Transcript

Will: [00:00:00] Knock, knock. Hi, knock, knock. Hi.

Hello. Welcome to Nut Knock High with the Glock Flecks. I am Dr. Glock Fleck. I am Lady Glock Flecking. And we are excited to have you here today. We’re going, we’re talking about something a little bit different today than we have in the past, talking about it. Mm-hmm. Health, it, healthcare it, healthcare it.

We, uh, a wide arranging conversation, uh, about, um, just every, where it’s going, where it’s been. Mm-hmm. 

Kristin: Why it’s been where it’s been and Yeah. Going where it’s going. We 

Will: basically like throw our guests some, like, things that we want and like tell him to make it happen. I, 

Kristin: yeah. It’s a little bit like Christmas morning and asking, you know, Santa Claus for some things that we 

Will: want.

And so in what this, what it made me think about, uh, was actually the time that I spent as a [00:01:00] super user for Epic. Mm-hmm. I remember that. Do you remember that? Mm-hmm. I do. So I was like a, I did it as a fourth year med student and a little bit as an intern. Yeah. As well. I, like all my vacation time went toward Right.

Going to mostly the health, the, the Henry Ford Health System. Mm-hmm. When they shout out to everybody at Henry Ford, um, when they went live with Epic, this was like 2013. This was pre 

Kristin: glam Flecking. So there may have been some people, some listeners out there who interacted with you and did not know it.

Maybe 

Will: I, I, I got, you know, paid extra money obviously to like, go and do this. That’s the only reason I did it, because it was the worst job ever. Real bad. Uh, because what I had to do was they, they, they put me in like some area of the hospital. So at Henry Ford I was mostly in emergency medicine and uh, I just, I had to walk around and like, Help people, like teach people how to use, how to do like discharge summaries and, and admission orders and all.

Just put it in anything, all like make smart phrases, all this stuff. [00:02:00] So, and uh, and you can imagine like Henry Ford’s a big health center and so you can imagine people were stressed and, and we were in emergency medicine Yeah. And learning how to use Epic. And so, uh, it was a high stress situation. Mm-hmm.

Um, and I do remember at one point during the week I was working with a cardiologist. And I think it was a cardiologist. Uh, and he was, you know, toward the end of his career. Mm-hmm. You know, uh, and that, that, that was, it was the hardest for those individuals because they’d been on paper charts for their entire, for like 30 plus years.

Right. And all of a sudden here, the last few years of their career, they had to like switch over to the most complicated thing in the world. Epic. Uh, very, very different, um, experience. 

Kristin: And that’s your electronic health record system. Yeah. Right? Yeah, that’s true. So when you go to the doctor and the doctor’s like typing into the computer, they’re typing, likely using Epic or something like Epic.

Yeah. There’s lots of ’em 

Will: out there, but Epic’s the one, so that’s the one we were on. We were, we were [00:03:00] working on. And, um, and so I’m, I’m working with this, with this doctor and he’s not saying anything and I’m like working it, walking him through how to do like a, I think it was a admission orders or something.

And um, and as I’m sitting there like teaching him, he just, he stands up and he just walks away. Like he didn’t say anything to me. I was, I was like, I didn’t know what was going on. So I just, I, you know, I, I went on to do other things. He, he actually didn’t come back that day. And, uh, and so toward the end of the week, I, like, I asked someone about this guy.

I was like, Hey, I was helping this guy. I haven’t seen him since. Like, what, what was going on? And they told me he retired. He, he, he decided you were the last straw. Yes. He decided that he would rather end his medical career than listen to me talk about discharge or admission orders for one more second.

That was it. So that gives you a little, little flavor about what the, uh, what the epic [00:04:00] super user job was like. Mm-hmm. And so shout out to all the epic super users. You got a hard job. Uh, but thank you to they, do they still have those, are people still doing that? I mean, people are still going live. I mean, I feel like, I feel like everybody’s on some kind of health record electronic record system at this point.

Actually we learned 97%. That’s right. Yeah. We did learn that. Um, and, uh, and so yeah, that’s still out there. They’re still doing it. Yeah. I don’t know. Maybe international. I don’t, I don’t know if it still happened in the US but Yeah, 

Kristin: I remember what I remember from that time is, is you coming home and expressing a lot of frustration about the triple clickers?

Will: Oh, triple clicking, yes. Yeah. Lots of, I mean, that’s a, like a lot of the job was just sitting there watching someone try to like, Do something. Right. Right. And, and a lot, a lot of you out there, you love to click three times on things like consecutively. It’s my understanding, and I’m know it by, by no means a computer expert.

That’s true. That there’s never a situation where you need to click three times consecutively on one thing. In 

Kristin: fact, it usually, um, creates more confusion than anything else. [00:05:00] That’s right. That’s right. I was that weird. Funny things start to happen. It’s funny that you remember that. 

Will: Yeah, yeah. Oh yeah. I do.

I think I was having nightmares about Chip. Yeah. Anyway, let’s get to our guest today. Let’s do it. So, um, we have, uh, for our guest, Dr. Mickey Repath, and it’s just fascinating guy. He’s, uh, the national coordinator. For health information technology at the US Department of Health and Human Services, where he leads the formulation of the federal health IT strategy.

This is like, he’s like the health IT guy. Yeah. He’s the nation’s 

Kristin: health it man. 

Will: Yeah, he is like, so if you have a question about like health, it facts him your 

Kristin: suggestions, facts. 

Will: This is, this is the guy. And it really was like, it’s just, we had a fascinating conversation about all kinds of stuff. I, he answered all of my questions that I’ve had as a physician working in, in healthcare, in medicine, and dealing with all these things.

So, um, and he’s a fun guy too. It 

Kristin: was, he was a fun conversation. He’s got a good sense of 

Will: humor and I don’t know what preconceived [00:06:00] notions you all have about it people. Right. But it was, it was a very gregarious, wonderful individual. Not that they aren’t, it’s not 

Kristin: what you would expect. He doesn’t even like a basement.

That’s right. That’s right. He gave us some stories about that. Well, let’s get 

Will: to it. All right, let’s do it. Here is, uh, Dr. Mickey Repath.

All right. We are here with, uh, Dr. Repath Mickey Repath. How you doing, 

Dr. Micky Tripathi: Mickey? I’m doing great. Yeah, thanks. I look forward to talking to you. Thanks 

Will: for, thanks for joining us today. Now, I, I gotta start, um, with a question. How does someone become the world authority on like electronic health? It, because it’s not exactly something that a kindergartner will say that they wanna do when they grow up.

Like, I, I just like, how did you get to, into this field? It’s, it’s, it’s kind of fascinating to me. 

Dr. Micky Tripathi: Yeah. It’s, uh, you are right. I didn’t, uh, you know, sort of pop out, especially, you know, I’m old, so, uh, you know, back then it [00:07:00] would’ve been, you know, amazing vision to say electronic medical records. That’s where I wanna be.

Um, so, uh, I was working for a consulting firm and we went out to, uh, Indianapolis to do some work, um, with the Reagan Street Institute out there. I don’t know if you know those folks, but they’ve, you know, in Indianapolis, it turns out, is like a beacon of health information technology, unbeknownst to a lot of people.

Really? Oh, yeah. There’s, there’s, there’s an institute out there called the Reagan Street Institute, and, um, founded by a guy who was an industrialist who went to a hospital. Know, and, um, and was shocked by what he saw. Like he couldn’t believe that, you know, that they were using better technology in dishwashers than they were using in hospitals.

And so he created this institute enough, um, that I think both of you’ll probably attest to that being the case. Um, and, uh, so he, he created this institute that worked on health information technology. So anyway, I was working for a consulting firm. We went out there, we did a bunch of market research, and we kind of looked at it and said, wow, this could be, you know, like a really interesting business.

This is like in [00:08:00] 2002. Yeah. That’s what got me started in, in this area. And I, I just like love areas where you mix science, technology. Policy and business. 

Will: Well, you probably saw the, the landscape of health it and realized, whoa, there’s some work to be done here. 

Dr. Micky Tripathi: Yeah. Yes. It like, it was gonna be lifetime employment, unemployment for the rest of my, yes.

For the remaining part of my life. Yeah. And I mean, 

Will: cuz you, you’ve been at, I mean, just the, the change that you’ve seen over the last 20 plus years, uh, of, uh, you know, going from paper records, uh, exclusively pretty much, right? Um, yep. To just this, this really rapid adoption of, of electronic health records and, uh, different healthcare, you know, record systems.

And, and so how, how do you feel about the speed at which this has happened? Is it going fast enough? Is it. Is it too fast? Is it, you know, how are we doing just in general? [00:09:00] 

Dr. Micky Tripathi: Yeah. You know, my, um, my, my clinician friends will kill me for saying this, um, but I think it’s going at the right pace. Oh, okay, good.

Which is to say that, you know, if you, if you, um, and I know, I mean, you, you were on the front lines of, you know, living this, right? Mm-hmm. Of this change. So, um, actually I should ask the question back at you, but just to give you, just for the context. You know, like in 2010 or 2005, whenever it was something like 5% of providers were using electronic health records, and that was self-reported.

So that was also, you know, my brother-in-law’s access database, Microsoft Word with macros, that’s all electronic health records. Right. And then we invested a ton of money through, you know, federal incentives and private sector to the point that we’re now at the point where 97% of hospitals and like 85% of ambulatory providers are using electronic health records.

Wow. So that’s like a short, probably 10 years. You know? And if you think about, um, the, you know, this is the, like the most complex [00:10:00] part of the biggest economy in the world, flipping that from like pretty much 0% adoption or 5% adoption to 97% adoption in 10 years, that’s a pretty remarkable achievement. I think 

Will: that really is.

And so what, so was it the, the subsidies you’re talking about, was that what really started driving it? Like what was the impetus to like really turn. The lever and, you know, just really get it ramped up. Do you think 

Dr. Micky Tripathi: were the factors there? Yeah, it was, um, so I, the, the problem we had, you know, before the federal government, so the federal government dollars were huge.

Mm-hmm. Um, and it was, it turned out to be about 35 billion in incentives, um, through Medicare and Medicaid. Um, you hopefully got one of those checks. Yeah. You know, like to make sure mm-hmm. That, you know, that all, all of the really advanced physicians got them. But, uh, but you know, before then the challenge was, um, that, you know, that there was like slow adoption of electronic health records.

But, you know, healthcare, uh, you know, as you know, healthcare is really [00:11:00] complicated in our country. Right, right. And so the challenge from a technology perspective was that, um, it was kind of a prisoner’s dilemma. Like, you know, doctors felt like. Well, I don’t wanna, why should I invest in this technology?

It’s like $40,000 a user or whatever, but I get no benefit, right? You have no pricing power as a doctor. It’s not like you can say, oh, I’m gonna pass this on to my customers. Well, you can’t charge anymore. You know? Right. And, um, and the health insurer isn’t gonna pay you anymore. And the health insurers on the other side felt like, well, I don’t wanna provide, you know, the, the subsidy for the electronic health record, cuz I can’t prevent that doctor from using it on patients who aren’t my members, right?

Mm-hmm. So they felt like, well, you know, I’m gonna pay for the whole ehr, but I’m only 10% or 15% of that patient, of that doctor’s panel. And so, you know, therefore I can’t capture all the benefits. So we like at this real stalemate that everyone felt like, well, it’s good for society, but not in my interest to do it.

Um, so then the federal government came along, um, in ni in 2010, high tech [00:12:00] and said, well, there’s a public goods problem here and also Medicare and Medicaid. Have a really distinct, you know, kind of incentive to say, well wait a minute, our providers are all across the country and it would be great for them to adopt electronic medical records cause we believe that’s good for Medicare and Medicaid and good for patients at large.

So how about if we provide the incentives and kind of share the cost? And you know, in a way it’s not that different than businesses do every day. If you think about, you know, right Ford and Toyota and Walmart, they invest in their supply chains. I know you, I know you don’t like to think of yourself as a part of the supply chain, but sorry, sorry to break it to you for Medicare and Medicaid, you’re just supply chain.

I’m, I, I get it. Absolutely. 

Will: Well, you know, it’s, I remember, so I, when I came into medicine, so I started in med school in. Uh, 2008. Eight. And, and so this was very, and we had, it was like a, the hospital I was in, which is Dartmouth Hitchcock Medical Center, um, [00:13:00] we had this, uh, kinda hybrid system. It was, it was like the, we had, uh, the, some, some of it was on this, I don’t even remember what it was called.

Yeah, 

Dr. Micky Tripathi: the agro, I forget what that was called. 

Will: Yeah, yeah, yeah, yeah. Cis some something. I don’t know. Anyway, I’m not, I don’t know what it’s someone out there is yelling at their Yeah, exactly right. They’re like, right now it was, it was this. Um, but then, but then we 

Dr. Micky Tripathi: still did, we never should have laughed. I missed that system, 

Will: but then we still, we still did, uh, orders, like on paper.

So it was this weird, you know, hybrid thing. And then I was there when we made the, the switch over to, to Epic. And that was, that was a huge deal. And would you call it. Epic. It was, it was, was, it was an epic, uh, for some people would call it an epic fail. Oh. That, that we, you know, but that was, you know, it, we, we understood, I think that the reason why we needed it, you know, for all the reasons, just to make things more efficient and, uh, I mean, in some ways more efficient, but just the documentation, uh, more thorough.

[00:14:00] And you could actually read the handwriting. You, you mm-hmm. Mean you could read the text. You didn’t have to try to read doctor handwriting. Um, but it was a huge challenge for a lot of the physicians. And it was, there was a lot of stress around the go live and, and switching over to that kind of system.

Um, and so, you know, I feel like we’re at the point now though, where everybody accepts that that’s the best way to do things. But we also now have all these different systems that still don’t seem to. Talk to each other and in a lot of ways, and that, that, that seems like a big struggle right now as opposed to like actually getting people on board with electronic health records.

Am I wrong in like seeing like that’s, that’s still like a big problem that we have in this whole system. 

Dr. Micky Tripathi: No, you’re absolutely right. And I think, you know, a part of that is just kind of the, you know, the nature of adoption. Like, we gotta get everyone from paper to electronic first and then start to [00:15:00] think about what are the things that, you know, we want to build on top of that in, you know, interoperability being one of them.

We want the systems to be able to talk to each other, and we wanna be able to do things that are more than just like, better billing and getting rid of file cabinets, right? I mean, we, you know, we, we, we, uh, expect more out of the 35 billion investment that’s it that we’ve made, but I think it’s appropriate actually to phase it.

We, um, in a prior organization that I, um, worked for, um, we implemented electronic health records among, you know, community docs. Mm-hmm. And, you know, and often O N C and the whole program gets criticized for not doing interoperability from the beginning. I guess I, you know, I would argue that, That was actually really appropriate to phase it.

Cuz I remember, I still remember one of the, one of the physicians who we brought live first. So this is back in 2005, right? Really early. Mm-hmm. And we brought, you know, him live, his practice live. It was a him brought him live on his, on his, on his ehr. And we had a lab interface set up with the hospital and we turned it on.

And I wanted to be there for the [00:16:00] ta-da moment to see the joy that would spread across his face. Right. And the la and the laugh started coming in and it wasn’t joy, it was terrible. It was like, stop it, stop. Turn this on off. Now what is this? And you know, and I was like, no, no, no. Those are, those are the labs that you can, it’s like, I don’t want them, I’m not respond, you know, how can I be responsible for all those?

Where are those coming from? It’s like, no, no, those are the same labs. That you ordered. They’re just not coming in via fax. They’re coming in electronically. Right. But he was just like, turn it off now. Yeah. I was like, I’m having enough problems just dealing with the EHR that I document. Now you’re bringing in all this other information.

So I think part of it is just that cultural thing that you first gotta get people settled. Mm-hmm. Um, second is one, early learning we had in implementing EHRs with all these docs is if you screw up, they’re getting paid, then everything else stops. Right? And everyone always criticizing, oh, you know, you just focused on revenue cycle.

It’s like, well, people need to get paid. Like the minute that the revenue cycle broke and all of a sudden cashflow [00:17:00] stopped coming for 2, 3, 4 days, the practice is like, all right, we’re done here. You know, thank you so much for coming. Take all your computers and, and you know, we’ll see you next decade, but you know, we need to get paid.

So that was the other thing is you gotta focus on Gotcha. Landing safe is kind of how I think of it. It’s like, let’s land everyone’s safe first and then we can move to the next thing. That, the last thing on interoperability, I think is that, um, Is that, you know, standards change a lot. Like if we had, you know, cuz we were in the, through this federal program, you were starting to implement EHRs like in 2012, like 2011, 2012.

And think about what technology was, you know, was like back then. And uh, you know, we would basically have been like baking in a o l you know, for all these systems. And now we have much better ways of inter-operating. You know, you think about the apps on your phone and all of that, that’s like restful APIs and all of this technical mumbo jumbo.

Mm-hmm. But a lot better standards now that are much more lightweight. And that’s what we’re trying to push the industry toward, is those lightweight standards. So it, it made sense to wait because you know that things are gonna change and if we don’t have to make those decisions that early, [00:18:00] let’s not make those decisions until later and let you know all the other parts of the technology develop.

Will: Are we still in the early stages of the achieving the interoperability? Oh yeah. I was gonna, or are we like, like where on the spectrum are we here, are we in anywhere close to, what space are we 

Dr. Micky Tripathi: in? Um, I would say, you know, we are, we’re, we’re not infants. I think we’re toddlers. Um, okay. And you know, the reason I say that is, is we throw a 

Will: temper tantrums and we’re breaking a lot of things.

We break a lot 

Dr. Micky Tripathi: of rules, wear tantrums appropriately. Um, but, uh, uh, there is interoperability that’s happening. So there are networks now that, that exist mm-hmm. Um, that connect up EHR systems and, um, there’s one called care quality that exchanges like, you know, they do 50 million transactions a day. Okay.

Connecting up, you know, provider organizations on the backend. And just to give you a sense, you know, the SWIFT Global Banking Network does 41 million a day. So, you know, so that’s a lot of interoperability that’s happening. Mm-hmm. Um, the problems with it are the [00:19:00] data. Is still highly variable in terms of quality.

So you may get, you know, like if it’s not, if it’s coming from a different EHR system, for example mm-hmm. You may get it and it’s still like, ugh, you know, that it didn’t come together seamlessly. I’m having to mm-hmm. Go into this other tab and find it in the basement of the EHR and, you know, and, and it’s hard for me to read and, you know, I really just wanted to know if the patient was allergic to penicillin or something and I now I have to read through an 80 page electronic document to figure that out.

It’s a lot easier. Just pick up the phone and, you know, right. And call. So I think we have those challenges that now we are better and better at delivering the information back and forth. You know, more work to do for sure. Mm-hmm. But better and better at that. But the next level is, well, how do we make sure that the data is actually useful?

You know, and then it’s giving you the right information at the right time so that you can actually, you know, make better use of, of that information, um, and get through your day in more efficient ways than you’re able to today. That’s, that’s sort of the next set of challenges that we wanna mm-hmm. And are, are we 

Kristin: looking at like, [00:20:00] standardization as a part of that to, you know, make the data systems from each place be able to be more, um, you know, easily compared with each other and, and merged together, or?

Yeah. Is maybe AI something that can help with not having to do that as much? Or what does that, what does that look like 

Dr. Micky Tripathi: exactly? God, we’re only a few minutes in and AI came up already. Yeah. Oh man. Absolutely. I knew we were gonna get there. Um, standards are certainly a part of it. Um, cuz you know, because it, that is a challenge and computers are, you know, really dumb in certain ways.

Right, right. Well before AI, computers are really, really dumb. Right. So they, they, you know, if, like, if, if that lab came in and here, you know, in your, in your lab it’s, you know, sort of a blood panel in that hospital and this mm-hmm. It’s a CBC or something, the computer’s like, oh, those are two different things.

I have no idea what that is. And so if you want to, if the data isn’t standardized, it makes it really hard for, you know, for you to be able to get it integrated in the right way and do all the great higher level things you wanna be able to do with it. Um, right. You know, the hope is that with AI you have the ability to say, [00:21:00] We can actually learn and see that those four or five different things or, or the things, the, those different lab results that the computer thought were four or five different lab results are actually the same, you know, the same lab that was being done.

It just happened to be done by different labs. So a better ability to make sense of that information, to turn data into information, I think is what we wanna be able to do. Yeah. That, that 

Will: would make a lot of sense, especially with how many different electronic health records systems there are out there.

Right. You know, that, that display things in different ways and 

Dr. Micky Tripathi: Yeah. Different organizations. And it’s even deeper, you know, I would argue, and you can tell me, you know, you’re being a clinician, I’m just a fake doctor. I’m one of those PhD doctors. Um, but you’re like a real doctor. Um, is that, you know, that the, that that, I think it goes even, you know, it’s deeper than the ehr.

It’s that providers doctors themselves, Document differently and they want to document differently. Right. You know, so I often hear, you know, how come you didn’t require that the EHR vendor do this or this? And I was like, well, the minute I did that is the minute that you would tell us that [00:22:00] we were, you know, uh, a socializing medicine because we were forcing you into that template that came from Cerner or eClinical Works, right?

Yeah. Yeah. You know, and is that what you want? And I’ve, you know, I’ve helped doctors implement e HR and the first thing they do is they tell the software vendor, you need to adjust the software to my way of documenting. Yeah. Cause I document better than all those other guys and gals. 

Will: Actually, you know, you you got it.

Pretty nailed the, yeah. 

Dr. Micky Tripathi: Especially in your case. I know that you documented 

Will: position better or, or my, my scribe documents 

Kristin: better than, yeah. Let’s be honest’s not documenting anything. 

Will: You know, it’s funny, the, the, as you’ve been talking, I keep, I keep thinking back to, um, to, to cprs. The, the VA health system.

Yep. Which has, which has been around since, I don’t know, the eighties. Right. It’s a long time and, and I just, it’s been a while since I’ve worked in a VA system, but, um, that seemed to have [00:23:00] interoperability down pretty, pretty remarkably at, uh, for how old it is and, uh, uh, just being able to. Pull up all the records on your patient, regardless of which VA they’ve been to in the country.

Mm-hmm. And, uh, do you feel like we’ve learned lessons from that? Was that like a, a stepping off point for any of this? Or is that just a completely separate thing that, uh, doesn’t really inform our. You know, thought process on this at all? 

Dr. Micky Tripathi: I guess. I think it does. I think, I mean, you, you said, um, you had a key phrase in there, which was you could bring all the information from the various VAs.

So it’s like, you know, they’re all using the same software. It was just, you know, sort of different instances of the software, different databases under the same, you know, kind of basic technology. And so that made it easier for them to be able to bring it together cuz it was, you know, basically the same technology.

But I think that there were a ton of lessons, um, yeah. That, you know, that were learned and continue to be learned from the va. Um, because, you know, it kind of showed what [00:24:00] the promise was. It showed that you, if you could actually get these systems, connect with each other, here’s kind of a vision of the future of, you know, what that can do for.

Um, you know, more holistic view of the patient and for better quality. I mean, uh, you know, my mom, it’s funny, my mom was a physician with the VA for like 35 years and my dad was in private practice and, you know, for a long time there was the kind of know private practices, you know, higher quality and that’s where, you know, the highest quality.

And then the VA started being able to show data that demonstrated that mm-hmm hey, we got this technology and we actually deliver pretty darn good quality. It turns out. And, you know, my mom was like, wow, look at the va, right? Who knew? The VA actually delivers high quality. Um, so I think that there are a ton of lessons there and they’re continuing to be tons of lessons.

I mean, they’re going through growing pains right now as they move to a commercial vendor. But I think one of the challenges that they found, right with the vi, with the Vista system is, you know, when it’s customized, it’s really hard to keep up with that. And once you, you need to keep growing and building, and if that’s all custom development, it ends up, [00:25:00] you know, um, having a lot of overhead and a lot of weight on top.

So 

Will: just for Kristen’s, uh, um, you know, information, the, this Vista he is talking about, the, which is the, the documentation system at the va? Yeah. Basically it felt like a glorified, uh, word document. Mm-hmm. Basically kinda like what it, what it seemed like. And, but you could customize your own documentation pretty well.

I honestly, when we moved over to Epic for the first time, I was like, happy to go back over to the VA and be able to like, it just, it seemed so simple at the time, but, but you know, there’s other issues with, with that as well, but, um, but yeah, I mean it’s, you know, it, it just, you go to something like the, the, the systems we have now, and there, there’s, you can see how it would be very overwhelming to someone to like just dropping them into this, um, when they’ve, you know, bid on, uh, just your paper records and.

Writing. I mean, we still, in our practice, we have some paper charts still that we have, like [00:26:00] they’re old now, but we What? We keep a few. Yes. We don’t, 

Dr. Micky Tripathi: we don’t document this. You’re gonna killing around. We, I’m, I’m sorry. They’re records. We, they’re records, records. Anything. We’re gonna, we’re sending the police out to, to confiscate those.

Don’t 

Will: tell any, I’m gonna, we’re gonna delete this episode. We’re gonna edit all this out. Um, but man, I just, so very occasionally, like if someone’s had LASIK or some eye surgery from like 20 years ago, you know, sometimes I’ll go back and I’ll look at that paper record, the documentation. My God, it was, uh, it was, it’s, it’s hard to figure out what was going on.

Uh, and it’s like it only made sense to the doctor themselves. And so, My point about saying this is, is that it, I think I see one of the huge benefits of everything we’ve been talking about, the interoperability and the way we’re documenting now with our electronic health records is that in the end, I think this is such a great thing, uh, for the patients.

And I think from the [00:27:00] patient perspective, it probably feels chaotic. You know, there’s, there’s all, you know, yes, it does, right? It does. But uh, in the end, I feel like it’s, it’s, we’re moving in the right direction toward just being able to educate our patients a little bit better, having them have access to some of their records just more, more easily.

And, and I don’t know. So could you speak on that a little bit on how you see where we’re going, really improving patient care and our Yeah, like, 

Kristin: you know, what I would like with patients see is I would like to see. And I don’t, sorry to mention AI again, but I feel like it might be helpful for this. Um, you know, he and I both have somewhat complex medical histories, right?

So, I would like to see the ability, like technology be able to come in and, and, you know, do pattern recognition, which is what it does so well. Right. And be able to say, you know, this patient over their lifetime has had this, this, this, this and this. And, you know, just really quickly and easily be [00:28:00] able to tell, oh, they have this, you know, complex condition or, or whatever that a lot of, um, you know, human beings would miss.

So, you know, that would be delightful from a a user perspective. Can I just, like, do you have a suggestion box that I can drop that into or 

Dr. Micky Tripathi: you just did. Okay, good. Exactly. Um, I think, I think we’re getting there. I think we’re really getting there and we’re really, you know, sort of at the cusp of that kind of capability.

And what, the reason I say that is, um, you know, you need at least two things for that. One is, is you need the interoperability. Mm-hmm. Because, you know, Dartmouth Hitchcock, let’s say only knows so much about me. Right. And in order to be able to, you know, really in a complete way, do what you’re describing, you know, you wanna be able to have, well, I need as much information as possible before I can, you know, sort of turn the algorithm loose and then be able to, you know, get the most accurate type of view of you as an entire person.

Um, so first off, you need interoperability, and that has to be higher quality data. So, as we were describing before, you know, if it’s [00:29:00] interoperability with dirty data, well great, now I’m applying my algorithms to raw sewage. What am I gonna get? Am I gonna get potable water outta, outta my algorithms on raw sewage?

I dunno. Um, um, but uh, you know, so that’s the first thing. And then the second is, is the algorithms themselves. You know, how do we bring those to bear in a way that, um, that they’re easy to use, that they’re understandable and that they’re safe? I mean, uh, you know, the, yeah. Uh, the, you know, I’d love, you know, both of your views on this.

I mean, we’re, we’re just at the, you know, just at the, at the beginning here of this revolution, um, with chat G P T and everything, making these tools really, really easy to use and almost dangerously easy to use because you can just start right. Just using them. And, um, and a couple of the challenges with this, I mean, I’ve heard from providers who get concerned about algorithms because of the black box nature of them.

You know, they kind of feel like, well, Take the, whatever results are coming out of this that no one can explain to me where it got those results that said [00:30:00] that your risk is high. Or I could use my clinical judgment, which I actually know something about. So until you can explain to me what the black box does, I’m gonna use my clinical judgment.

Um, but Right. Hopefully as guild those get better and better. You know, I’ll have greater comfort with them, but we need some guardrails around them. I think just so you know, people feel a greater sense of safety as well, because you can make decisions that, you know, that are dangerous. Um, uh, you know, in, in certain cases.

Will: Right. That’s why I kind of, maybe I shouldn’t scoff, but I kind of scoff at the, this whole idea of, you know, replacing people in healthcare with, with ai, uh, and, and you know, you get on social media, you see people that are playing around with it and like show how it’s just, it’s not there. It’s not even close really with being able to replicate the.

Thought process of a healthcare professional, taking care of people and Right. And, um, 

Dr. Micky Tripathi: um, but it passed the mle. Is that, 

Will: but yeah, because we all know that that’s, that’s, uh, you know, the highest [00:31:00] quality evidence Exactly. For, for someone being a doctor. Um, 

Kristin: right. It also doesn’t get at the fact that like, it’s still people putting the data in, you know, and writing the algorithms and, you know, you can’t really completely extricate humans from the technology.

Dr. Micky Tripathi: Right. Yeah. Right. So, yeah, I dunno. But I think, I mean, I think that’s a great point that, uh, you know, that and, and it’s so early, you know, like who knows where, you know, where this is headed. Um, that, you know, that right now it’s kind of, well, is it automation? Meaning we’ll get rid of doctors, it’ll all be, you know, computers doing it, or is it, you know, something that is really a part of, you know, human assisted.

Right. You know, sort of care, right. That you know that at some point tool in a toolbox. Yeah. And, and that, you know, and I could see a point, um, where, you know, as a patient I may actually want to know, well I’d love to know that you know, you as a dermatologist, that you actually used some AI in the background to screen through, you know, 2 million patients before making a judgment on whether of that mole actually is cancerous or [00:32:00] not.

But you know, I also would take comfort in the fact that you’re making the final decision. Um, right. So there may be a little bit of a demand kind of thing too, where patients, you know, wanna know actually that you’re using the tools that, you know, the people have a sense can actually help you and Right.

But also that you’re in control and that the humanist and, you know, is sort of in the loop there. Mm-hmm. I think the other thing, getting back to your point about, you know, wanting to be able to have, you know, sort of what’s the dream here? Um, yeah. Is we’re doing a lot to make information available to patients.

So that patients can have the ability to take an app, an app of their choice, download the records onto their, onto their iPhone. We’ll talk about some of the concerns with that in a second. But the, but the, you know, but the idea is that you ought to be able to take your records and maybe it’s in five different places, take those records in five different places, maybe bring in, you know, other information that only, you know, like your Fitbit information or whatever sleep app you’re using or whatever else, and your over the counter, you know, uh, uh, you know, uh, [00:33:00] purchase data and your food data, and you can imagine services developing that say, we can take all of that information and mm-hmm.

Give you, you know, information about your wellness and, you know, advice. And I’m sure nothing will go wrong with any of that, but No. Yeah. No 

Kristin: insurance companies won’t, that’s opport to use that in any way. 

Dr. Micky Tripathi: Right? Right. That’s the opportunity for you to be able to do those things that you know your healthcare provider isn’t gonna do, because that’s not the way we think of healthcare in the us.

You know, healthcare is in the US is when you get sick. Then I show up at the doctor, I show up at the hospital and they use whatever medical information they have and that’s what they do to make you not sick anymore. Versus a view of, well wait a minute, we’re on this continuous journey of different degrees of, you know, kind of wellness.

All of us are temporarily healthy at points of our lives. Um, yeah. And your ability to have more and more information that services can develop around and provide you with information that guides you through that entire, entire patient journey, that’s, you know, that’s kind of what we wanna be able to [00:34:00] enable, 

Kristin: right?

Yeah. And I think patients are always going to look for information and try to figure out their own things, right? They’re doing that right now with Google. I don’t, I mean, you can’t just like take that out of the equation because that’s not human nature. Humans are going to be curious about this thing that’s causing them a problem and they’re going to do what they can do to figure that out.

So building technology that enables them to do that in accurate and Safeway instead of. Who knows what ways that lead to, who knows what misinformation I think would be 

Will: beneficial. Yeah, I think that’s, yeah. I think that’s one of the challenges is that, uh, a lot of medical information can be dangerous without context.

Right. And, um, that’s why you talk with your doctor about, about, uh, you know, your health issues and, and you know, so I, I know. You know, there’s been a lot of conversation lately in the past year or so about, uh, you know, having your medical tests and results available to your, to, available to you immediately, right.

[00:35:00] As soon as it’s coming in. You’re welcome. And is that, that’s you, did you do that? 

Kristin: I’m a, I know this is controversial, but I am a big fan of that, so thank you for Well, well, 

Will: no, and no, and, and I, I think, uh, it, it’s, it’s interesting to hear different perspectives on it because, you know, there, there are a lot of people, I know a lot of physicians who feel like this is a dangerous thing and that, um, uh, you know, without the right context, it can, it can lead to a lot of anxiety, a lot of o other issues.

Um, but maybe 

Kristin: the technology can help provide some of that context. Right. You know, that, that just 

Will: missing. Right. And that’s, yeah, exactly. That’s where I was, I was going next, is that I, I think. The, the solution isn’t to just not do it right, because that, that’s not right. It’s patronizing 

Kristin: too. Right, exactly.

People can’t handle their own information. 

Will: People should, they’re, it’s their information, it’s their own body. It’s the things happening inside their own body, and so they need to have that information. Uh, but we have to just be able to also give that other context or be able to let them, [00:36:00] not set them up to, to not understand what they’re seeing.

Right. I don’t know. I don’t know. I don’t how to make that happen. Can you fix that? Can do that too. Yeah, we’ll add that to the 

Dr. Micky Tripathi: box we’re working on. We’re working on some of these things, so, you know, so the, uh, come on, Mickey. 

Will: Let’s go. 

Dr. Micky Tripathi: Come on, let’s take it so long. Um, the, uh, uh, you know, I think we’re in this weird transition on that, which is, you know, we’re not gonna.

To be able to sort of engineer all the, you know, the perfect solution before doing it. I mean, you know, my experience is it’s not until you actually do it that people start to realize, oh, wait a minute, we need to have some more context around some of this stuff. Like, as you’re pointing out better education to patients and have that push to them.

But until we said you need to make the results available, that’s when people start paying attention and saying, right, oh, okay, yeah. We need to be able to do that. And right now it’s really klugy and, you know, my, my, my daughter is a physician and she talks about situations in the hospital mm-hmm. Where, you know, she’s a pediatrician where they, you know, literally race down to the, um, [00:37:00] waiting room to make sure that they’re able to talk to the patient before, uh, the patient’s parents before something shows up on the app that they, you know, wanna make sure that the patients Wow.

You know, the parents have an understanding. So, you know, right now it’s all like manual and we’re trying to, you know, sort of, um, uh, figure it out a little bit ad hoc. But the idea is that. The technologies will rapidly develop to provide context, um, as well as, uh, provide capabilities that are more calibrated to individual patient preferences.

Because I think that there’s a whole spectrum that the current system just never really, you know, sort of addressed, which is, and what I mean by that is the current system was every hospital physician made kind of arbitrary decisions about, well, we’re gonna wait a week before giving you these results.

We’re gonna wait a week and a half. And that meant that all the people who, you know, who actually really wanted the information right away were just left out. You had no choice. You couldn’t get it right. And what we’re, you know, the reason to do it the other way is to say, you know what, we should make it available.

But if there’re, you know, if, if there are patients who say, [00:38:00] I would rather you wait a week, then by all means, You know, our, our regulations say that’s totally fine. Now the technology hasn’t totally caught up. You know, some vendors have developed that capability to allow you as a patient mm-hmm. To literally come into the portal, say, I would like to wait a week before any results, or I’d like to wait before, you know, wait for my provider to call me first.

Um, and what we need is for, you know, for the supply side to kind of now meet that demand. Um mm-hmm. But otherwise I think it just wouldn’t happen unless we, you know, sort of said, you know what, let’s make the results available to, you know, to everyone and then let’s everyone adjust to that. And we also don’t think about the, on the other, other side of it, you know, for every one of those anxiety ridden, uh, you know, sort of situations where, you know, someone got the result before they were able to talk to the provider.

I mean, you know, I’ve, people on my staff, um, one, you know, one our, our head of policy who wrote a blog about this so I’m not sharing anything that she wouldn’t feel comfortable sharing, where she found out she got breast cancer on the portal and she felt like that was actually a positive experience cuz she could collect her emotions.

She could do a bunch of Google searching, she could talk to friends who are [00:39:00] physicians, so that by the time she talked to her physician, she felt much more poised and better prepared to actually have, you know, the, the conversation she wanted to have. Um, right. That’s a good, that’s where 

Kristin: perspective I fall on it, which is why I’m a fan of having access to that information is I, you know, I don’t know.

I wanna be able to do just that of, you know, get my head wrapped around it. Otherwise, you go into, or at least I do, go into the doctor’s office and they give you this information, and then you’re just kind of like, in shock and you don’t hear anything else that they say for the rest of the appointment.

And, you know, I don’t know. I think it’s 

Will: a good thing. I, I totally agree. It’s, and it’s hard. It’s hard for. For physicians to put ourselves in that mindset because we know too much about medicine. Like we, we are, we know all these things, so it’s hard for us to think Okay. From even when, even when a physician’s been a patient.

Mm-hmm. Like, it’s hard. It’s hard to think, okay, what if I didn’t have any medical background knowledge whatsoever. What would I want here? And, um, because a lot of it’s just being able to empathize with other people. But it’s hard [00:40:00] to do that when you just, we already have the information and, you know, 

Kristin: you remember, we remember how anxiety provoking those days are in between, you know, the waiting days of I noticed something and I have to wait for my appointment to see whether it’s anything harmful or I got this test, but I have to wait for days or a week to get the results.

And those waiting days are just excruciating. 

Will: Yep. What I do know is that nobody sh, I don’t think people should have to wait just because, uh, their doctor’s an ophthalmologist who doesn’t work on the weekends, like, like, come on. Like, let’s, let’s, 

Dr. Micky Tripathi: well, we’ll work on that. An exception to the rule. That’s legitimate exception.

Right. You know, another really interesting point that our, you know, and this is just, you know, a function of our medical system, which as we know isn’t as responsive to patients as we’d like it to be. Um, there’s a patient advocate who we worked with who points out that, you know, for all the conversation about the trauma of a patient getting a result before they talk to the [00:41:00] provider.

You know, think about the financial side like. Our healthcare system has no problem delivering, you know, a 17,000 surprise bill to a patient. Mm-hmm. And thinking about, you know, what kind of trauma does that count, you know, does that cause Yeah. Right. I I would argue that in a lot of cases that’s a lot more trauma that, that’s imposing on individuals Yeah.

Than, oh, yeah. Than their test results. And what kind of trauma does it 

Kristin: cause to not know when you want to know. Right. You know, that, like, what I was just getting at. Yep. I mean, it’s 

Will: tricky. No, you’re right. You’re right. I mean, you don’t have to tell me twice. Yeah. The, the insurance company is causing more trauma than anything on Earth.

So Yeah. For the most part I’d be a bit of an exaggeration, but anyway, anyway, anyway. Well, let’s, let’s take a little bit, let’s take a little break and we’ll, well, you cool off for a second? Uh, you mentioned, you mentioned health insurance. Sorry. Uh, yeah, let’s take a little break and we’ll be right back with, uh, Mickey Pathy.

Hey Kristen. Have I ever told you about Ddex? I’m afraid 

Kristin: little eyelid mites. Oh gosh. [00:42:00] No. Don’t do that. Ugh. Ugh. I’m 

Will: just saying if you’ve ever had red, itchy, irritated eyes, it could be ddex blepharitis. You might have 

Kristin: some little friends on your eyelids. They’re not quite this big. Well, that’s 

Will: comforting.

To find out more though, you can go to eyelid check.com. That’s E Y E L I D check.com to find out more information about Dex Blepharitis. Don’t freak out. Get checked out. Today’s episode is brought to you by the Nuance Dragon Ambient Experience, or Dax for short. This is AI powered ambient technology. It just sits there in the room with you, just helps you be more efficient and it helps with, uh, reducing clinical documentation 

Kristin: burden.

Yeah. And that can help you feel less overwhelmed and burnt out, and just kind of restore the joy to practicing medicine, and we all 

Will: want that. So stick around after the episode or visit nuance.com/discover. Dax, that’s n U a N C e.com/discover, Dax.[00:43:00] 

All right, we are back with, uh, Mickey, Dr. Mickey Repath. And we, uh, so I, I want to just, uh, have you talk a little bit about your own background because, uh, we’ve talked a lot about, you know, your experience, the, the awesome things that you’re doing, and it, uh, most of which I probably don’t understand and I never will be able to understand them.

But, um, you have a. This isn’t your first foray into the medical world. Uh, I understand your, your parents are both physicians, is that right? Yep. And, uh, and you had a couple interesting jobs growing up in the medical world. Yeah, 

Dr. Micky Tripathi: I did. So I was a, uh, an orderly as we called them back then. Do they still use that term?

You 

Will: don’t hear that word anymore? No, I don’t even, honestly, what exactly I, I think I’m orderly as like in the movies where, Like you have someone pushing a bed around. Yeah. Like that was like kinda an orderly, 

Kristin: right? Like you take orders like, hey, you [00:44:00] person 

Dr. Micky Tripathi: orderly. I guess from a, I never even made that connection.

Literal standpoint. I’m ordering and you are the orderly. Yeah. Oh my God. Maybe that’s it. Order the orderly. Exactly. That must be it. Well, I was definitely taking orders. I mean, that’s for sure. So you were the weren doing the grout work? Yeah. Yeah. I was kinda the equivalent of like the nurses’ aide. Right?

You’re one step up from the volunteer, like nurses’ aide. I don’t even know if they used that term anymore, but, um, it was sort of the male equivalent of a nurse’s aide. Yeah. You know, I wore all white. Um, and, uh, and so I worked summers as an orderly in the, in the community hospital. Um, a job that I’m sure I never would’ve gotten without, you know, my fathers having, you know, had lots of connections with the hospital.

Um, but amazingly, We, you know, I was like 16 and 17 years old when I was doing this. Mm-hmm. They had us doing stuff that, you know, that I don’t think they allow or ways to do today. Like I was doing, uh, fully catheters, um, on men. Wow. For those, for those who don’t know what a fully [00:45:00] catheter is, it’s, you know, when you, well, I’ll let the doctor 

Will: explain it.

It’s a, yeah. Yeah. It’s a, you get a, you get a tube up, your urethra up into the bladder, so, and it’s, you know, that’s, that’s, 

Dr. Micky Tripathi: that’s, that’s the medical way of, of saying it. Yep. 

Will: So, so you were doing that as a 17 year old, 

Dr. Micky Tripathi: you were like, so I was a 17 year old. I was doing that. I was doing, you know, the pre-surgical enemas, you know, waking someone up at four in the morning and saying, you know, good morning.

Oh wow, here’s your enema 

Kristin: here. Have ever considered that your, um, whoever it was that was supervising you just really did not like you. 

Dr. Micky Tripathi: That’s, that’s fun. Now that I think about it. Maybe, maybe. Um, yeah, so we were doing that. So I was doing that. And then I also was, uh, I was in charge of morgue duty, well, not in charge of, but I did morgue duty.

That’s what the order lease would do, is if someone died. Oh man. We were responsible for going up to the patient’s room. Um, you know, um, uh, uh, [00:46:00] wrapping them up, um mm-hmm. You know, obviously being as respectful, um, as, uh, as we could with the, uh, with um, uh, the process. But, you know, wrapping them up and putting them on the gurney and bringing them down to the morgue.

And, um, that was fine during the day, but, you know, one summer I did the graveyard shift. Mm-hmm. And it turns out there’s only one orderly in the hospital in the graveyard shift. And we would hang around the ER all day, but then, you know, a call would come for morgue duty and that would mean that I would have to go and, um, and deal with that.

Um, and, uh, that wasn’t fun cuz it, maybe you can tell me why are all morgues in the basement? Like, yeah. Why do they have to be, be a really scary, traumatizing experience for me. 

Will: Ass possible. Yeah. Yeah. Because probably, I’m sure it’s dark down there and, and this, yeah. There’s no 

Dr. Micky Tripathi: windows. No windows, pipes, clanking and probably easier to keep cool.

Surrounded by cadavers 

Will: and, right. That’s probably it. It’s probably, probably cuz it’s below ground and so you get to save a little bit on refrigeration. Yeah. I guess. [00:47:00] I, I don’t know. Yeah. Yeah, yeah. So, but did those experiences, um, they didn’t make you want to. Run, 

Dr. Micky Tripathi: not be a doctor, was be a physician. Yeah.

So we had this whole thing where, you know, of course the, you know, the, it turns out that a lot of the morgue duty calls were in the cancer wing, which was a different building from where the ER was. And so when you get the morgue call and I was in the ER to have to go down to the basement, go through the tunnels, which are, as you can imagine, from a, you know, 1920s era, community hospital, you know, dim incandescent lights.

Yeah. Place, you know, gosh, at about, you know, one third of the frequency that you would expect and clanking pipes, that it’s all steam skeletons going through. Yeah. And so you have to go into the morgue and you have to get the gurney. So it’s like going in and like getting the gurney and then racing over to the, you know, to that cancer wing.

And then you have to bring it back. And they always told us, you know, go in and you walk it all the way in and there’ll be other gurneys with bodies there, and you put it in order, you know, next to [00:48:00] that. And there were like two doors you had to go in. So you opened the first door. And then of course, yeah, it was like a vestibule.

And then in order to get to the second door, you had to go all the way in. And that means the first door is closing behind you, right? So, oh, yeah, yeah, yeah. So, so I’d go in with I getting hives, just hearing it. Kristen, go to the body, claustrophobia open the first door. And this is, you know, it’s, it’s the middle of the night, so there’s no one there, like you’re the only one there, you know, open the door, kind of go in and.

I am, you know, I am very embarrassed to admit it, but I will admit it here on this public show, that I would open the second door and I would hear that first door click and my heart would start creeping up through my throat and I would just gently wish the patient well and push the gurney and, and turn around and race out.

That printing as fast as my 17 year old legs could take me. Um, it was, it was a pretty scary experience. I I, to this day, I mean, I didn’t see it, but [00:49:00] every single time I just had this vision in my mind of one of them, like sitting up. Yeah. As I was going, I did not wanna see that. I thought it was gonna happen.

Yeah. Oh 

Kristin: my gosh. 

Will: Pathology was not in your future. No 

Dr. Micky Tripathi: thing. Definitely not. Or being a mortician. Yeah. That wouldn’t have worked either. Yeah. 

Will: And I imagine you weren’t, uh, uh, you know, doing any documentation in an electronic 

Dr. Micky Tripathi: health record at that time? No, they don’t. Orderlies didn’t do any documentation of anything.

I mean, I, I assume someone documented, there’s no record of you even be there. Patient, patient had a Foley catheter put in, but no one ever asked me to document anything, so. 

Will: And how are your Foley, uh, inserting skills these 

Dr. Micky Tripathi: days? Do you think you can, I’m, I’m out of practice, let’s just say. Yeah, thankfully so.

Oh man. Thankfully, so, yeah. Yeah. 

Will: Did your, because, because I know your father was a, was a, was a surgeon, general surgeon, is 

Dr. Micky Tripathi: that right? He was, you know, back, back then, um, I, I, I don’t think people do this now, but he was both a family doc [00:50:00] and a general surgeon, so he was like the old Marcus Welby type doc.

So he was, you know, he had a solo practice his whole career and he would, you know, see all generations of the family. But then when you needed your appendix takeout taken out, you know, he would refer you to the hospital. He would go into the hospital, he’d do the surgery, he would do rounds every day. He would do house calls.

I mean, he did, you know, kind of the whole thing. As the 

Will: classic, like Yeah, yeah. House call. Everything 

Dr. Micky Tripathi: you just kinda take care of. Did. Yeah. I think, 

Kristin: I feel like it’s got, it’s, it’s, I’m sure it was difficult as well, but I feel like it’s got some pros that we’re missing these days. Oh yeah. You know, of like one person who knows a lot of things about each patient.

And this gets back, I guess to, to what we were saying before about trying to make the technology catch up to that, to be able to kind of pull together all the information over a lifetime. I don’t know, I like that aspect of it anyway. 

Will: Yeah. But not the aspect where those docs were like working like 120 hours a week.

Nope. 

Kristin: Mm-hmm. Nope. That 

Dr. Micky Tripathi: was no good. Right. I mean, he was on call like by, you know, [00:51:00] 27, like growing up. I remember him, I remember many times, you know, watching Red Sox games, watching Bruins games, 9:00 PM gotta go. Uh oh. There’s dad’s call and you know, yeah. He’d get up and be like, I’m off to the hospital.

We’ll see you. Right. Yeah. It was a, it was a different model, but, um, but there was a lot of, there was a lot of high touch. Yeah, there was a lot of high stuff. Exactly. That’s a good way to put it. Mm-hmm. What he didn’t know though, and uh, you know, I’d asked him once I started getting into electronic medical records, and he was surprised too, that I was involved in electronic medical records.

He’s like, so what? You know, what, what’s the point of these things? You know, I deliver high quality. And I was like, I, you know, dad, I know you do. Um, but you know, said just for example, you know, you see what, you have 2000 patients roughly, probably, right? Mm-hmm. And how many of those are diabetics and how many of those would you say are well controlled?

And it’s like, well, statistically I like how, I have no idea. You know? And that was the point, right? For every individual, like you could name every individual [00:52:00] one and what he’s doing with each one, but like as an office and as a practice, he didn’t really have a good population health view because he didn’t have the tools to do that.

And you know, I think that’s a part of the point. That’s a good, 

Kristin: that’s a really good point. We need to find a way to get both, you know, to get that high touch personal experience and also, To have the kind of bird’s eye view that the data can 

Dr. Micky Tripathi: provide. Yeah. The, the chat bots are gonna give you the personal experience that you’re seeking.

Will: That’s, that’s the thing, right? That’s, that, that’s, uh, AI is gonna get us there. You just, well, you know, a, a future where you, you, you walk into a room and. You just start talking and then it’s just, it all gets captured and it’s there. And uh, and then you 

Kristin: don’t even have to walk into the room. You can just do it through your phone from your home.

Will: There you go. Practice medicine from your home. That’s right. Yeah. Well, not everybody, there’s surgery. There’s 

Dr. Micky Tripathi: something you might wanna actually be seen in person, but every now and then, like 

Kristin: ophthalmology, that didn’t work very well remotely during the pandemic. Mickey, I, 

Will: wait a minute. I can’t, 

Dr. Micky Tripathi: I still, [00:53:00] why can’t you just like, nightmares look in my eye?

Isn’t that enough? 

Will: Yeah. I still have nightmares of trying, trying to do, like, on the fly at the height of the pandemic when everything was shut down trying to do, uh, tele, tele-ophthalmology. Mm-hmm. Uh, it, it, it works better for certain specialties than 

Kristin: others. Also, these patients are patients who have difficulty seeing.

Dr. Micky Tripathi: They have difficulty 

Will: seeing. 

Dr. Micky Tripathi: And, and that’s, that’s a very good point by definition. 

Will: Yes. And so giving them instructions on how to, you know, go to a website and Right. Operate, put a, put a little password code in there. Yeah. Right. They had its challenges. It’s challenging, right? Yeah. All well, I have, so, so Mickey, sometimes what we’ll do is I’ll have like a, a just like an elaborate game or something to play, but honestly I just have one question for you.

One question that I think is probably on the minds of all of the medical professionals who are listening to this episode right now. Is there anything that will actually kill the fax machine?[00:54:00] 

Or are, is this just, uh, an immortal being? It’s the 

Kristin: cockroach of the technology 

Will: world? Are, is this, are we like 200 years from now, are we, will we still be using, we’ll still be faxing. Can we just like spend a few minutes here talking about. The fax machine and how it’s still a thing right now. Yeah. 

Dr. Micky Tripathi: Um, I, you know, I think the analogy thoughts is probably a really good one.

Um, there is certain beauty in the fax machine. It’s very, very flexible, right? You can scribble anything and just send it. It doesn’t care about standards or anything like that, you know. Um, but uh, yeah, I think, um, that is an ongoing source of frustration. Um, there have been, you know, sort of, you know, uh, I think one of my predecessors had a kill the facts or ax the facts.

Ax the facts. I think it was like CMS said, you know, sort of a thing on ax, the facts. And we’ve been, you know, talking about that for years [00:55:00] when I was working in Indianapolis. Um, and we launched this health information exchange network across the city to just to deliver lab results to all the docs, um, via like a, you know, a portal.

And one of the things we ended up having to do was, you know, I ended up, you know, going to all the different hospital CEOs and saying, and the only way for this to work is for you to literally tell all the docs. You’re not gonna fax them their lab results anymore. Like, you just have to shut it off. And we had to have all of them agree, because there were so many docs who wanted, who still wanted to get the a, the faxes, right?

It’s like, well, you’re never gonna move them off of that unless all of you agree, because you’re all competing with each other as well. Right? It’s like, well, we have to get everyone to agree to shut off the faxes, and that’s the only way that we can move forward. But obviously it’s, you know, it’s a big country.

It’s really hard to like, yeah. Turn off all the faxes. I think, um, you know, funny, my, my daughter is a, she’s a third year resident. Mm-hmm. And. She, you know, she’s been in multiple systems with like Epic and Cerner, and I was asking her how [00:56:00] that’s going. And she’s like, those are fine. She’s like, they’re not, you know, she’s like, it’s all the older docs who have a problem, you know?

She’s like, epic, Cerner, I don’t care. You know, you know, the training is fine. The systems work fine. The thing that she couldn’t figure out was one day they told her, fax this to a community doc. Yeah. And she was like, literally like, what, what exactly do you mean by that? She’s like, oh, take this paper and shove it into that machine.

It’s like, you gotta be kidding me. Why don’t you, someone used to show me how to use that thing. Well, the 

Will: explanations that I’ve been given about why the facts is still around is because it’s, it’s, it’s, uh, safe. People say it’s, it’s HIPAA compliant, which, right. I take issue with because you have something that’s just printing to some un random place.

How is that monitoring it? 

Dr. Micky Tripathi: Where, who’s gonna see it? It’s actually, yeah. In many, many ways it’s not safer. I mean, you think about it, you don’t know what’s happening on the other end. Right, exactly. All of us have been in, I mean, most places are pretty good, but all of us have been in places where the fax has just left on the machine.

Right. Yeah. Or right. Lots of stories of people of literally, like, like there was a story a few years ago of, of a bank mm-hmm. Talking [00:57:00] about how they were getting patient records. Oh, no. And they kept calling hospital saying, oh my God, stop faxing these to us. Yeah. And it took them like a while to get the ba, the hospital to stop faxing patient records to them.

Oh, wow. Wow. That was, that was obviously a hip breach Eventually. But yeah. I mean, there are all sorts of, and, and there’s no traceability. Right, right. You know? Right. So, so you can’t go back and do a, you know, a good audit log. And there are lots of reasons that, you know, to be able to argue that LF faxes are not as secure as electronic information.

Right. I think it’s, I think it’s like cultural change. Yeah. They’re too easy still. And, you know, and, and I think that the job is on all of us to. Make everything, make the alternative easy enough that people will naturally gravitate to it. I mean, my mom was, she just, she had, um, her uh, uh, she broke her hip last summer and we had to bring her from one hospital to the rehab hospital.

And they’re both on really good EHR systems. I won’t name the brands. Mm-hmm. And I know they’re connected in the backend. Remember that 50 million transactions a day I was [00:58:00] telling you about? Mm-hmm. Well, those two hospitals are definitely connected on the backend, and yet when we’re about to transfer her, they printed out her record and handed it to me and they’re like, bring it to the other place and they will up upload it.

And I’m looking at them like, you guys are doing this right in front of me. Like without shame. Cause you know, I have no time. I’m dealing with my mother. Yeah. But I think that’s part of the problem is that the systems are actually getting connected on the back end, but the, but the frontline users are, are kind of victims in this.

Right. The frontline dock. The frontline registration person, they’re not, you know, no one is coming to them and training them and saying, you know what? We have all these systems that are here to make your life easier. Cause when I was describing to them, you realize your systems are connected electronically, and they’re like, that would be awesome.

When is that coming? It’s like, oh no, it’s here. No one, just, no one has told you this deep, dark secret that lives in the basement of the hospital. 

Kristin: Oh my goodness. It’s happened already. And you’ll still use pagers too, like 1980s 

Will: beers. Oh, you know, we got, we gotta have some way to, to be [00:59:00] able to have work.

Find us at any moment. Cell phones. Yeah, I, well, but again, like you, you gotta, you know, safety and what I don’t, I don’t know like that. I feel like the 

Kristin: HIPAA I thrown out, I don’t know. I think that gets used as an excuse more than an actual to Yeah. Reason. 

Will: Yeah. 

Dr. Micky Tripathi: Told I, that’s probably right. Someone told it’s solvable problem.

Someone told me some, something to that someone told me has my daughter who I trust, you know, she’s like, there are parts of the hospital. There is no cell phone coverage, like you’re way down in the bowels of the hospital, down in the surgical cell or something. In the mor. The pager will still, and the pager and the pager works.

So things and just try like, I’ll take that at face value. I’m not gonna question her. It’s like the facts, pagers and facts. Yes. Like the facts though. Cockroaches are Twinkies faxes 30 years twin from now. 

Kristin: Yeah. McDonald’s, french fries under the 

Will: see. Oh yeah. I mean there’s some places that also, like when you, you know, radio radiologic imaging as well is another thing, right?

Like there are some places where they’ll still like, They’ll, they’ll ask for the disc physical Oh, wow. The physical disc of your images. Yeah. And [01:00:00] then you take it to a, an office and they, they don’t have a disc display. They don’t have a way to to, to put it into any of their machines because like, you know, so that’s another, uh, I mean, don’t 

Dr. Micky Tripathi: have anachronistic slicking around here.

I don’t if someone gave me a cd, I don’t really know. Well, you don’t. Yeah. It’s like, I know. I don’t really know what I do with it. I, someone showed me the other day, they got a cd and so they, like, they wanted it sent electronically. Right. And they were frustrated. And then the provider, you know, finally it’s like, all right, fine.

Give me the darn cd. I’ll figure out what to do with it. They got a cd and on it it said, for provider use only. Oh my 

Will: gosh. 

Dr. Micky Tripathi: It’s like, yeah, come on. This is patient empowerment in the Right, in the 21st century. Right. Yeah. 

Will: So, so what I’m hearing though is that we, we have. All the technology, everything we need to get rid of these archaic systems.

It’s more just about making sure that information gets [01:01:00] permeates through the entire healthcare system. It needs some change 

Dr. Micky Tripathi: management help and yeah, there’s change management. There’s, you know, and, and while we try to be judicious about regulation, there were just some things, like back to my Indiana example, which was, you know, one city and a lot of work convincing all the CEOs to do this one thing, you know?

And there are certain times when regulation. At some point just says, you know what? We need to give everyone a little bit of a kick in the pants and just say, you need to move to the next level. Rip the bandaid off. Right. So our draft, our regulations, we have a set of regulations that are called information blocking regulations.

Mm-hmm. And it comes from the 21st Century Cures Act of 2016, which basically said that patients should have electronic access to all of their information. And you’re basically telling the healthcare industry, we need to, you know, sort of enter the internet age finally as it relates to exchange information, particularly with patients, but with others as well.

Provider or provider and you know, and all of that. So we should start to see more of a change as that really starts to kick in here, that you know, that [01:02:00] hospitals and other settings. You know, start to realize, all right, we have to make everything electronic that we can in order to, you know, to meet the requirements of this rule.

It doesn’t happen overnight because, you know, these systems are really complex and some of ’em are really old. Um, but hopefully I think that’s directionally is, is uh, you know, really starting to take place. Now. Well do, that was a same set of regulations that did the immediate lab results thing. Mm-hmm.

Yeah. 

Kristin: Do you see, um, other disciplines coming in and, and being useful in this? Cuz as you’re talking, I’m thinking, you know, what I would do as a patient if I have all of my electronic records, you know, if I had the technical know-how, I just feed that into AI myself and see what it says. Right? Like, that’s just, people are curious about their health, so that’s 

Dr. Micky Tripathi: what they’re gonna do.

That’s, that’s what we want. That’s, that’s that. I mean, that’s the ecosystem that we want, that we want to create. Which is giving providers and patients the opportunity to say, you know what? I can, the, the, the, the friction of data sharing is no longer the problem. I can get the data that I need. And now a whole innovation economy can develop on top of that to allow you as a patient, for example, to do [01:03:00] just what you’re talking about and have services that are customized to your need.

You know, you can imagine a whole bunch of niche services developing of, yeah. Oh, you have Crohn’s disease, or oh, you have, you know, diabetes and you know, here’s all the information that you have and we can provide the service to you and give you reminders and texts and all of that. I think the one challenge we haven’t talked about, which is it’s a real issue in this country, is that we don’t have strong privacy protections mm-hmm.

On that data once it leaves the confines of hipaa. Right. And, you know, and HIPAA. Has been called, and I agree with this, you know, the most important and most misunderstood law in the world. Yeah. That’s, that’s both important and, and misunderstood. Yeah. And that people, you know, we saw during the, during the vaccine vaccine politics of people Right.

You know, sort of saying that’s a HIPAA violation. Yeah. Right. And in all those times they said it, it was absolutely not a HIPAA violation. Then there are lots of places where it was a HIPAA violation and people didn’t even know it was HIPAA violation. Right. Um, but the challenge is with HIPAA is that, um, the minute that you download a record onto your [01:04:00] device as a patient, assuming it’s not like in an app that’s provided to you by your provider, like MyChart app from Epic or one of those.

Mm-hmm. Mm-hmm. If you just download it onto your device is the vast majority of people I think, don’t realize that you have taken full responsibility now. For the security and privacy protections on that. And all of us know what we do with apps, right? I mean, I do it too, right? You download an app and right, the user agreements that have 15 pages of, you know, fine print, you’re just like, click, click, click, click, click, click, click.

Just get me to the app. And literally if that app says, we’re gonna take all your data and do whatever the hell we want with it, and we’re gonna sell it to the highest bidder, okay? And you just click through it. There’s actually nothing in the US that’s illegal about that. Right. And that’s, you know, that, I think that’s a big thing that we need to figure out as a society is how to give patients the protections that they need to be able to use that data in ways that, you know, that they expect and that they’re not surprised by and Right.

You know, and, and obviously with some types of healthcare data, you know, one spill could actually have a, you know, a real [01:05:00] impact on your life if it leads to discrimination downstream and employment and, you know, all sorts of other things that could happen with the wrong information being shared. Well now, now that’s 

Will: a big concern.

Now I’m getting scared. 

Dr. Micky Tripathi: You just, just remember, just, just remember there was a lot of potential value, but you are responsible. That’s right. Once it’s on your phone, there 

Will: you go. You are respons responsible. Personal responsibility. Well, let’s take a, let’s take another break here and we’ll be right back.

All right. We are back with, uh, with, with Dr. Mickey Repath and. We’re going to take a look at, uh, one of our, uh, listeners, uh, medical stories. So we have a story that was sent in by Michael and, uh, let’s see, where does it start here? Okay. My partner and I were finishing up paperwork on a call, uh, and we’re parked just outside a convenience store.

Uh, they were par, oh, I work as I, I, I, I missed, I’m struggling here. I work as a paramedic and we get some wild stories. He says, okay. So his partner and they were finishing up paperwork on a call and were parked just outside a [01:06:00] convenience store. They decided to get some ice cream, um, uh, that cuz it was a nice, beautiful summer day.

We made a whole two steps into the store when we got a call to the mall for a worker who had amputated their finger in an industrial machine. It’s probably a, probably a fax machine, I would guess. Yeah. Our patient was well and in good spirits. The security guards being diligent first aiders managed to track down the severed finger and apologetically explained they did not have any ice, and instead used popsicles to keep the finger cold.

Once we arrived at the hospital, we transferred the patient along with their finger to the nursing staff not to be denied in our request for ice cream a second time. Oh no, I’m afraid we released the brightly colored rockets from their protective plastic. Container and enjoyed them thoroughly. Oh my goodness.

Hey, that’s resourceful. It’s true. You deliver the finger. True. And then the popsicles that were keeping sustainable option. Exactly. The popsicles that were keeping the finger cold. Not what, not exactly. I, I’m 

Dr. Micky Tripathi: working. At [01:07:00] least they were. Is there a point to the story here? 

Will: I don’t think that, Nope. Not at all.

Not at all. Just a severed finger story. So just making you, uh, making you feel glad that you ended up in it and not, uh, know, taking care of severe fingers. Anyway, thank you for that, 

Dr. Micky Tripathi: Michael. I was supposed to be a doctor but didn’t work out, have care adjacent, didn’t work out. Healthcare 

Will: adjacent. Right.

Exactly. Were your parents, are they, were they pushing you? Were they like, Hey, don’t you wanna go to med school? 

Dr. Micky Tripathi: Both of ’em are parents and both of them are immigrants from India, so Yeah, it was, you’re gonna be a doctor. Right, right. What kinda doctor you gonna be? They didn’t 

Will: specify, so you went back different route.

You didn’t become a doctor different. 

Dr. Micky Tripathi: Right, right, right. Yeah. I mean, to their, you know, to their credit, I think my dad in particular, um, when I started sort of showing misgivings, he was like, you know, you, if you don’t want, if you yourself don’t want it, It’s, you know, it won’t work anyway. It’s too hard.

Yeah, it’s too rambling. You, you know, you got passion, so it was very good life advice. 

Will: Well, I think you ended up right where you’re supposed to be, so. 

Kristin: Yes. I like to think [01:08:00] so. Also, isn’t it rich that you have a PhD and feel like a failure, right? Like, I think you did fine for 

Dr. Micky Tripathi: yourself. Thank you. I appreciate that.

I’ll let them know. 

Will: Well, Mickey, we thank you so much for taking the time to be with us today. Um, what, do you have anything that you’d like our listeners to know about? Anything you’re working on? Anything, any final 

Dr. Micky Tripathi: party words? Uh, well, what are we working on? You know, everything we’re doing is, uh, and I know it’s all, you know, sort of steeped in the language of regulations and rules and all of that.

Um, I like to think of it as, you know, as, as the beginning. Of being able to really use technology in healthcare and information technology in particular. You know, we’ve laid, we’ve spent 10 years as we were talking about laying this digital foundation, and now we can all start saying, well, what is it we wanna be able to do with all of this now that everything’s digital or, you know, we still got some paper.

I know you’ve got some paper we’re gonna go find, you know, root that out and burn it. But, um, but, you know, but, but now that you’ve got this digital foundation, you can start to say, you know what, this is all bits and bites now. And how do we like, [01:09:00] try to red drop them, redraw the map of the way we think about healthcare, um, to really take advantage of, you know, of this electronic data.

That’s why I’m really excited about having, you know, being in this position right now because I feel like all that hard work is now behind us and we can think about all the really cool things we wanna do that’s exciting for patients, for medical science, um, for providers, all of that. So I think, you know, just, you know, um, uh, I think for any individuals who are listening, like whether you’re a patient or a provider, start banging the doors.

With your expectations of, Hey, wait a minute, this isn’t the way it’s supposed to work. Mm-hmm. In internet economy, I’m supposed to get my results every day. I’m supposed to have electronic access. I, you know, the CD doesn’t work for me. Um, and, you know, start having those expectations that you would have of the hardware store.

We should have that outta the healthcare delivery system as well. 

Will: I completely agree. Absolutely. Yeah. Well, thank you so much for being here. 

Dr. Micky Tripathi: This has been, this has been so fun, and thank you to Absolutely thank you to both of you for all that you do. Um, oh yeah, thanks. I think you bring a lot of insight and a lot of fun to, you know, to all of this, and I really appreciate it.

Kristin: And we’ll bring some things 

Will: too. [01:10:00] Yeah, yeah. I, I, I, I’m a little bit, I’m a little part of that. Yeah, that’s right. All right, Mickey, take care. Thank 

Dr. Micky Tripathi: you. Thanks.

Will: Well, Kristen, did you learn a lot about it? 

Kristin: I learned a lot about fax 

Will: machines. Yeah. Yes. Mm-hmm. Yeah. I I, I’ve been dying to ask him that question. Yeah. I was, I was like, I was holding that in until the very end. If even 

Kristin: he can’t fix that issue. 

Will: Well, it’s, the thing is, it’s fixed. We just gotta make people not use them.

Yeah. It’s like, it’s like for all, get on that addicted to our fax machines. Like we can’t just stop for yourself using them. You guys gotta have a fax. It’s been, this is like a week since I’ve had a fax. I gotta get a fax, got fax, withdrawal. Gotta get a fax. Okay. Anyway. Thanks for listening. What are you even talking about?

I don’t even know. Uh, let us know, uh, what you thought of the episode. We’d love to hear from you. You can email us, knock hi human content.com. Visit us on all the social media networks. Uh, you know, Instagram, [01:11:00] Facebook, TikTok, TikTok, YouTube, 

Kristin: YouTube, LinkedIn, Twitter, all 

Will: of them, all the things. Uh, you can also hang out with us and our Human Content Podcast family on Instagram and TikTok at Human Content Pods.

A thank you to all the wonderful listeners leaving feedback and reviews. If you subscribe and comment on your favorite podcasting app or on YouTube, we can give you a shout out like Gothic potato too. I like that one. Gothic Potato. Two from YouTube. Bro, keep up the great work because it was entertaining and super informative.

Thank you. Gothic potato. You keep sending us, uh, all, all your medical stories we really love. That’s like one of our favorite parts is hearing like. All the interesting 

Kristin: stories. So many stories out there. Medicine is 

Will: crazy. It is a lot, a lot going on there. Uh, and we also, uh, full episodes of this podcast are up on YouTube at De Glock and Flecking.

Every week we have a Patreon. Lots of fun perks, uh, bonus episodes, or react to medical shows in movies. Hang out with other members of the Knock-knock high community like [01:12:00] us. We’re there too. Uh, early ad-free episode access, interactive q and a livestream events, and a lot more. patreon.com/glock and Fleck.

And or go to Glock and fleck and.com. Speaking of Patreon, community Perks, new member. Shout out to Patrick S. Patrick s Thank you for being a patron. And shout out to Patrick the patron, pat. That’s right. Shout out Patron Patrick. As always, shout out to the Jonathans out there, virtual head nod to you all.

Uh, we have Edward K, Jonathan. A. Jonathan. F Caitlin, C K, L, Leah, Lucia, C Mary, and W Mark, Mary, H Mr. Granddaddy, Omer, Patrick, Ross, box, Sharon, s Steven, G Abby, h Rihannas, Lee, C Cha W and Dr. J. You guys, they’re making, they’re making it hard on me. 

Kristin: Yeah. You’re having some trouble reading today. 

Will: It’s hot in this room.

It’s hot air conditioner’s. Hot. Not working. It’s hot. So I’m getting a little, uh, loopy here. Yeah. Uh, Patreon Roulette. So shout out to one of our, um, members of need, uh, emergency Emergency Medicine, emergency [01:13:00] Medicine, tier of Patreon. Uh, so we’ll do our little, uh, roll. Eleanor. F Thank you for being a patron.

Thanks, Eleanor. And thank you all for listening. We’re your host Will and Kristen Flannery, also known as the Glock LECs. Special thanks to our guest, Dr. Mickey Trapi. Our executive producers are Will, will Flannery, Kristen Flannery, Aron Korney, Rob Goldman, and Ashanti Brooke, editor and engineer Jason Porter.

Our music is by Elmer Bins v. You wanna say this part, 

Dr. Micky Tripathi: deliver 

Kristin: bit of knock archives, program disclaimer and ethics policy submission verification, and licensing terms and HIPAA release terms. You can go to glock and plugin.com or reach out to us@nonahidecontent.com with any questions, concerns, or is most especially fun medical puns.

Knock knock high is a human content 

Dr. Micky Tripathi: production. Nice job.

Will: Hey, Kristen, do you know why I got into medicine in the first place 

Kristin: to spend your evenings on [01:14:00] documentation? Of course. 

Will: Uh, no, actually that never even crossed my mind. Hmm. Weird. I got into medicine to actually take care of patients to, to be able to form relationships with them, and that is a better reason.

Care for them to listen to them, to actually look at their eyeballs while I’m treating their 

Kristin: eyeballs. Well, I would hope that you look at where you’re treating. It’s an 

Will: important part of being an ophthalmologist and it’s easier than ever with the nuanced dragon ambient experience, or Dax for sure. This is AI powered ambient technology.

It’s just in the room with you and it helps you be more efficient and reduced clinical documentation burden. Uh, it basically lets you get back to being a physician and practicing the way you wanna practice. 

Kristin: So it’s like having a 

Will: Jonathan. It really is. To learn more about the Nuance Dragon Ambient experience, or Dax, visit nuance.com/discover.

Dax. That’s n uce.com/discover dash.[01:15:00]