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Nick:

Good afternoon, everybody, as well. Good morning. I would like to welcome everybody to the webinar entitled Digital Health The Future of Patient Experiences. And before we get going with the questions and answers, I would like to introduce Robin. So in our last webinar, we spoke about telehealth as a new normal and how telehealth solutions are transforming health care models. Well, today, Robin Farmanfarmaian. She is a very distinguished sports business Development Council member; health care thought leader, published best selling author and professional speaker, cofounder of Face Toucha, where she joins us to share her experience and insights on digital health, the future of patient experience.

Again, it’s the title of the webinar. So let me just begin and say digital health is the convergence of digital technologies that would help. I’m sure everybody is sort of the Internet of things in digital enterprise architecture. And when they speak of big data, it’s not just big data to multivariate the type of content, a set of files. Health care, living in a society in a digital health market, is expected to reach approximately five hundred and ten billion dollars by twenty-five. Of course, to the baby boomers giving up their own age. So let us begin to find out from Waupun how digital health care has evolved and how it can positively impact healthcare providers and patients. Again, Rob, and welcome, and I apologize for your last name, so I will have a series of slides to present and give you control to present those slides. Thank you. Perfect.

Robin:

So, hi, everyone. I hope you will be able to see my slides. As he mentioned, I’m Robin Farmanfarmaian, and I said my last name on stage incorrectly. So don’t even worry about that. It’s a tongue twister. So as you mentioned, I’m a professional speaker, early-stage entrepreneur. And today, I’m going to be talking to you about that new shifting patient experience. And that’s really happening because of the shift in health care delivery, all of the different trends and technologies making that happen. So let me talk to you a little bit about who I am. So my life goal is to impact one hundred million patients worldwide. As an early-stage entrepreneur, as you heard, I’m a co-founder of Phase Touch Aware, an Apple Watch app that alerts you when you touch your face to break the habit and reduce your risk of catching the disease. We did this as a part of the pandemic, obviously, but typically I’ve also worked on things like curing cancer, sleep apnea, inhaled insulin with a smart, connected device for diabetes, and even virtual reality for stroke and brain injury rehabilitation. But that’s kind of crazy, right? Like, I work across some of the world’s biggest diseases, and it’s because I believe in paying it back by paying it forward. You see, I’m a severe chronic disease patient as well. And at the age of 16, I was misdiagnosed with an autoimmune disease. By the time I was twenty-six, I’d had forty-three hospitalizations, six major surgeries, and three organs removed. And at twenty-six, my doctors kept telling me I was cured at that point.

But they kept upping and upping my opiate dose because I was in extreme pain, extreme abdominal pain. So eventually, I was on eighty milligrams a day of methadone. Now, this is a gigantic dose. I mean, essentially you’re taking heroin at that point now, which my doctors and I said I’m a shot and I could not function. I couldn’t work. I said I need off from these medications now. And she said, well, the next step could be to implant a morphine pump into your spine surgically. Are you kidding me? I was twenty-six. I couldn’t even function. And they were telling me that was the rest of my life. So I said absolutely not. And I fired my entire health care team, went home, and dropped my own methadone dose by about 40 percent. So I went through pretty severe, essentially heroin withdrawal for a week. I ended up rebuilding my health care team. I got diagnosed correctly with Crohn’s disease, put on a biological medication called Remicade. And within twenty-four hours of that first dose, I went into remission. By taking control of my health care not only gave me back my life, but it most likely saved my life. And so I believe in paying it back by paying it forward. I know I’m alive today, not just because of that one doctor. Still, because of the pharma medical device, hospital systems, even the government all working together to provide this robust health care system that allows me to be alive today. All right.

So now that I’ve shocked all of you, the story you serve as an option. Now I’m going to talk to you about all the cool technologies that are really empowering other patients to not only take control but pull health care into their home. So right now, we’re starting to see a lot of point of care diagnostic devices hit the market. What that means is a diagnostic device that comes to the patient versus a patient having to go to a traditional setting like a hospital or clinic. We all know about the Apple Watch.

Apple Watch now, of course, has a clinical great single lead EKG monitor. So what you can do is you can take your EKG, send the data to the healthcare cloud where it can be shared across the care team and, in some cases, analyzed by artificial intelligence. And then, of course, if you do need to see a doctor, you can do it right then and there on demand using telemedicine. But a lot is going on way past telemedicine. So I’m not even going to cover that.

You can actually now get it in the home. Companies like He’ll Heal an app. You just go on it and order a doctor or a nurse on demand the same-day or next-day appointments and come to you. And in fact, for the past few years, that’s how I’ve done my flu shot. I’ve just used a field doctor. They came to my apartment, asked me a couple of questions, gave me the shot, bam, less than five minutes, and fully paid for by my insurance company.

Now, let me tell you about what some of these big guys are doing because these are really the movers and shakers in health care as these types of companies go, the rest of health care has to follow because they are just so giant, so united health care. This is the largest of the private payers. It’s a Fortune five company with 50 million lives. They now send a doctor or nurse to your home for free one time of year if you’re one of their patients to do a full checkup. They also have been pushing telemedicine since way before the pandemic. I was getting emails once a week, even back in twenty nineteen, saying, hey, if you, by the way, if you want to see a doctor right now, click here for one of our doctors on demand, and we’re going to cover that for you. Humana, another large private payer, has moved late-stage kidney disease into the home. And again, this started before the pandemic, which needs dialysis. See, patients who are on dialysis typically have to go to a hospital three times a week, and each session lasts about four hours. So their entire life is just going in and out of the hospital for the rest of their life unless they’re lucky enough to get a kidney transplant.

Well, Humana is changing the game for patients. Can you imagine, instead of spending your life in the hospital, you get to spend it at home and have the health care professional and the dialysis machine come to you. 

Now, let’s talk about Wal-Mart. Wal-Mart again, it’s one of the largest companies, they have over two million employees and one million of them here in the United States. And they are self-insured, which means it’s in their best interests that their employee’s health care is not only good but inexpensive. What they’re doing is called medical tourism when one of their employees needs some kind of major surgery. They are actually flying them to other states where they can receive good Care at less high prices. CBS has over 9000 retail stores in the country. Now they are spending up to about three hundred and fifty million dollars over the next few years, beefing up their primary care clinics in their retail stores. Right. So you go in there, you can buy your groceries, get your prescription, and then monitor one of the top five most expensive diseases because that’s what they really want to focus on, things like hypertension, which impacts one out of every three Americans, by the way, diabetes and coronary artery disease, otherwise known as I had never seen it seems very interesting to go to CBS because I believe they bought Aetna.

Nick:

Yes. And a major, major company. Oh, OK. And going back to Wal-Mart, just a quick question. How does Wal-Mart address having insurance across state lines, different states when that particular state may not approve the insurance? And I’m thinking of New York, where I live.

Robin:

Right, well, companies like Wal-Mart have enough clout to be able to do special deals, right? Like a regular private insurer, United or Blue Cross Blue Shield goes to Stanford Hospital every year, and they renegotiate

contracts. Wal-Mart does the exact same thing because they are both a payer. Right. But then also the employer. And so they just make special deals.

Robin:

When you’re that size, you can oh; he has to have a lot of clouts. Exactly. Sure. So we’re seeing a lot going on in biometric monitoring. And because this has gone mainstream, places like C.M.S., which is the center of Medicare and Medicaid, they are the ones who set the standard in health care, and they are leading the way with what’s called remote patient monitoring codes, R.P.M.. And so when you go into your doctor, if your doctor says something like, oh, I want to track your Apple Watch, you’re not confused. It’s a much easier sell. And that’s a big deal when you are talking about healthcare and medicine. So things like Apple Watch, Not only are they now clinical grades for the EKG, but they just got clearance in the past couple of days for their next version, which is going to be Spiotta. They’re going to be monitoring your pulse oximeter, the amount of oxygen in your blood. Now, this is incredibly important for things like the coronavirus, but it’s also important if you have, say, allergies, asthma, or COPD. Now, they’ve launched a giant clinical trial with Johnson and Johnson. 

And if you are over sixty-five, you can get either access to a discounted watch or be paid to be part of this study. And it’s going to be a giant study around fifth atrial fibrillation. Now, why you care about a fib, by the way, is it is usually a silent disease, symptomless. You have no idea you have it. But if you do and it’s, by the way, picked up by that single lead EKG, if you do, you are five times more likely to have a stroke.

Right, so you may as well find out right now, you know, if you have a fib now, the one on the left, that is the Occitan again, clinical greyed, FDA cleared for the pulse oximeter. We also see watches do other things. The one on the right, that’s Omron. It’s five hundred dollars direct to consumer blood pressure monitoring. Watch. Now, this went on the market about a year and a half ago and sold out immediately. There is a massive demand for this. And as I mentioned, with one out of three Americans being hypertensive, this is a big deal.

One of the things we do not have in health care is massive clinical databases on blood pressure readings on patients in their home environment and when they’re not sick. Right. Because most of the biometric data that we have has been taken in hospitals or clinics when their patients are not feeling well or have white coat syndrome. And that happens to me. It probably happens to you. I run into the doctor’s office, run up the stairs, sit down, and then take my blood pressure. It’s not going to be what it’s normally going to be because I’m anxious. After all, I’m at a doctor’s office. You always get anxious. But I also just probably ran in there. Having blood pressure readings on patients in their home environment and while they are sleeping is huge when I’m on the left.

That also clears the FDA recently, and that is the bio, and they do the blood pressure monitoring a little bit differently. But again, it is a clinical grade. And this one is really cool. OK, so this is title care, so Care is available and Best Buy for about three hundred dollars is a telemedicine platform. Now, the way it works is it comes with four clinical-grade medical device applicators that fit onto a live video camera. So the applicators are an otoscope that looks in your ear or your child’s ear, a stethoscope, a temperature monitor, and a tongue depressor. The way it works is to imagine you have a really bad sore throat or a screaming toddler with an earache. Instead of taking them in the middle of the night to the nearest emergency room, you call a doctor over video through the app. The doctor walks you through using these for clinical-grade medical device applicators on yourself or saves on your screaming toddler. And because the doctor has access to seeing the live video camera feed, she’s the one who’s looking down the throat. And so she can say things like, hey, move it a little bit to the left or move it a little bit to the right to have a really good view. And it’s almost as if the doctor is reaching their hands through the computer screen.

We’re seeing sensors going onto existing inhalers again, back to things like allergies or asthma, both propellor and adhering, have cleared the FDA and let you just put them on your regular inhaler. Now, this helps track when and where you use it so that you can determine with your health care professional if your allergies or asthma are worse or better in certain times of the day or, of course, in certain environments. We’re also seeing diabetes monitoring getting simplified, and, of course, that is a really big deal. Traditionally, of course, you have to prick the end of your finger, drop blood, blah, blah, and you take your blood glucose, and you have to do that multiple times a day.

Well, instead, we now have what’s called GMES continuous glucose monitors, one on the left. That’s the DexCom, very similar to the average restyle, Deborah. Both are on the market. The way they work is they stick onto the skin, sometimes on to the ABS section, and it has a little filament that sticks right under the skin that measures glucose in interstitial body fluid. Now, this is a bit of a delay from your blood glucose levels, but this is great because it does continuous monitoring, and because it interacts with things like your app, it can alert you when your glucose is getting a little bit off. Now, the one on the right, this is the other sense. This is implantable. You have to go to your health care professional here in the United States.

It’s gotten clearance for three months. So the health care professional puts it right under the skin. It works just like the DexCom, where it measures glucose and interstitial body fluid. But you don’t have to worry about putting a filament in and out. It just stays there for three months. And in fact, in Europe, they are cleared by CE Mark for six months. Now we’re also seeing sensors going into clothing. And remember, all of these things count as RPM remote patient monitoring, which is now reimbursable by CMS. Medicare. Now, this one is very cool. It’s by a company called Sirene Care, again, reimbursed by Medicare. Now it has temperature monitors in Sock’s that measure the temperature of the bottom of your feet. Now, why this is important is because in the world of diabetes, and especially when you have advanced diabetes, if you get a tiny little hot spot on the bottom of your foot, it can actually advance to a skin ulcer. And when you have a skin ulcer in that location, it can literally advance to an amputation. I mean, if that doesn’t give you chills, it should. So what these do is they alert you and your healthcare professional if a tiny little bit of a hot spot is forming on the bottom of your feet because you can’t feel this if you have advanced diabetes, by the way. And so the temperature is taken by the socks, you’re alerted, and then you can heal it before it turns into an ulcer, which would eventually lead to an amputation.

Oh, and by the way, you can just throw them in the washing machine, that’s it like there’s no special care. These sensors can be washed, something like 50 uses or something like that. We’re also seeing blood labs going into the home, and the patient orders these. This doesn’t go to your insurance company. It does not go through your doctor. You just go on CBS dot com or Everleigh well, dot com. You order a test kit through the mail. It comes to you, and it does everything from things like cholesterol, glucose, of course, fasting, glucose, kidney function, liver function, thyroid function. And in case you have a really hot date, do a lot of the STDs now, the way it works, it’s between sixty dollars and says three hundred dollars a test, depending on how complex the tests are. You get the kit in the mail you prick the and your finger drops of blood go into a little container and bam you throw it back through the mail, and they use what’s called police certified labs, which are standard here in the United States, which means you and your doctor can take action on these results. So you don’t even have to go into a doctor to get your labs done. And this is me, by the way. It’s that room right there about two feet away from me. That’s my living room.

And I get the vast majority now of my health care in my apartment or within a two-block radius. I mentioned earlier; I already get my flu shot in a home here. I’m getting my Remicade now. I’ve been on Remicade for about 20 years. It’s a game-changing biologic. Nobody tries to do the math. I’m still obviously just twenty-nine. Now, the way it works is I use what’s called a full-service pharmacy. My doctor sends in the script, and they ship me the medication on ice by a special medical courier. And the company I use is called Option Care, which is actually minority-owned by Walgreens. So it used to be called Walgreens, the Dallas option care, but they sent me the medication. I put it in the refrigerator. The next week they deploy a nurse to my home. She mixes the medication on-site, which would typically be done in a hospital pharmacy. And then she administers the medication to me over a period, about five hours, because I get a couple of other things done simultaneously. And she draws on my blood labs that my doctor wants, and she drops them off at the nearest labcorp, which is one of the giant labs here in the US Now, when I was doing this in the hospital, it took me about eight days to recover. And this is a pretty hardcore medication. It’s for autoimmune disease. So, you know, they’re suppressing your immune system.

And I thought it was the medication. And so I knew if when I get my meds every six weeks, I’m just going to have a week or I’m not going to feel well. Well, five years ago, I moved it into the home. My recovery time went from a very hardcore eight days to a mild less than three days just by changing the patient experience. Now, this is not something we’ve been able to take into account all these years because pharma and clinical trials are already difficult enough. And there was no way to really kind of get that data from patients saying, hey, I feel much better when I do this in the home, then when I do it in a noisy environment such as an infusion clinic. Because when I went to my infusion clinic and I used very high-end hospitals, I’m in the San Francisco Bay Area; you can’t walk five feet without walking into one of the top doctors in the world. But see, hospitals were built, right? Yeah. Hospitals weren’t built for fun, five-star experiences. They were built to save and sustain life. And so it’s definitely understandable. But the experience I went in there was fifteen other patients at the same time on IVs in one giant room. And so if I wanted to, I had a curtain. But that means I heard beeping from their IV poles nonstop for five hours straight. Right. Plus, televisions blaring, conversations happening, and there were no windows.

I was in the bowels of the hospital. It was almost as if I were sitting at busy airport security for five hours straight, getting pretty hardcore medication. So, of course, changing that environment really changed the equation for me with this med. But let’s take this one step further. I’m doing vaccines in the home. I’m doing IV medication that’s planned. Well, a couple of years ago, I got one of those twenty four hour GI flus, the pretty uncomfortable few days for a normal person. But with Crohn’s and no large intestine, it’s life-threatening. And within hours. And so I went to bed on a Friday night, and I was like, I wasn’t feeling that. Well, Saturday morning by 7:00 a.m., I knew if I did get IV saline and IV magnesium, I would die that day. Absolutely. And that the problem is, is I didn’t want to call nine one one. First of all, I was in no state to actually talk, so I couldn’t get across to doctors or the ambulance drivers what was actually wrong with me. Right. So they’d have to do a huge number of complex tests even to figure it out. And all I knew, all I needed was I’d be sailing. When you’ve had Crohn’s disease your entire life, you know what you need in these kinds of things. You find that with chronic disease patients, but also they would have brought me to what’s called a level one trauma center because that’s only a mile from my house, is the nearest emergency room.

A level one trauma center is prepared for brain surgery, heart surgery, major traffic accidents, and gunshot wounds. All I needed was a nurse their first day out of nursing school to come to give me IV saline and magnesium. That’s it. And so, instead of going to the ER, I used an app called IV Doc, and I ordered a nurse on demand. This is direct to the consumer. It doesn’t go through your insurance company; it doesn’t go through your doctor. Now, the nurse arrived at my house about an hour later and was in my bedroom faster than if I had actually gone to an emergency room and gotten IVs that way. So the nurse was there about two hundred and fifty dollars. A leader gave me megadoses of IV magnesium, which I needed, and two sailing liters. And I used them and my full-service pharmacy when it opened up on Monday for the next four days, keeping myself out of the emergency room and out of the hospital. And by the way, it cost only a few thousand dollars; I think, all in which my insurance company did cover the stuff through my full-service pharmacy. Had I gone through an emergency room with stomach pain and that sick we are talking; this would have been tens of thousands, if not closer to one hundred thousand by the time I was admitted. Yeah.

And so, you know, why would I go to the hospital? Now, let’s take this one step further. If I’m doing vaccines, I am doing medications that need to be mixed on-site by a nurse or a pharmacist and sent over. I’m doing on-demand urgent Care, essentially. Oh, and by the way, before I talk to you about these clinical trials, CMS. Just launched, it should be live this month, and next month there should be three programs, it’s something like three. But what it is, is they have now partnered with hospitals all over the United States that have ambulances, and the ambulances now go to a patient’s home when they’re called nine one one. And suppose they are able to treat a patient on-site like they would have been able to, in my case. In that case, they no longer go into the emergency room if the patient needs to see a doctor, because, of course, ambulances typically only just have nurses and technicians and the ambulance drivers, but they don’t actually have physicians. The physician is called over video right then and there by the nurse. Now, if needed, they will also bring them to the urgent care center before actually taking them to an emergency room, which is a significant difference in price. Right. And so not only am I pulling my own Care, but CMS is trying to pull Care out of the emergency rooms as well. Now, let’s go into these virtual clinical trials,

companies like Science Thirty-seven.

They just did another 40 million dollar raise last month, bringing their total funding to about one hundred and fifty million dollars. And in one of their rounds was Sanofi, one of the largest pharma’s largest pharma. And so, you know, the big farmers are really thinking this way as well. So the way science thirty-seven works partners with the pharma or the med device, they ship the medication to the patient’s home, just like my Full-Service pharmacy. With it, they sip a smart tablet. So all the clinic visits take place over the video, and then if needed, they can deploy a nurse to the home environment like the way I do it. Or if the patient needs something like an MRI or a CAT scan or something, they can do it in their local vicinity. This is a really big deal in the world of clinical trials because

typically, once you pick your clinical trial sites, which hospitals or clinics that you’re going to be running it out of, you are then limited to that geographic location and that geographic limitation to that patient pool, which means if it’s just in New York as a California person, I can’t join that clinical trial. But as we know, not only clinical trials are very difficult to fill, incredibly difficult to get as many patients as needed into them. But expanding the global patient pool, not only will they be able to fill the clinical trial, but they could potentially save more lives, right? Exactly. Good point.

And Makan is just out of upset with UPS’ medical equipment division. And they’ve not only been doing clinical trials in the home, but they are also working with Merck to do vaccines in the home. So shipping a vaccine to the patient’s home and then deploying the nurse. I’m sorry, I just have a quick question and there are so many questions you raise. An excellent point, Robin. Thank you for my background in biomedical research, particularly in analytical projects for the CDC. And by the way, I was in your backwoods at the University of San Francisco. With all this data being collected remotely. Per patient basis.

Nick:

Wouldn’t this have the net effect of speeding up trials of new experiments of medications because now they’re able to take all this data and use machine learning algorithms, supervised learning, and that too really? Break down maybe by patient segmentation, like customer segmentation in marketing. So do you see any positives, or is that occurring? Because I have not seen it in terms of a massive scale.

Oh, yes. So when I was just talking about before with the Apple Watch and Johnson and Johnson, Apple Watch has also launched a coronavirus study. Fitbit has launched a coronavirus study. And so they are already doing exactly what you’re talking about. But in terms of either treatment, seeing if they can see if people have coronavirus days before they actually exhibit symptoms. So these big guys are starting to do that kind of thing.

And in terms of, you know, it’s ironic, and we discuss this. A couple of days ago, where I’m old enough to remember when the physician made the visit to your home family practitioner, it seems like it’s turning back with the difference or the advantage of now, instead of relying

upon a local family physician, you have physicians anywhere in the US, and so that personal customer relationship management is really coming into play. So it’s, but it’s really amazing.

My last question, I’ve worked for a national health care system for Great Britain on a major project. Overall, there are systems, and I worked for Lockheed. What do you think? National health care, if we would all be political, if we go national health care, wow. And now the governments in.

Nick:

Robin, because when you were mentioning receiving medications through a remote physician and so on in New York, now if my doctor refills my medication for cholesterol. Since it’s a controlled narcotic, it has to go to Albany for approval. So I’m wondering, where do you think we’re going? Because of the free market place and all this innovation can lower health care costs. But at the same time, we have. The perspective of national health care.

Robin:

So that whole Medicare, for all things, is not going to happen, not anytime soon. I mean, when you think about how big those private payers are, and these are private corporations, no one told them they should be the guardians of the health care industry. These are public with stockholders and boards of directors, and they have to show a profit. These are giants, right? These are some of the biggest companies in the country. So they need to be on board.

Does someone have to figure out how you turn these giant public companies into a government entity with all of these stockholders? Right. And so just those negotiations and figuring out that kind of a plan for all the private payers, that’s going to take years. Yeah, I know. When I was director of product development or spent a lot of time in Canada on their national health care system, it was ironic. They were turning into a mix of seventy-five percent national health care, but twenty-five percent allowing private insurance. So this is a business. 

Nick:

Yes. Business, you know. Exactly. Exactly. But I’m very interested in getting into artificial intelligence. So thank you for me interjecting several questions. Thank you.

Robin:

Sure. So I’ll spend the next 10 minutes or so and then we’ll open it up for questions. So because all of the stuff I just talked about is really collecting all of the data that we need to be able to use. I and, in fact, I am not even new technology. It’s old technology. And it was a phrase coined in the nineteen fifties with the reason we see so much going on in health care because of this one simple fact that life begins at a billion data points. We need it that much clinical, great data cleaned up, aggregated to even think about using artificial intelligence. Now. Exactly, yeah. The really cool thing about technology is it makes things seamless. A lot of companies are working to be that beautiful report card that gives you like that minute by minute check up on your health. That’ll be a beautiful dashboard on your smartphone, or your smart tablet. Now, while there are a lot of companies working on this right now, Apple is winning this war. Not only did Apple take the vast majority of the music industry’s profits for years just by being that thin software layer that aggregated the buy seller marketplace well, but they have also now partnered with most of the United most of the hospitals here in the United States.

And with just a couple of pushes of your buttons, if you have an iPhone, you can download the patient portal side of your EMR, your electronic medical record. These are the first ones in the private know in the private space. Not the VA has been able to do this for years, like ten years, at least. But Apple was the first one to really aggregate EMR data from multiple types of Ima’s. Not only that, but they are controlling the data collection. Now, there are two clinical-grade sensors now on the Apple Watch, and those are just to start. They are going to all be multi-functional over the next couple of years. They’re going to add a lot more capabilities to the Apple Watch. And by the way, the Apple Watch over 50 million have been sold worldwide, and they outsold the entire Swiss watch industry last year.

Nick:

Exactly when I worked with the late Dr. Clayton Christensen from Harvard University, the S curve father, disruptive technology. I had a chance to work with him when I was working on my MBA at Rochester Institute of Technology. And if you remember, two thousand and three, the iPhone was making its introduction, and a lot of people didn’t know how to use it. It was so innovative, like a Swiss Army knife. So my whole point is a lot of these clinical biomedical innovations are really not innovations. They’re disruptive technology because they’re disrupting the way we do business within the clinical and medical research. And they have six.

Robin:

Yep, exactly. Now, in terms of AI software programs, we’ve seen more than 50-50 clear the FDA, more than half of that, by the way, as it was in twenty nineteen. Now, most of these are around things like radiology, imaging analysis, CAT scans, CAT scans, MRI echocardiograms, because, of course, that is what AI is best at, which is predictive analytics. Right. And that’s imaging analysis. But we see it hit many other areas, especially things like cardiology. Now, most of these are just really to help the health care professional. So you’ve got your radiologist, and the eye software program will say, hey, by the way, did you look at these three things? Right. And it will give the reasoning on why that AI program thinks that all of these, except for one case that is and that’s a company called Idy X, it is clear the FDA to be the world’s first AI. algorithm. This diagnostic does not require a health care professional of any kind to interpret the results. This is a big deal now. In this case, it’s a very narrow usage. It’s artificial, narrow intelligence for those of you who know a lot about artificial intelligence. It’s really good at this one particular thing. This is for what’s called diabetic retinopathy, which is a leading cause of blindness in patients who have diabetes. Now, where it works, though, is that the patient has to go to the health care professional to get their eyes checked because the equipment is still costly and big. But you can do things like a primary care office or even eventually have this in a CBS.

Right, or a Wal-Mart, because, of course, getting into an ophthalmologist takes time and a lot of money. Instead, you can go to something like primary care, get your eyes checked, and in 60 seconds, the software program will be able to analyze it and tell you a binary answer. Yes, the patient has early-stage diabetic retinopathy or no; the patient looks good to go. Come back next year and get checked. We also see a whole new category, of course, called digital therapeutics. These are acts by prescription only. You cannot access these apps unless you go to a doctor and they give you a prescription. So the one on the left, this is a company called Perre Therapeutics, and they’re really the world leader right now in digital therapeutics. Now, this is for addiction, but they have a bunch more that are about ready to come out on the market, one on the right. That’s a company called Big Health with its products, LEPO, and it’s around insomnia. Now, both of these use what’s called CBT cognitive behavioral therapy, and it’s used in conjunction with your health care professional. So you don’t just get prescribed the app, and then that’s it. 

You’re prescribed the app, and you are interacting with your health care professional as well. Now, this one’s really cool; this is a company called Brain Check. Now in the world of dementia, one-third of dementia cases are preventable. If that doesn’t blow your mind, this should now be the world of dementia; typically, we don’t go to a neurologist until we’re so far advanced that dementia is actually impeding our daily life.

And if it’s impeding your daily life, you are too far advanced for pharmaceutical intervention or behavior lifestyle modification. Right. But if you go, brain check is just the standard neurological exam. They’ve been electrified. They’ve been a game of hiding, and now you can get it through your primary care office. When you think about the fact that there are about a quarter-million primary care docs in the United States, but only fifteen thousand neurologists. It’s much easier to test patients in the primary care office, get a baseline on your brain health the same way you do with your cholesterol or your glucose. And then you can catch things at the very, very early stages before it actually goes into dementia and it becomes untreatable so that you never actually get it. Oh, and by the way, it’s an app, so your primary care, you can go in and use an iPad there, or they could actually send you the app to use on your iPad. But I do want to make this point. Healthcare Artificial intelligence is never, ever going to replace the doctor. It’s doctors who I use. I am going to be the ones who replace doctors who don’t. This is a very, very important part. We are not getting rid of the doctor. We are just enhancing their abilities. All right, and let’s just switch into a couple of minutes of voice technology, and then we will open it up. Did you have a question, Nicholas?

No, I was just going to say that they’re using robotic arms to assist surgeons, minor things at Cornell Medical. So it’s, and they’ve been experimenting while I was experimenting with trying to have some level of human consciousness into it and into this robotic sort of machine. So it’s very interesting.

All right. So let’s flip into AI voice technology because this is really getting a stronghold. Now, the reason we are starting to see a lot more voices like Amazon, Alexa, and Google home is that the error rate for understanding spoken English for an AI has dropped to under three percent. That means it is now better than human beings because an American born English speaker has a four percent error rate. I can now outperform myself at understanding spoken English. And in the US, over eighty-seven million people now have smart speakers. And in

terms of Google, over a billion have been distributed, and it’s available in 30 different languages. So you can imagine the amount of data now both Google and Amazon are collecting daily and utilizing on a daily basis for clinical data analytics. Now in health care, it’s going to be hitting very specific areas, things like boufal biomarkers. Now, this is really cool. It’s by being able to use a patient’s voice, the tone of voice, the way they string words together over some time, even at the speed or the slowness of the voice as one data point that can help lead to an overall diagnosis. Now, there are quite a few companies if you want to Google, Google Saund, and they’ve got a lot going on in the voice space, but also Mayo Clinic.

Last year they published a white paper, and they saw a correlation between coronary artery disease, Cadd, which is the top five most expensive diseases, and a patient’s voice. So we will get to the stage where Amazon, Alexa, will have a voice skill, which is the same thing as an app, a skill that will be able to tell when you set your alarm through Amazon. Alexa, if, in fact, you are starting to get in trouble with your coronary artery disease, it’s pretty cool things like patient engagement and communication. And I’ll show you a slide in just a minute on some of the

hospital management systems and what they’re doing. But really engaging Amazon, Alexa, into your actual health care on a daily basis. Of course, the physician notes the EMR is, of course, extremely onerous and difficult to use the electronic medical record. There are many voice boxes out there because one, there’s clinical work, says one called ADA. So you just use it just like you do with Amazon. Alexa, you go up to Clinical Works EMR, and you say, hey, ADA, pull up. Robin’s lab results from today and the voice bot will be able to do that makes it a lot more streamlined for the doctor and the nurses and aging in place. And I’ll show you a couple of devices with that.

But being able to keep our seniors in the home longer because instead of trying to do something like the program a VCR, which even I can’t do at the age of twenty-nine, they can just interact with their Amazon, Alexa and to say, hey, call my doctor or hey, call my son, and they don’t have to worry about it. Now, like Amazon, Alexa is now piper compliant. This is a big deal now in terms of some of the big guys, Express Scripts, who take care of a huge number of prescriptions here in the United States. You can now check on your medication delivery or refills through the Amazon skill, like the bongo. If you hadn’t seen them, they went IPO, and then they just announced their merger with Teladoc. So they are a giant. Now, in the world of digital health, the Vango helps manage things like chronic diseases like diabetes, and it hooks into the jams, the continuous glucose monitors. And so now you can go up to Amazon. Alexa, check on your glucose readings because it’s actually reading your CGM, which is pretty cool. Signa, again, one of those large private payers is about five or six of them, and Cigna is one of those. You can actually interact with your insurance with your Amazon.

Alexa, now atrium health, is a very innovative chain of hospitals in North Carolina. And you can find the nearest urgent care or even make an appointment with your doctor by just saying, hey, Amazon, hey, Alexa, you know, in the Voice app and then using it with your voice. Now, in terms of the hospital systems in the hospitals, that’s already going into it. Such companies like Cedar Sinai, which is very important, one here in California as well as Northwest Health, they’re putting smart speakers like Amazon, Alexa in patients rooms so they can interact with the care team, they can interact with the room and say pull the curtains or turn on and off the television and in some cases even interact with their medical records management. So you can ask the smart speaker for your own lab results that day. Mayo Clinic is using it for skin sutures for post-surgical instructions. So say you have some kind of a skin problem. You go into the hospital and get sutures that will send you home with an Amazon skill app that will check on you. How cool is that? And Boston Children’s is using it to prep their operating room, doctors, and nurses before they go in there to do an organ transplant. So they don’t have to worry about looking at screens or looking at the paper.

Amazon, Alexa, will just tell them what to expect when they go into the operating room. And we see it in different ways than just those simple speakers, one on the left here, that’s the eye Powell robot, and it’s specific for dementia care and for child care. Now, this is just a smart speaker on wheels with a tablet. Like it doesn’t actually do anything. It’s not going to sweep your house or do your dishes. It can do things like dance, but otherwise, it’s just a rolling, smart tablet and speaker. You can interact with it. One on the right. That’s the cue. And it’s coming out of

Israel and it’s specific for eldercare. And so it comes with a smart tablet and that smart speaker, it can do medication reminders. It can do things like reminiscence therapy, which usually a caretaker with someone who has dementia would go over the same stories over and over again all day long to really help the patient remember things. Instead, the like you can do that takes the caretaker’s place and, also, the, you know, grandma schedule. So if grandma walks past her every day at 9:00 a.m. to go get tea in the kitchen and the king doesn’t see grandma do that, you can alert the care team.

I see benefits, really. Yes, you’re wrong; you’re showing the walking while the robots are physical; there have been huge advances in discrete manufacturing, particularly military systems using robots from Nissan that basically are taking on a level of human consciousness. Now, do the Racheli, their position on the various manufacturing sounds amazing?

Yeah, it is pretty cool. Oh, and I’ll close it out on a story coming out of Wal-Mart, and then we’ll open it up for some questions. Thank you. So as I mentioned, WalMart has like half a trillion dollars a year in revenue. Like this is a giant company, and they are self-insured with a million employees. So it’s in their best interest for multiple reasons that their employees are healthy. They took 20 years of consumer shopping data. They layered it over 20 years of electronic medical record data. It turns out if you change your laundry detergent one time in a year, you are 50 times more likely to have diabetes or prediabetes. That’s chilling, right? Well, it turns out one of the first symptoms of diabetes is sensitive skin. And one of the first things people think to do is, oh, my skin all over my body. It’s sensitive. Maybe I developed an allergy to my laundry detergent, and they switched it out. Well, Wal-Mart, since they understand and know which one of their employees has switched out their laundry detergent for the year, they can send them an intervention. They can say, hey, I have this free Apple Watch. Oh, and by the way, as long as you get ten thousand steps a day every day, we’re going to give you a one hundred dollar bonus at the end of the month. Isn’t that pretty cool, and they don’t even have to disclose things like there might be prediabetes because it’s only a risk adjustment factor at that point, but they’re making sure we get to those patients who are at risk. And that was one way to identify them. And with that, I will take some questions.

Nick:

OK, Robin, again, thank you very much. So the first question is from Ryan Murphy, and he basically says currently, patients are enjoying communicating with their physicians using digital health tools. But will patients prefer digital health systems? Even post Covid19.

Robin:

Of course. OK, so if you think about it, if you saw your primary care doctor and it was just for an annual checkup or something like that, we didn’t need any tests done. Usually, you have to take, what, four hours out of your day? You have to leave work, or if it’s with your kids, you have to take them out of school. You’ve got to drive there in traffic, park, pay for parking or go through complicated parking systems. I know whenever I went to Stanford, I would get lost. Like, I’m like, where is my car? And it actually takes a huge amount of time and effort out of your day for a ten-minute appointment that if you don’t require tests or anything, hands-on. And about half of my appointments, even with my doctor, don’t require him to touch me at all. I would much rather do this over video or even by email. I’ve been taking those four hours out of their day, and like with everything else, change was for some people. But now that they’ve experienced, they’re like, why would I do it any other way? Now that I get IVs in the home? Why would I ever go to the emergency room to get an IV?

Nick:

Exactly, exactly. And, you know, just take a look at the executive, rather male or female traveling when we used to travel a lot. The ability to do telehealth is just amazing. It’s just amazing. This question comes from Greg Sanker. There’s a lot of hip hop data associated with Telemann. What are the implications for technology, infrastructure, and information security? I’m a former CIO.

Robin:

So I was actually advising a company recently that does security application code scanning, and so they have invented a method that is able to scan every line of code throughout the world every day. So that kind of thing is going at scale, and it will be able to find some of those discrepancies. I mean, that’s something we have to worry about in every world, whether it’s healthcare or finance. Right. But the one thing I do tell patients because a lot of patients are really freaked out about this, they’re like, oh, wait, I don’t want my medical stuff out there. They say, why are you worried? Why are you worried? Nobody cares. There’s nobody in the world who actually cares what your glucose or what your blood pressure is. Nobody in the world cares that I had surgery right like that. That information can’t be used. What can be used is the rules and regulations on how to apply that information. So there’s five or six major payers, plus some of the government ones, the VA, CMS, and then you’ve got your big conglomerates like Kaiser Permanente. So that’s maybe ten companies in the United States, probably know the medical history for 90 percent of Americans.

They have the information they have. It’s the rules and regulations on how they are able to use that information that you care about right now in terms of criminals, criminals, again, they don’t care about your blood pressure readings. They use some of these medical devices for our digital health systems as a backdoor to get into personal information, which includes your Social Security number, mother’s maiden name, and bank or credit card information. That’s what you care about. So it’s the back door to the financial stuff. Nobody in the world cares about your medical data.

What about in other industries like the auto industry? Years ago, there were these third parties, while there are still these third-party data companies, and they would collect data and then sell it to GM or Ford. So basically they could do there. They could develop effective marketing campaigns. Nothing personal, like you said, but it’s trying to get a reading on while we should send some sort of ad? Do you foresee that? And with all these medical devices, remote medical devices, and telehealth, do you foresee data occurring? It’s already occurring. Think, and then when you think about Amazon, I didn’t click this one into my presentation because there’s a limit, but they just came out with their digital health watch, and it will analyze your voice for emotions.

Now we have smart billboards that already recognize us, right, so that you walk up to a smart billboard and it changes based on who’s looking at it. So maybe it would show me an ad for, I don’t know, t and show you an ad for a race car or something like that. Yeah. Now combine that with the fact that even ten or twelve years ago now, like IBM, Watson was working on things like psychotic breaks. So they took one hundred people at risk of having psychosis. And you’re about one percent risk between the ages of seventeen and twenty-five or twenty-six or something like that to have a psychotic break. And so they took at-risk individuals, and they used artificial intelligence to analyze their tone of voice, their facial expression, the way they studied words together over a period of time, took all of these data points, and they were able to predict with one hundred percent accuracy.

Nick:

How long ago was that?

Robin:

Twenty, fourteen, twenty, thirteen. Because in twenty seventeen, I did a project for the University of Rochester in Rochester, New York, for mental illness, like, for instance, different medications for bipolar or how would it affect different patients? Again, patient segmentation. But I would have my own analytical engine called Winston Churchill. But basically, it would not only give you several paragraphs of its interpretation, but it would also give you statistical analysis on your certain emotions. And it was really amazing because it came to really good use to help intercede before someone, rather, did something or committed suicide. So, yes, very interesting.

Very helpful. But Facebook knows more about my mental health and my political status. And I’ve never posted anything about my mental health, and I’ve never posted anything about politics. It knows exactly my personality. It knows my mental health already. Yeah, yeah. When you say personality, well, you know, Robin likes to ask Open-Ended questions. So Winston wants and needs to respond to you in this way. The next question is from Mr. Howard. How effective do you think digital health apps can educate patients to reach the stage of self-management and improve their quality of life?

So what gets measured gets monitored. Right, good. It’s the same thing in healthcare business intelligence as it is health care, and if I can’t measure it, I can’t improve it. Right. But just giving the data points, I mean, you might have gained 40 pounds, but you didn’t realize that because it creeps up over a period of time and you suddenly weigh yourself, and you’ve got that data point. You’re like, wait for a second, how did this happen? And you take action on it. That’s a very simple explanation. But I mean, of course, when you’ve got blood pressure, cholesterol, I haven’t done my cholesterol in a few years. I don’t really know if it’s you know, it’s probably good. I’m a vegetarian and skinny, so I’m guessing it’s good, but maybe it’s not. And if I don’t know what, I’m not going to do anything about it.

Exactly. This question is anonymous. How do you see the use of drones for drugs, for blood, for delivery of drugs? It’s already happening like it’s already happening, so Zipline has a one-point two-billion-dollar valuation; they have been delivering one hundred and seventy different medical products, including vaccines and blood products like IV units of blood for maternal bleeding in Ghana and Rwanda. Now, for three years, it’s only a three or four-year-old company with a one-point two-billion-dollar valuation. Metronet has partnered with WakeMed Medical Center.

And so Metronet has already done a huge number of drone deliveries around that medical system. They take someone’s labs, blood labs in one building, and then a Metronet drone three times a day will fly it to the laboratories. I mean, we are seeing drones being used extensively in health care already in this country. And now that Amazon has gotten FAA approval to be treated the same way UPS has, which is as a cargo plane. And when you have the same FAA rules and regulations around a cargo plane, it means the drone can go out of the line of sight of the pilot.

Really big deal. And in some of these cases, I believe UPS is actually approved for fifty-five pounds, so it can carry fifty-five pounds. And I know Google Wing, they also have FAA approval as a cargo plane, and they have been delivering hot cups of coffee in Australia for like a year. Like, you order coffee from Starbucks, and then a film comes and drops it down. You take it off, that is excellent. You know what? I wanted to ask you about Jeff Bezos with Amazon. If I remember several months ago that before COVID-19, he said, we want to get Amazon into the healthcare industry. How do you think Amazon may kind of revolutionize it or disrupt it or, you know, from everything from any facet of clinical care? What do you think?

So there are many ways that Amazon is attacking it, so, as I mentioned, the halo, that’s their new wearable tech, it’s their first foray. Of course, they’re going to go clinical-grade like everybody else. The technology exists if other people can do it. Of course, Amazon can do it. Not only that, but they are experts at supply chain management, health care, its supply chain management. Now, their acquisition of Pillpack is about a billion. They bought it for genius, not because of the pill pack method, like, oh, you put a bunch of medications together in a little baggie. Like, that’s not groundbreaking.

Not only do they buy that audience like those customers who are already involved with Pill pack. They have licenses to distribute medication in every state. And in reality, going back to Wallmart like would customer relationship management and supply chain. They have done this for a year. And matter of fact, tell that to my students when I teach. I would say, what is Walmart’s core competency? It is their supply chain and customer relationship management. 

Nick:

Here is another question. Do insurances really cover telemedicine services? Ex. Video chat consultation, mhealth, and responsive service, etc.?

Robin:

So, right now, there is an exception going on because of the coronavirus, so most of the large payers are covering 100% with anything to with telemedicine at clinic rates. Now, a big thing happened recently at the CMS, as I mentioned as CMS sets the standard of care for such a thing as peer pressure for private payers. So, CMS was going to just temporarily reimburse at the same rate as in-person clinic visits to have a telemedicine visit, and that has been extended to the end of the year. And that will be again extended permanently. So, you know, until November, may a change or maybe not as there is a lot going on. But at least through December, Medicare still covered telemedicine visits as if they were in the clinic. 

Nick:

And I know myself that after getting retired, I will be 65 in December, so Medicare, I would just want to make a quick footnote to this webinar; it’s excellent. Robin Thank. Here is another question from Jonathan Weisman, ‘Patient-centered healthcare that allows data to be brought into their safe place, watching AI and machine learning, and using all these data bytes should be as important today as it has been in the past. Does the future hold architecture, it gives assurance with data with all the FDA and data for making better choices? It goes back to the enterprise architecture, specifically the digital enterprise architecture, the IoT. So what are your thoughts on that?

It will be fine. If you will think about the eight months from now, the HHS put out the new rules for the data interoperability and so when that out, they were EMR companies were fighting it for a little while, and they were getting some signatures, and then I came come on board and so now its a government regulation on my interoperability piece. Things like Amazon Alexa being HIPAA compliant with the iPhone being able to pull the patient portal side of the EMR data to the iPhone as well as control the data aggregation and data collection. It will be solved in the next few years.

And also, it has been applied to machine learning to clean up the data for the preparation. It almost seems like where we are headed with all these devices; if I had to put a bow tie around it all, it’s like having a personal assistant, which is your medical advisor or nurse, a practitioner. By having all these devices, you are one step away from a human. Is that a fair assessment? So, we see a lot of AI and healthcare coaching programs. And that’s what is a digitized intervention. The fit bit was a great coaching platform about a year and a half ago, and remember now Fit bit is taking the FDA about going clinical grade. They are able to pulse Oximetry on average at consumer-grade, but they are talking to FDA to go clinical grade. They bought a health coaching platform and health coaching aspect of Fit bit coaching; when it notices that you did not take enough steps that day, it will ping you.

When you look at the staff, nurses, lab technicians, and the physicians, through their graduate programs, they are being schooled in the system how to do it. I know because, at Cornell, I lecture in these areas, and the best way I say it’s they communicate with the geek like me. But you say the keyword Interoperability. It has a lot of meaning in healthcare management as it’s required in point to point integration with integrated healthcare. It’s also in the cross-platform application sharing functionality, as compared to most industries, interoperability is considered something else. Thank you for explaining that.

Nick:

This comes from Stephania Levy-Rosenthal. This is all logical machines; they don’t understand the meaning of the words we say… can you please talk a bit about emotions? Can machines have their own emotional states?

Robin:

What we are able to do in the world of artificial intelligence is called ANI, which is artificial neural intelligence. It’s really good, and for one big specific thing, it’s ten times better than a human being at least. Now what you are thinking about the emotions involved is AGI – artificial general intelligence, and that’s more like simulating a human being and adding that care component and now that probably a couple of decades away. But some companies like Hugo are training the emotions right now as they have the AI digest a huge number of fiction books. Think about this for a second because when you read nonfiction for the fact, these are facts. It doesn’t say, Oh! Robin walked into the room and flipped the light switch and then was a little bit startled because the cat came out of the side room. There are emotions; there are movements you do not normally have, and in a nonfiction book. I am training in these fiction books and wondering how much the machine needs to learn. 

Nick:

I just want to Thank You. You analogies, and you are an inspiration. And you offer a lot of top-notch medical expertise. Thank you for sharing this information with us in a PPT format, and thanks for having a great webinar. Good Bye. 

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Originally published September 17, 2020 4:14 pm

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