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November 2018

Digital Health, the Disconnect

As I returned from my talk on digital health in Las Vegas to a group of physicians, ranging from mid-career to near retirement / and retirees, I realized that the spectrum of generational disconnect among physicians in terms of understanding and acceptance of what has become the new way we view and practice medicine. I remember a time just out of residency 15 years ago when I joined my first practice. EHRs were just being implemented in our hospital, and I came across a number of senior physicians who decided it ‘was the right time to retire’ as they did not want to have to convert their practice and thousands of paper charts to a CMS mandated electronic record. They did not want to adapt to the new technology then and I see this now when we talk about digital health, Artificial Intelligence, Wearables, Internet of Things. I don’t think we can stop the technology train. Either we get on board or de-board. I don’t blame those who feel that its not worth the effort. After all, technology seems to be moving at lightning speed that it could make your head spin. Just when you figured out ‘Meaningful Use’, it went to this dark grey phase and we all had no clue what its was useful for. Just when you thought that million dollar EHR software your practice purchased 3 years ago and took that many years to get everything converted and working, you find out that it is useless, inoperable, dated--- just like last years iphone. Because the software you need now is not compatible to your EHR.

But at the same time, as seemingly accelerated technology has taken healthcare (last model is gone with your last blink) there are I believe more to rejoice about. I had one senior physician comment “star trek” medicine when I spoke about AI and the role that computer modules and deep learning have helped remove some of medicines redundancy and how these computer learning can have amazing accuracy, consistency that often were variables in medicine. For example in Radiology, dermatology and ophthamology where often these specialties rely on visual learning.

There was an interesting study conducted by JASON, a think tank commissioned by the U.S Department of Health and Human Services on Artificial Intelligence. The study compared machine learning where + 30,000 dermatologic images of malignant lesions with confirmed biopsy were taught to the computer. When a head to head comparison of The malignant images of the lesion were shown to the computer vs large set of practicing Dermatologists, the accuracy of identifying a malignant lesion visually alone was astonishing on par or even more accurate than the dermatologists surveyed.

Radiology has been in the forefront in digital health for years. I remember being a resident over 15 years ago, and we were using “tele-radiologist” from overseas when it was after hours on the East Coast, for them is was the middle of the day. It afforded our local radiologist the flexibility of not have to work after hours. We see this Telemedicine increasingly used in remote and not so remote facilities. For years it provided physician access to more rural areas of our country otherwise lacking the specialties. Now we see its use in more hospital microcosms. With the convergence of large health systems and push for value care, efficiency, and more streamlined care. We see more systems creating their own environment to solve throughput, efficiency, specialty accessibility, and provider flexibility. Several ICUs, even in urban settings use teleICU for after hour care. This works because most ICUs are self contained and protocol driven. A perfect example of how ‘protocols’ (analogy to computer protocols) can work very well, of course with the appropriate trained providers to manage and oversee these systems and protocols. Another example of the use of telemedicine in the ER’s. Hospital systems utilized telemedicine to help decompress their multiple site ERs and facilitate admissions.

An example of how telemedicine can provide value based care was an article from JAMA:

“Implementation and Evaluation of a Large-Scale Teleretinal Diabetic Retinopathy Screening Program in the Los Angeles County Department of Health Services”.

Here was the situation: LA county Dept Health Services : >800,000 pt visits/year.

There are 200 PCP clinics , but only 6 optometry + 4 Opthamology clinics to serve the population.

Diabetic Retinopathy affects 50% population w DM in Latino population in LA county

The Average wait time to see Specialist for DR screen > 8 months

Here was the objective: To determine whether a primary care–based teleretinal DR screening (TDRS) program (using trained existing certified medical assistants to use the cameras in primary care settings and to upload these digital images via our web-based screening software (EyePACS software; EyePACS LLC). reduces wait times for screening and improves timeliness and decrease need to see specialist.

Here was the conclusion/findings from this study: Among the 21 222 patients who underwent the screening:  A digital TDRS program was successfully implemented for the largest publicly operated county safety net population in the United States, resulting in the elimination of the need for more than 14 000 visits to specialty care professionals, a 16.3% increase in annual rates of screening for DR, and an 89.2% reduction in wait times for screening. Teleretinal DR screening programs have the potential to maximize access and efficiency in the safety net.

We are at exciting time where technology can be the bridge between conventional medicine and providing a more efficient great quality patient centered care. Much of the redundancy and labor intensive paperwork, red tape can finally be reduced and bring back direct great patient – physician care. Providers will have more meaningful time with their patients.