Episode Transcript
[00:00:00] I'm Dr. Robert Groves and welcome to QuickConnect, short commentaries on current issues in healthcare.
[00:00:08] Please enjoy.
[00:00:10] I think digital health has a critical role to play in health equity. You know, it's logical if you live in rural America, if you are in a community where you don't have access to reliable transportation, if you have issues where you're not able to, to just drop everything and spend several hours at a physician's appointment in person.
[00:00:35] And this describes a lot of those who are underserved in the population. So I think digital health has a crucial role to play in terms of the sharing of information and delivery of care that is independent of geography and much more convenient for patients.
[00:00:53] A great example of that is in virta health. They have something they call continuous remote care. And it takes advantages of, it takes advantage of several aspects of digital health and in particular the social network that we call the Internet to dramatically improve the effectiveness and the efficiency of care delivery. So first of all they have community. There's a whole group of users who congregate together on the Internet, share recipes, share stories, encourage each other. The second thing that they have is lots of patient education and that is self directed from all of the webinars and references and resources that are available on the app on the website and then coaches as well that help guide members through their change in life experience and their change in life habits, their, their daily practices, specifically as they relate to eating, but other aspects as well. And then the third thing that they have is they take full advantage of the two way exchange of information. Bloodsticks for both ketones and glucose be followed on a daily basis as can weight and other measures can be added as needed. And then the fourth thing that they do is take advantage of team based care.
[00:02:11] So you don't need the physician to comment on dietary changes, for example. In fact, most of us got very little training in that. And unless the doc has a specific interest, they're likely to know less about it than somebody who is actually trained in nutritional therapy.
[00:02:29] So I, I think all of those things bring state of the art care within reach of the average and even the underserved population.
[00:02:39] And so I think it's critically important there. Now, with regards to artificial intelligence, I think we have a long way to go there. There are some things that artificial intelligence can do amazingly well. For example, highlighting areas of an X ray that deserve the radiologist's attention, highlighting skin lesions that might be malignant, highlighting pathological samples that might be malignant. AI can be very good at that. Because it looks at things over and over and over and gets better and better with each time. Now there's an inherent bias implicit in a lot of the AI research and that it's done on the typical white patient. We need to shore up that gap and we need to make sure that we don't implement systems that are going to have inherent bias. And this is one of the reasons why, at least in my mind, we will need a physician at the end of that chain to make sure that whatever the AI robot comes up with, it actually makes sense in the context of this given patient and this given set of circumstances. It has always struck me that our tendency to rely on technology and healthcare as a panacea, the next big thing, is going to solve all of our problems. I don't think it's true.
[00:03:56] Technology should be a tool to serve the primary relationship between caregiver and patient. If it's not doing that, then you know, to some extent it's in the way. And we see this today with EMRs that in spite of best efforts were built primarily as billing systems. And I went through that transition myself, going from paper notes to electronic records. And until you actually experience it, it's hard to predict what kinds of problems arise. And there are several of them. One is I found myself doing scads of clerical tasks. The specifics of order placement and finding the right order and mixing up bags of IV fluids, which nurses actually get far more practice at doing. They're far better at it, as is a pharmacist. Pharmacists are irrepr replaceable in terms of being able to do those sorts of things and compare drug, drug interactions, et cetera. So that technology really slowed me down. The other thing that happens is notes get buried.
[00:05:01] There is so much information in an EMR and it's spit out in a non narrative fashion that it's really easy to simply get lost in all of that mishmash. Whereas before I could go to progress notes in the physical chart, flip over to that, and I would read what were the progress notes delivered by caregivers in a sequential order.
[00:05:26] That can be much more difficult to find now. And nurses notes used to be pretty meaningful in that they would, I could read them, you can tell a little bit about what's going on with the patient. Nurses notes now with charting by exception and all sorts of other schemes like that, really difficult to interpret. And I, I would be surprised if physicians spend much time looking at them today because it's just almost impossible to glean the nuggets of useful information out of the barrage of stuff that the EMR documents and records on a daily basis. And then the final problem is when we have pre made order sheets and when we have pre made notes, I don't know if there are errors of commission or omission but, but let me describe it to you. Previously when I wrote a note, I simply wrote down what I thought was important and pertinent to that patient in the chart.
[00:06:20] Obviously notes changed when we got into levels of care 99291 through 5, et cetera. Once that started happening, then yes, that influenced the content of the note a little bit. You might include information that's somewhat extraneous to prove that you did it. But they were still very readable notes. Now not always, it wasn't perfect. There are some notes that were illegible, some physicians who wrote notes so brief there really wasn't much information and you know, all of those things existed.
[00:06:50] But the problem now is, particularly with carry forward is you'll get nonsensical notes sometimes that say, you know, a 54 year old comatose male alert and oriented times three. Well, obviously that doesn't make sense. And what happens is if we're not really careful when we carry over a note from the previous day or we cut and paste, for example, will have information in there that is no longer relevant to the patient's condition today.
[00:07:20] So the physician's job has changed and it changed on a generation that was not trained on the electronic medical record.
[00:07:30] Now I presume that's getting better, but I look forward to the day that we have electronic scribes that can capture the interaction between a patient and a physician and from that glean the pertinent information and deliver it in a narrative note that makes sense for everybody. I think we're pretty close to that. I know Microsoft has been working on that for some time and there are others, but I think that's where we need to get to. And until then, you know, in a lot of situations it makes sense just to hire a human scribe to get that work done. Because the most important part of health care is the relationship between the physician or caregiver and the patient. And anything that we can do that we can do to enhance that relationship. That that's the kind of digital strategy that I'd like to pursue. How do we make that better instead of worse? How do we make it easier to get through the documentation piece instead of harder? How do we make it easier to order the right stuff instead of harder? So that's What I'm looking for, I'm looking for us to really think of the digital strategy as tools. They are simply tools to enhance human relationships and improve human efficiency. You know, one of the projects that we're very focused on in Banner Aetna and that we've been talking about for a while, that we've had a couple of goes at is improving the prior authorization process and we have the technology available today to do that. Healthcare moves slowly. I know some of the larger organizations that provide this service to others are working towards that goal. There are sort of two strategies. One takes a statistical approach, if you will, to prior auth and looks at the history of a given doctor and predicts the probability that they've got everything in line and this will be a, you know, good to go and approves it on that basis. The other strategy is where AI will actually go in and read the chart, if you will, to see if all the preconditions are met and be able to give feedback in real time so that if you know the conditions aren't met, you can act then instead of waiting for two weeks when it gets denied and the patient showed up for their mri. So that's another strategy that's out there and being trialed by some.
[00:09:54] And there's still going to be about 20%, you know, somewhere between 10 and 20% that will need direct human intervention. But gosh, if we could get, you know, 80 to 90% immediate approval, a number while the patient is actually still in the doctor's office, that would be a phenomenal step forward.
[00:10:13] Now the other thing that I wonder about is why can't we use AI to move this to the front of the line instead of trying to do it on the back end. In other words, what if we could simply guide the doctor with information that pops up in real time or an alert of some kind that says, gosh, you're thinking about organization, ordering a knee replacement and this patient, you know, has not had physical therapy. Now you know the purists out there who believe that surgery can fix anything and everything and should be, should be used non sparingly. Let us say they scoff at this physical therapy recommendation, but it is evidence based and I'm not sure how much of it is actual physical therapy. I think there's a significant contribution there, but some of them just time. We get very impatient with injuries and as we age those injuries tend not to heal as quickly.
[00:11:09] And also we overestimate the benefit of surgery very often. Ultimately the prior authorization process can go away. But it has to be replaced by something that guides physicians to the most cost effective therapy available in a given circumstance. That upfront AI to help guide decision making in real time. I think that's where the future lies. It'll be a while before we get there.
[00:11:39] And then the physician's job again. We talked about this in previous shows. The physician's job changes from one where they are trying to remember everything that should be done on a given patient to identifying when the consensus established expected clinical practice does not fit perfectly. And by the way, none of them fit patients perfectly. There are always reasons to modify a bit, either based on the patient's life goals, the context, coexistent disease. That's why you have a physician in the room and that's why the physician ultimately is responsible for making those decisions. But the job is no longer remember everything. The job is now identify where specifically it is appropriate to deviate from an expected clinical practice because of the specific circumstances circumstances of this patient. You know all of that to say that I'm optimistic that we will see breakthroughs in prior authorization within the next couple of years that'll make it much less onerous, much more efficient and much less costly not only for, you know, physicians and the delivery system, but also for insurance companies. They spend a ton of money on prior auth and and don't love it anymore than than the average doc. So I do think it's something we have consensus that we'd like to fix. And at Banner Aetna we are laser focused on identifying any early successes in that field that we can bring to our market to help docs and patients get what they need in a timely fashion.
[00:13:19] The professional ideas and opinions expressed in this podcast are mine and do not reflect those of any current or past employer. Thank you so much for listening and we hope you'll join us next time on the Groves connection.
