm not excusing this, we're smart enough to create the bill.
We're smart enough to do price transparency. And only 15% of hospitals being compliant is, is really just a matter of prioritizing it and putting the resources around it. But with that being said, it's a lot more complex than just saying. Hey, give us your prices. We want to know your price for M and M's and and swaps and there's a lot more to it who came into the room, who didn't come into the room how much time did they spend with you?
What's their level of expertise different things that were ordered and that kind of stuff. there's a lot that goes into building a bill and there's a lot that goes into price. Transparency. I agree. Hospital and home, we've talked about a lot system overload. All right.
we'll hit the next story. The next story is on innovation. where tech innovation needs to happen. They talked to Becker's talk to two people. They talked to Brad Rimer, who is the CIO for Sanford? And they talked to Sarah Vaizey, who is the vice president and chief digital officer for Providence.
And Brad says data. He says there's a lot of things going on. I could talk about a lot of those things, but data is probably one of the most important, challenging areas to address as well, because we're trying to figure out how to prepare the data ecosystem. I'm talking about it in the largest sense.
What's the data ecosystem need to look like. For this generation of healthcare solutions, what is the amount and the importance of the data that is being created and consumed outside of the EMR. And that is growing exponentially. As everybody knows, all those systems in the topian world need to work in concert with each other.
To really gain the benefit of improving patient quality care, the patient experience and provider experience. I believe the data is key for doing that. And whether you're talking about it as data governance, the identification of data, accessibility, interoperability, and machine learning, you name it data is the lifeblood of the future of digital health in my mind.
So Brad says, Hey, data is the foundation for all this. And by the way, I'm hearing this more and more, which is where we're implementing this new AI mechanism. And we thought our data was good. We were doing some really good stuff with data. And then we start to implement these AI and machine learning things. and We realized our data's still not that good. We have a long way to go.
Yeah. this is the Halamka thread as well in terms of. When you start talking about AI and machine learning, how is it going to be regulated? How is it going to be transparent? How do I know how the system arrived at that particular answer or, or recommendation and what, what population was it based on and is it applicable to my population?
and even to get to that level of the conversation, You of course have to have what you just referred to, which is good data, clean data semantic interoperability between the data where it still means the same thing in system a, when you send it over from system B. And I think good health systems probably realized this within the last five to 10 years, if not longer ago, And started making those investments into a enterprise data, warehouses, data scientists, and things like that, because they realize pretty quickly that without the data you were going to get left behind and you needed you needed governance and you needed tools in order to start to harvest that data, to get to the conversations that we're having now.
And, but it's not just unique to healthcare, right. How has Amazon so successful data how has Tesla I think you told the story, Tesla is selling isn't a car company, it's a data company, right? It's every time you drive that thing, it's the it's collecting data points. It's, re imagining the models, et cetera. And so I, I think that the entire planet is. Is running on data right now. And healthcare is unfortunately a little bit behind. That's all
so Sarah Vaizey with Providence says our healthcare system is so complex and difficult to navigate and understand. And the infrastructure is very antiquated. The business models are challenging and the operations are very convoluted. I think it's hard to point to something that. Require rethinking and modernizing and perhaps disruption as well. And she goes into talking about that stuff. I find it interesting and I'll try to remain positive here.
I think SARS brilliant. And, and I love having conversations with her. She always causes me to, to think about things, but this is the same stuff I could take that sentence and I'll bet you, I could go out and find when Erin Martin joined Providence. Umpteen years ago, eight years ago, seven years ago, as the we're going to bring Amazon thinking to healthcare.
I bet you, I could find that very same sentence seven years ago. And now he's back with Amazon and the person in charge of Providence is saying the same thing. So said seven years. Th this is, this is the cynical side of me. That's saying, all right, what's it going to take to break this free it it is complex.
There are government regulations. We're talking about the care of people. So you can't make mistakes. We're talking about know Byzantine financials systems with insurance carriers and Medicaid and Medicare and whatnot that you have to. Yeah, you have to have a PhD. We're talking about payment models to physicians that literally took me about almost the better part of a year to understand how physicians get paid.
And I'm pretty sure that's changed since the last time I was brought up to speed on how that works. And so you have all those complexities, what's it going to take to break out of this? And is it going to come from? And I, I think to a certain extent, it might come from outside of my come from the transparency of the world.
It might come from the Walmarts of the world. The, the, the payers have a, a steady stream of income. And so they're doubling down on telehealth and ease of access and better programs for diabetes and better programs for oncology care and those kinds of things, because they're getting, they're getting money either way.
And it feels to me like the, the, the organizations that are getting squeezed are the healthcare providers, because they're sort of on the end of that, all those financial models and the regulations, and they can't figure out how to disrupt their own model.
Yeah. I think you're spot on. And so to answer your, what's it going to take question? I think. It is at the it's at my comment earlier about the mechanics of how everyone gets paid follow the money. You talked about some of the disrupters, whether it's the Walmarts or the the CVS minute clinics or whatnot they're definitely disrupting and they're taking the, they're taking the easy stuff, right?
They're taking the cream in terms of the stuff that's high paying and lowest effort. And then downstream what are the hospitals and the health systems going to be left with? If they're not careful is the really high acuity, low margin stuff, your, your traumas, your ICU stays the procedures probably not that's although the ambulatory surgical centers are sort of picking that off.
So yeah, I, I do think we're at a genuine inflection point, but for most people it's still not that. And so I think it's the confluence of all of those things you mentioned in terms of disruptors, a pandemic external forces. And then also the mechanics of payment. All gonna need to, to squeeze in order to effect a positive change.
Yeah. And caught third there's part of me that's cynical on says, Hey, we've been saying these things for too many years. And then there's part of me that I read the Daniel, Barchie quote. Yeah. Yeah. We have some really good ideas out there and we need to, we need to play with them. We need to get them into pilot and we need to start moving them forward.
And I believe in the overall brain trust, that is that is the healthcare provider network to come up with new ways to deliver care increase the number of touch points, improve the. The overall health of our communities. I think there, there are opportunities. I think we'll figure it out.
I hope so, hopefully that you're the cynical one. See, you spent too much time with me. We need to be positive. I really, I really do believe that I believe that we'll have the workshops today at AMIA and we'll continue to share the strategies that we are implementing across sport. Colin, always great to hang out. I'll let you get back to your workshops.
As always, I appreciate about.
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