 Good morning and welcome to Grand Rounds everyone online Eric. I'm muting your computer one moment. There's a little echo All right. Welcome everyone To Grand Rounds. It is a packed house for those of you online It's almost standing room only so we definitely want you to keep keep coming in person. It's wonderful to see everyone Ethics conferences have been really a pillar of education at the Moran for many years Certainly, they were among my most memorable Grand Rounds from my training and onward We have very much upgraded to dr. Eric Hansen both in terms of his running today's grant today's ethics conference but also he's going to be Really the director of our ethics conferences moving forward he has a Background in philosophy and he's a very thoughtful person. You'll find his perspectives to be there very thought-provoking And I can recommend no one better for just a sit-down lunch to have a conversation about anything than dr. Hansen So how much is a picture worth is the title? Without further ado our ocular oncologist retina surgeon former international global fellow and ethics conference chair dr. Eric Hansen Awesome, thank you. Hopefully I can live up to the expectation of provoking thought and thinking it's interesting. I Didn't actually have a lot of intention of Speaking and making you listen to me for an hour about ethics. I don't have that much delusion of self-worth But turns out O caps is a tough time to recruit Much thought into humanities and ethics for rightful reasons. And so we do have a sneak peek for next year's Ethics conference around this time will be on The merits of standardized testing for segmenting society and defining futures and I'll start taking volunteers for that discussion tomorrow so but today you're stuck with me and What I wanted to talk about is something that Is actually been in the conversation in the literature as well as in the news a lot in recent years primarily due to COVID and the way that it Reshaped many aspects of our society But interestingly it's been something that's been around for decade. It's not as new as it might seem for many of the stupid discussions that we're having and at the the Moran it's Or the University of Utah I should say it's still a relatively newer Project or scenario that dr. Hartnett has been running for I think about five five years now and so As we expand the tele-optimology practices both at the Moran at the University and outreach and then nationwide And globally if we keep expanding outward, I think it's something important It's something that is important to consider in all its breadth. Sometimes I I've found that it gets narrowed down to a certain conversations or certain types of technologies that are discussed but to think about How we're doing it and how we're doing it well or maybe not so well, so I really want this to be interactive I know it's tough over zoom so I'm gonna lean a little bit heavily on the standing room only audience They crowds this space So please do use the chat if somebody's moderating, please let me know if there's questions that come up in the chat and I really do Want to invite your participation so I have no financial Interest other than to make more money. Hopefully someday But nothing that relates to this What is tele-optimology? So actually I want to pose this question to the audience So when I say tele-optimology, how would you define it or what comes to mind? There's so many answers. I can't hear them all at once Cole is eating Sean when you think of tele-optimology, do you have a definition that comes to mind or certain practices? Yeah, and I don't know if people on zoom can hear the audience. So just a quick summary. He said he thinks of the use of imaging and technologies for Expanding access kind of remote areas and I do think that for many people I think myself included that would be the first thing that comes to mind when I think of tele-optimology Maybe not if I said telemedicine, but definitely when I said tele-optimology I think that's probably the first thing that would come to mind but I'd like to kind of expand the The definition a little bit and I think it's important to do so because when we think about telehealth or the melis telemedicine And then tele-optimology being a subset. We have to think of both the delivery of ophthalmic care So that's you know, could be screening images things like that information But then also education so think of training patient education All of these things are part of what we use for telemedicine or telehealth And we use telemedicine telecommunication technologies that can just be a phone It could be a landline phone could be a cell phone or we might use more advanced digital technologies now We're thinking about cameras. We're thinking about some of the other more modern technologies That we're using in health and we're using in you know, telehealth in particular You know, things like zoom for example would be Kind of probably both digital and telecommunication And so why do we even need tele-optimology? Or you know, and I'm gonna focus on tele-optimology. Well, you know, COVID became one very acute scenario where we needed it Why because people couldn't come to the hospital They couldn't come to the clinic for routine care or for non routine care even for acute care There was huge barriers and we've talked about in other You know other Grand Rounds other ethics Grand Rounds even last time, you know, it's fear-based But there was also policy and regulation that kept people from coming to the hospital for anything other than pretty much urgent or emerging care And so there was a pretty rapid expansion on a policy level on a societal level for the use of telehealth Not just relegated to our specialty one of the interesting things about ophthalmology is before For COVID and COVID in particular It was one of the most highly impacted specialties as far as the fall-off of patient visits and Available patient care that we saw of all specialties across the country We also before the pandemic had the lowest use of telehealth Which actually surprised me because we think of ourselves as using technologies being probably from you know kind of cutting-edge on Using tele-screening tele retina, but overall we were the lowest specialty The specialty uses telehealth the lowest before the pandemic this obviously changed during the pandemic and certain subspecialties in particular neuro ophthalmology oculoplastics We're you know able to use it quite readily whereas others retina UV-itis things like that where you need a lot of imaging or post your segment exams were less able to use it as a successfully But thinking past COVID as being you know something that was you know, we're hopefully Fingers crossed emerging away from in the next few months We still need to think about teleophthalmology as a real need because there's an increasing number of people in this country And there's a decreasing ratio of available specialists in particular Ophthalmologists and retinal specialists. There's also the reality of distance in geography, Utah I mean probably captures it as many as much as any other state in the country because We have yeah, we have the Salt Lake City Valley We have this tertiary care center the center of excellence Once you get outside the Salt Lake City Valley people are spread out and after travel a long way for specialty care So even if they have primary primary care, it's much harder for them to find access to ophthalmologists and in particular retinal specialists and And then also access which we think of insurance payment people just having to work and the Effect that having to go to a doctor's appointment has on their their work at their life their family and non adherence Which we always think about as well, which often relates to social determinants of health or these factors So now I would like to ask The increasing crowd which is so nice to see how do you guys use teleophthalmology or telemedicine now? Like what are the ways that you use it day in and day out? You can just like throw things out Yeah, my charts a huge way we use telehealth Yeah, yep, so smartphone usage is huge the myriad of ways we used it smartphones Anything else you guys do on a regular basis Yep, and it includes calling a patient on the phone I think that that's like I don't know maybe like the low hanging obvious fruit We think we forget about like if you just call a patient whether it's from your smartphone Doximity or from the Moran. That's the tele like that is the use of telehealth You are using telecommunication to bridge distance for patient care and patient education You need any other ways that people are using it Sean already mentioned imaging screening. He had did some studies in Nepal Regarding that anything else that All right, ah So I think we kind of hit on virtual visits screening the other thing that I know Dr. Orozco uses a lot I'm not sure who else is using this frequently is at home monitoring which is becoming a more frequent thing We use it in retina. It's gonna become more prevalent in AMD Hopefully in DME there, but they're also using it in glaucoma for pressure monitoring and that is also telehealth and probably going to be Incredibly helpful if you think about the patients we treat for their long-term care, especially in these chronic diseases that we're managing And the other thing that we saw an uptick in and Jeff petty could talk a lot about is tell the training We're using this in Navajo. We're increasing our usage with our global partners But it's also what relevant to what Joe mentioned when you're just having consoles and you can send You know the fellow or the attending or whomever the senior resident a picture of your 20 die after exam That is tell the training as well And not only are you using it as a console but you're also saying what the heck is going on here And they can help out without going in-person valuing the patient. I think I saw a chat there. I didn't catch it Yep all the time especially in pediatrics. I think we do this a lot His parents often worry just they take a photo of the kids. I like yep They need to come in of this is normal after the surgery So how at the Maran are we using telehealth? Well, we talked about my my chart I use utilize the law virtual visits these things we just talked about the other thing is tell a retina and tell a Retina is just a subset of teleophthalmology or telehealth and we think a tele retina We think of screening so diabetic screening is probably the the biggest one because there is such a High prevalence or incidence of diabetes. They all need to be screened right every year a hundred percent of diabetics need to be screened every year But we also have to think about R.O.P. Dr. Hartnett I don't know if she's on but she's done a lot of work both in the diabetic retinopathy screening for telehealth here at the University but also with R.O.P. and R.O.P. across the country is It's actually interestingly becoming more and more of a standard of tele tele R.O.P. Dr. Moshafegi out of stance or Stanford has created a I Guess I don't know a conglomerate or whatever, but it is expanding where even some of the people I know who work You know on the East Coast Dr. Calvo who trained here in Nevada where their R.O.P. that they were doing as part of their Their practice their institutional collaborations they have with local hospitals is changing They're like moving away from these local retina specialists into this tele R.O.P. paradigm And I think that it's become more and more commonplace, especially as AI Starts to pervade the the diagnosis of plus disease in our R.O.P. stages. So What we're doing here in addition to what's already been done at the Utah diabetic center where we have an AI camera in place It's screening any of the patients that come into the endocrinology Clinic there at the diabetes center in particular is the VA is probably one of like the The most important things to mention when it comes to the United States as far as teluretina is concerned because it not only has been Probably the most successful implementation but also it was very instrumental in Spurring early adoption because the studies that came out of the VA's Tele teluretinal programs show that it was successful in catching disease and a reliable way just to do yearly screening for diabetics But then also we're trying to expand to what we're doing with from the an outreach or a public health perspective outreach becomes more and more narrow the way I think about it, but like if you think about the the trying to Capture everybody in the state with diabetes whether they had geographically limited Financially limited we need to think about also how we're we're not we don't need to think we are thinking about how we're Catching all the diabetics in Navajo, right? So we go down there on a regular basis we do screening but obviously this we're going to capture more patience if we can do it in a Telehealth paradigm where they're going to their primary care doctor You're getting point of care screening and then hopefully maybe point of care diagnosis as well So a little bit I just kind of mentioned point of care screening important care diagnosis I think these are two features of teluretina in particular that are really important For a couple reasons one is every time you separate either by time or distance One I think that one visit or one implementation of health care to another I think there's a chance for non adherence for loss of follow-up or for worse outcomes, right? So the more immediate the results for the patient I think the better we have as far as getting patients outcomes and helping them understand their care as well And so there's been a shift That happened many years ago with point of care screening and the VA as I said was one of them the Leaders in the United States on this and what does that mean? That means when a patient goes into their primary care clinic or any other clinic But in this case is generally primary clear clinic that they get a photo taken at that time They don't have to go to a separate visit and I have to come back for a bit just an imaging only appointment They don't have to go to an optometrist or an ophthalmologist or any retina specialist anybody they get the picture They're done there now for a long time that picture still then had to be transmitted You know using some technology and read by a physician and Then the result will be conveyed back to the primary care doctor and conveyed to the patient This was a huge improvement But it we still lost people to follow up because and then you have This delay in from their point of the imaging to the diagnosis Which I think creates a psychological barrier But then also you have like the the process of getting the primary care doctor to follow up in the results The patient getting referred and I think the more steps you add the more time you add the the more chance we have for failure So with the advent of artificial intelligence We've that been able to now start implementing point of care diagnosis where when the patient gets the image They get an immediate or near immediate result. It tells them you have disease. You need to go to your doctor And I think this is making I think this is is massive massively impactful So for example, we have this process implemented at the Utah Diabetes Center. So as soon as a patient comes in they got their Their appointment with their primary care doctor they get their a1c check They get their nerves checked and they get an image and if it says that they have DR and then in particular with the Software you we're using which is I know they also can get a result that says you have vision threatening DR Which is even like a higher urgency referral and Immediately We're creating a system where immediately that patient gets referred to us that right there So like they're getting a referral they sent either via email or through epic for that patient to be referred and soon It will hopefully cross our fingers. It will be integrated into epic so that that just happens as a like a boom boom boom automated result so you can imagine how and how helpful that is for the patient wherever they know what's happening why it's happening where they're going by the time that they leave their Appointment or to at least expect a call, you know the next day to get in a follow-up appointment so What's interesting about all this is the at the Like a great capture of the paradox of what it healthcare in America to me is America is actually a really bad for how good of technology we have and how good of health care We should have at screening diabetics, right whether there's metrics for primary care Clinics hospitals institutions, and I think it's like upwards like 80% like they have to reach of their diabetic screen Across the board depending on the studies look at it's like we're 15 to 50 percent. We're bad. We're not doing well You look at England right where they have a nationalized health care system They've reached 83 percent of screening and have lowered diabetic retinopathy as one of the major Causes of blindness in their country as a result Now I'm not here. I'm not trying to be political But the other side of this is okay. Yes, it is probably because we're so Decentralized and we're so fractured in how we deliver health care and your EHR's don't communicate Well, just trying to get a camera or a software to integrate into One EHR much less three is an act of Congress and you know how Congress is so The other part of it though is because we're so bad We it has spurred the advent of AI and these other very successful technologies, right? Because you're now like because we're so bad. We have to figure out other ways to do it Well, so they're like well, then this is how AI has become now an FDA approved technology I'm with two softwares that are allowed to do it with two cameras and so hopefully we can bridge the gap and actually Conquer this mountain ahead of us and I think we're making it there But it is an interesting way of looking at American health care so what um Yeah, good question. So the and I'll get to that a little bit as a barrier but Oh, so, uh, dr. Petty asked Are the the financial reimbursement is the reimbursement or financial incentives Of tell the screening a line to support it as a primary care model where they make money Versus the optometrist or ophthalmologist or versus nobody And the answer is I'll get into a little bit later as one of the the barriers to In pitfalls of teleophthalmology But it's more aligned with it for the primary care model. So it's it's More sustainable more lucrative for them, except it really depends on the pair mix and overall It's actually a huge barrier to successfully implementing tele Ophthalmology screening programs On a large scale, especially when you start diving into You know, an ideal pair of mixes pair mixes So where is teleophthalmology or telemedicine going so? A few things that I'll just kind of quickly point out um, so hopefully legislative expansion COVID was something that um, you know spur a fair bit of legislation regarding telehealth Although some of it has fallen off and I think there's a lot a lot more need for additional advocacy to Retake some of the ground that we lost after COVID and then And then to probably gain some additional ground as well I think the the artificial intelligence We're going to see a fairly significant expansion in the next few years. So right now we have basically You know two cameras and two softwares that are FDA approved You know, so there's going to be expansion to other camera models And it's only approved for dr. So hopefully we'll start to see You know it expand into other disease states glaucoma amd being the probably the the next They're going to be a highly relevant smartphone usage So already we use smartphones for a lot of things and I think ophthalmology I don't know if it's the most but it's got to be one of the most as far as Utilizing smartphones in daily practice. They think on consults. We can use it for the Snellon chart We can use it for a number of the like, you know, the Exams we do that we don't have access to the in-clinic tools We also use it for taking photos with their smartphone imaging the people using remote scenarios But I think that as you know, you think about how fast smartphone technologies are expanding with augmented reality And the computing power I think it's going to continue to be more and more of a technology that we can use Like even for, you know At home screening for example And and utilizations of that the other thing is tele-treatment, you know, that's something that we haven't really explored yet, but we're we're Not too far off. I would actually maybe say we're there which The I don't know if anybody's ever used this laser, but the novelist laser is a laser that you can basically plan and then deliver a retinal laser either a focal or pan retinal peripheral laser using Or you're basically like across distance So you can work in three paradigms with the way they the way that they promote it It can be distance learning distance guiding or remote planning So it can be used completely remotely without Somebody there who's an ophthalmologist or it can be used as a way of staffing A trainee or you know, if you're thinking about what we do globally We could be helping an ophthalmologist who doesn't have a lot of retinal experience from here By basically what they use is the the fundus photography. You can also use f a And then it plans the entire laser and then it can deliver it with The the algorithm able to basically avoid areas that are, you know, no fly zones I hate that they use that right now But that is what the the terminology they use on their website So that they have a no fly zone for where the laser won't hit So this is going to be more and more of a reality There's other a group out of Stanford that's also looking at remote delivery of Of retinal laser as well And then I know that there's a number of groups that are looking at how to Create and implement Tele injections, which I think we're a ways off from that But it's already in the works and you know robotic surgery is already here. It's it's it's a it's a matter of When not if And then the adoption will obviously be important, but it is this this is a really interesting technology that You know kind of offline. I think we should really discuss for some of the stuff we do with outreach and with our global partners um So trying to get back to a little bit more as we get into the the ethics of it as we Start to look at the ethics and the Bring this back to an ethics conference What are the things that you see as as far as the future not the things we're using right now But what the things that we're not yet doing that's going to be the most impactful for what we do in ophthalmology Yes, like it's I agree and we're doing so one of the things that was said was the ability to securely text patients and communicate with providers across healthcare systems You know, we we probably do so a lot Not us but other people in the in the country probably do so in ways that are not Truly secure and we don't even realize it if we had to be honest But I think that some of that is just awareness. So finding ways that we can be Absolutely compliant with the the security that we should be using And then the other one was the ability for EHRs to communicate So you really have a true snapshot and not even a snapshot like a full You know detailed picture of a patient's health who's getting care at multiple institutions And we've kind of piecemeal addressed some of these things, right? That's the thing is like my chart is a Start but not every patient has my chart. Sometimes I get on my chart to send a patient a message and I realize they don't even have it And so, you know, you're kind of stuck with the old the old school approaches and then care everywhere You know as a start, but I think 80% of the time I need it. It doesn't really offer me much at all And I think that the that the latter part Is going to have to be a policy based Decision like there's an eventually just have to be a law that says that EHRs have to communicate and have to Communicate in a meaningful way because there's so much proprietary interest. They're keeping things from happening in a rational or in a patient-centric way And They're just at this point to me. There's just no reason not to but I think it has to come from the government and It seems like they have other things on their mind presently All right, anything else So present barriers So I think the the main barriers to more and more implementation of tele-ophthalmology Whether it's tele-screening tele-treatment anything cost and reimbursement is a huge one You know, and it we'll talk about it a little bit more the technologies I think the technologies are actually the things that are happening the fastest and it's a lot of catch-up in relation to policy regulation You know cost etc Personnel even though it's supposed to eliminate or decrease in need for certain personnel I think there's still a barrier in the sense of a lot of these technologies and training so and You have a high turnover and a lot of the positions that are using them on the ground level So boots on the ground level and then legal and regulatory as we mentioned So let's talk about the ethics since this is an ethics grand rounds And we kind of just had like an overview of tele-ophthalmology I think there's a number of ethical considerations for tele-medicine tele-health and You know in our world tele-ophthalmology And so speaking in particular to tele-ophthalmology, these are the ones the primary ones that I identified I'm very interested if anybody has any additional ethical considerations that they face or that they think are relevant The obvious one patient privacy We talk about patient privacy a lot I don't want to spend too much time on this because it's something we like go through a HIPAA You know Course every year year after year and I think in a way that's very good I think in a way it also is a disservice. I think we've started thinking about Privacy in a way that's really narrowed it down to like what we learn on those HIPAA courses, which is like Don't think leave things on faxes, you know, you're how to transmit the data electronically But why why does privacy even an ethical consideration? Why are we even talking about that right like and The reason is that privacy goes into patient autonomy right confidentiality the patient Physician relationship human dignity like the right to be able to have a disease state or You know when we start thinking about reproductive or sexual health and have a relation with somebody in a way that you know That your dignity and your your privacy is protected but also privacy is not just your You know the way we think about it with the transmission of data. It's also Security so security is something I think the HIPAA courses do a great job of covering and that's the security How are the institutions and the technologies we use securing your data, right? So When we come to tell ophthalmology, I think it's an incredible thing to think about and Luckily with some of the things anything that's getting FDA approved and probably being being implemented in a clinic Like telescreening those things are should be built into it, right in order to get FDA approval in order to Be implemented in the healthcare system. They're probably having those security measures and those HIPAA compliance Measures implemented, but what about the things we do that we talked about on a daily basis, right consults texts patients patient calls things like that, right? Question that I have is I message HIPAA compliance It is end-to-end encrypted It's secure But is it HIPAA compliant? I have one no head shake That's correct. It is not Why is it not? It's it's encrypted. It has the the features of what it You know, it should be secure enough. But why is it not HIPAA compliant? I didn't know either. I had to look it up. So There's two reasons one is that there's no business relationship between apple and the healthcare, you know, whatever facilities or institutions that and so that's one reason that's but that's probably a Soft reason the other reason is that you have your iCloud backup on and this is just an important thing for digital privacy that if you didn't know now you know You have your iCloud backup on even though every message you send is very encrypted and probably impossible to be You know intercepted or hacked Your iCloud backup contains the key which apple owns and so it is susceptible to both hackers or you know Third-party government warrants, etc So everything that's stored on your iCloud even though it is encrypted It can be hacked. It can be intercepted. And so that's why it's not HIPAA compliant So unless that changes that is not so there's other apps like signal is is HIPAA compliant and then there's you know There actually are a couple Healthcare-based secure messaging apps. I just don't think they're very widely used people don't know about them That you can also utilize for patient, you know patient information Does anybody have any thoughts or questions of or anything about privacy? I don't want to spend too much time on it But I do think it's actually very important to think of it past just what you know, but we kind of Answer questions on on the on the Educational courses every year all right 100% and that goes I goes right into the next slide like perfect um, and that is that You when you do screening a you're going to identify disease Um, and if you don't have a way to treat it, that's one consideration But also if you can't identify what the the proper if you can't uh screen them properly You have to have a plan in place to get those patients an exam and proper Optomic care so and both are important. So there's best practices that have been suggested by the academy as well as a number of other medical organizations Regarding telehealth and tele-screening one of them relates to this ungradable images. What do you do with that? Well, best practices that patient needs an exam within a certain timeframe If you haven't even identified a way to get patients who Have identifiable disease Vision-threatening dr to get care, which is a real problem Like when you start trying to work in this space and you're working with a clinic primary cleric clinic, you know I don't know and you know, uh, you know Alaska or something. I don't know. That's just somewhere very far rule They just need to get their metrics up They need to screen their diabetics and I wish it wasn't the always the case but sometimes that's really how they're thinking They're really not thinking about I need to make sure this patient doesn't go blind They're really just like I need to get my screening metrics to par and screen my diabetics And so then you're trying to be like, yes, but we also Need to make sure that if they have disease that they don't go blind They're like, yeah, yeah, but but after we figure out the screening, right? And it's a real problem and that's a problem for a lot of public health, right? There's a mantra in public health You don't study something unless a study a population unless you can help them Well, I think it goes to screening as well You don't screen a population unless you can provide some help or at least some semblance of future help And I think the same thing just goes to these ungradable images, you know If you if you're like, well, and there was actually a study that came out of Thailand and appreciate Mike Murray for providing this reference in this slide Where they looked at the like the real world's implementation of a telescreening program And this is a very real thing where You get a patient and they have one eye that's perfectly gradable and the other eye is It's probably shouldn't be gradable just to be honest and you get that and I think a lot of providers in real world like, well You know, they kind of look around the glare and they move the picture and brighten the screen do a few things And they say well, I yeah, that's probably fine That's not the way it should be breast practices of that patient because if they have a media opacity You can't see the the entire picture needs an ophthalmic examination But if you haven't figured out a very like easy way for that patient to get that it becomes a barrier And then it becomes in a way that you fail the patient on an ethical level and Like on a liability level as well All right The other part that kind of relates to this is if we're doing telescreening in particular, what are we missing? Right, what are we missing because most most of the time we're not using ultra wide field cameras And this is something that again on like a regulatory level on a policy and reimbursement level could change But the problem is right. We have non midradiq ultra wide fields The cameras the optos we use it every day. It has incredible images that you can get through a non dilated pupil But it costs a lot of money and the reimbursement is not set up For any clinic, especially when you start dealing with clinics that are serving underserved populations to buy an optos So we're most often and what has been standard It is standard the standard pair is to use either a 45 degree or 50 degree fundus photos And maybe like the the ionic will take two they'll take a macular centered and a nerve centered But not always that's not the standard the standard still would allow for a 45 or 50 degree macular centered Image So there was one side of the looked at this and they noted that Just related to diabetic retinopathy in about 10 percent Of these cases there would be peripheral findings that would change the grade of diabetic retinopathy, right? So if you think of the number of diabetics We have in the country if you're screening them all point of care screening if that's where we're going You're missing a lot of people a lot But then you also have to think about the rare diseases. Yeah, they're rare But if you have a half percent to have a retinal tear or you know Point one percent you have a tumor. It's often the celery body that an optos would catch Those patients think they're getting adequate care They think that that is a substitute from ophthalmic examination And a lot of places when you look at what their practices are when you read about what they're implementing are using telescreening this way. They are not Necessarily requiring that every few years whether it's three years, which is What we've decided with some of the charitable clinics that every three years a patient should have a full dilated examination And I think that's best practice supporting the academy as well And they they they should have an exam within the first year of implementing their telescreening as well, right? Either they've had it a year prior or if they haven't within the first year Even if you take the picture they should have an ophthalmic examination with a dilated exam I don't think that that's really happening nationwide and especially with the use of these ai technologies They're going to be implemented. Um, you know in primary care clinics and walgreens. Who knows? I think that the patients are going to think that this is a substitute And I think a lot of things will be missed. We're going to see late presentation of peripheral disease And so I think it's something that we have to consider We also have to think about whose liability whose responsibility is that right if you as a You know an ophthalmologist help a primary care clinic implement an ai-based program Is that all the company's liability? Are you partially liable? Is it all the primary care doctor's liable? I actually don't know if you're if you're the physician It sounds like that there is some liability on you if you miss things, but if it's outside the The purview of the of the image then the liability gets a lot more murky Liability and responsibility are two different things. I think we have a responsibility to our patient Even if we don't always necessarily have a legal liability Any thoughts? So, um, Arianna also mentioned that we have um, we might have a biased Uh Image database based on the way that ai has is created with deep learning I think marshal had an excellent ethics growing around a while back on this And so if he was here, I'd ask kim because he knows a lot more about it, but basically it's the A subset of the garbage in garbage out phenomenon, right if you put a lot of images in but they're all of one social demographic And then you're screening a totally different different graphic Are your ai algorithms accurate and the problem is we don't really know We just assume they are because a lot of that's happening in that proverbial black box And that's a very good point the other point regarding ai and what is missed is if you're using ai and it's only set up for dr And you don't have a secondary Physician read you're missing glaucoma. You're missing amd. You're missing anything else basically And I think that's a very real thing and I think that we have to think about that Hopefully with as ai expands into those other diseases and some of that will be less significant But um, you know, for example, temple has a really beautiful program set up where they have the utilization of both Autonomous ai ai and ai assisted reads that still have a physician over read So the dr portion will always get an ai read Or an ai assisted but then no matter if it's ai autonomous or ai assisted It then goes to a secondary physician read for those other diseases And I think um, and I'm not an expert on this, but I'm pretty sure that the reimbursement model does allow for this Um, but I that would have to like I would like to talk to a coding expert Like whether they're able to double double bill especially for ai and we'll get into a second There's two different codes or separate codes, but um, it'll be interesting to know that It's something that I'm interested in trying to implement into what we're doing And so I'm trying I'll have to learn a little bit more about how that coding works But um, I think it's it's an important point about what ai is missing and we have to keep considering that at the more and more We use ai for any any part of health care so, um I don't know if people can hear but that uh Tyler has a particular knack for also reading my mind And made an excellent excellent, uh point and reference. So abraham vergassi who wrote um uh cutting for stone And as a physician internal medical infectious disease physician at stanford has written a lot and talked a lot about this and uh, one of the things he says is the the virtual patient meaning the patient an epic on our hr in america gets phenomenal care but the actual patient Maybe sometimes suffers because of the way we set this up and um, it's true that like you think about the way I mean we're Probably not as bad as some specialties because we're forced to look at the patient's eye and we touch them But a lot of specialties like they go in there look at the screen you're looking at all the labs You do your rounds now in the hospital in a room separated from the patient's bedside And you feel really good about what you're doing, but the patient has no idea what's going on And it's probably never been touched. You know, there's no physical exam and um He also it also does relate to the specter of what's missed We feel like we're doing a great job screening for diabetics, but are we really Doing the best for the patient's always and maybe not And so i'm going to skip ahead and then come back The the hope it was beautiful what he says and someday you should just look at uh, or sorry. I watched the ted talk Um, he talks about the physical exam as a ritual. You know to think of it beyond Um, just something we do to identify disease, which it is also it is also that function And in ophthalmology, we have are very reliant upon the physical exam One of the first thing that was taught to me when I was a first-year residency resident by one of my uh chiefs Was that the visit we're kind of lucky in ophthalmology, especially when you're treating patients You can't even communicate very well with because you can often make the diagnosis just by the physical exam We can see almost everything and now that's not always true But it's an incredibly important part of what we do And I think that that's why we have a unique Perspective on this of like what is lost with the virtual visit Compared to when we see that patient clinic But he talks about it a step further about the ritual of the physical exam Being something that is a ritual of transformation and he compares it to weddings and the ceremonies of matrimony and then the rituals of transfer of power and how these rituals have been ingrained in our society to Represent and help us understand transformation. And so in the patient doctor relationship he believes it's something as a ritual of Creating or transferring something from where there is a coldness to something there where there is trust And there is a relationship formed that is very real and allows for what like the The the full and a holistic version of healing should Um, and so I just wanted to skip ahead because tyler mentioned that but i'm going to go back here We have about 10 minutes. I think we have time to To keep on rolling here Around the heart fluid in the lungs he described in this wonderful manuscript inventum novum new invention, which would have you know what You're gonna you're gonna hear as deep booming noise. All right, so Testing testing boom boom. Okay back on track A little detour All right, that played a lot differently in my mind how that was going to work Just want to let you guys know on that one Um, so then we've also talked about cost and value and I think why do I would I include cost as an ethical consideration because I think we have to think about cost and reimbursement Ethically as a society as well as as providers and as individual providers Because we have to think about the way that it is influencing the care we provide and the care we're able to provide and I think That is why the importance of Advocation in our profession is of it is is so high it's so significant So what dr. Petty mentioned earlier about like well, what is the reimbursement? How is it set up? Well, in short, there's three codes um for telescreening and then there's also codes for uh Televisits during the pandemic for televisits. They allowed both uh broadband so virtual visits and telephone visits to reimburse unfortunately after the pandemic the telephone Visit type has had that reimbursement has fallen off especially with commercial providers So now you have a scenario where only people who have access to broadband can utilize virtual visits like true virtual telehealth visits And you can kind of already think about where this is going and then for telescreening The reimbursement I and I got to be curious everybody saw so I'm just gonna tell you so uh reimbursement if the patient does not have a disease Like $16. Okay. That's for a physician read of an image if they have identified a disease It goes up to around 26 to 30 dollars. Okay, if so if they have disease and then for every Exam after that it can be billed like that although then then they often should be in a clinic office anyways And then for ai there was a recent the it was recently uh valued so now it's like 45 to 50 dollars Right it's for an ai read so the physician read is less than a third of the ai read And the the argument for that as well the technology that was you know the a the research development and the technology But how does that like I mean, what where do you guys thoughts on on the on what that does? I mean, I'm just kind of curious like in in a both like how it makes you feel about the value of your expertise and what it does to You know a telescreening program on a large scale Dr. Bernstein, so speaking to both of those those things and kind of moving on the other the The other thing that the and so one of the things Dr. Petty mentioned was the incentive is a they incentivizing ai as the form of You may speak Sorry, eric. I was a great presentation. I was just gonna Just drop a comment that uh, I used to work with one of the diabetic written up with these screening programs a startup in san jose And they were one of the first companies to actually supply all of their their database and images and develop the algorithm The ai algorithm with google and one issue that they ran into is kind of what you were alluding to with just the holistic and kind of the The approach with the physical exam that they found in following up with their patients that 25 of patients with a positive diabetic retinopathy screening did not the only sorry only 10 to 25 of patients actually went to an ophthalmologist and actually followed up Even when they had referrals in order and even when they had a positive exam So and google couldn't really wrap their head around the fact that there wasn't good follow-up But I think like you said there's something in actually physically talking to a patient and educating them about what the screening is for So even though we have this technology ai and detecting disease 75 to 80 percent of patients aren't even going to an ophthalmologist or following up with a referral Absolutely. Thank you. This is god speaking. Thank you for your insight and wisdom So, um, I know we're kind of running out of time and so I want I do want to get to The digital vi which I think is a huge part of Thinking about teleophemology and it it relates to all that we've talked about So it's related to access to broadband So now if you have de-incentivized and done away with the reimbursement for telephone But you said okay, we'll still do it for broadband But some around 20 more likely 40 million people in this country mostly people of depressed socioeconomic backgrounds And a higher percentage of minorities don't have broadband access Well, you guess what you just done you've given better care. You've created tier of care artificially and the question is Who should tell the health or teleophemology benefit? most It's a trick question It should benefit everybody equitably right like that is the ideal we provide healthcare as physicians and supposedly as a as um, society equitably But what's happening is that's not the case and one of the things that happened during cobit is because of the rapid expansion, we're able to look at what was actually happening including in teleophemology and what we're seeing Is that the utilization of teleophemology services? Is skewed towards younger people more educated people more affluent people And there's a number of reasons for this all of which go into the great chasm We call the digital divide which is the widening gap between those who have access to technologies or have technology literacy And those who don't as society progresses forward in a certain way and what they and so It's important to note and one question I kind of had to myself is by Identifying disparity in usage. Are you identifying disparities in care? And I think that is an important thing to understand right so it doesn't mean that the results are different But we are seeing early on that people in uh, like minority populations people in uh, you know lower socioeconomic backgrounds are not using telehealth As well And then it gets even more complicated because a lot of these tell these screening programs That are being built around the country like in california with that huge statewide implementation with government support were to support some of these underserved populations But then if we create a cost scenario where the clinics that are providing care to underserved populations cannot afford ai And can't afford most of the other types of software that are out there for telescreen We're actually making the situation worse where the people who can go to the like fancy primary care doctor They can get the you know their ai screening get their print out go home boom boom boom But but the clinics that can't afford the 30 dollar Or whatever click fee when a certain percentage of their population is uninsured and won't reimburse They can't do that. It's not even an option, right? They don't have the funding And so now you're creating a widening gap even of the care that you were supposed to be You know decreasing with these new technologies And so right now where I think we're still in the phase of identification Okay, these disparities disparities are exist the exist and are widening But we still don't understand how we're going to address it I think it has to be on a policy level and also what are the outcomes From this gap and I think those are the next steps from a research standpoint. I'm going to skip these cases but basically The people you think might benefit Don't benefit as much. We got to think about real Answers to these problems. So like one way for people who don't have access to broadband. There should be like wi-fi broadband's Spots the patients can go Or government should support a broad rollout of broadband to make it a You know, basically a human right in our modern society to identify and List it as a social determinant of health because that would change the way we study it and Think about it from a health care implementation And then we already touched about the touch beyond the screens I think it's important to note that beyond just what dr. For gassy was mentioning with the ritual of the physical exam There's also very real cultural Differences in what people want or expect out of their health care visit Like maybe some of us are very comfortable with a virtual visit That feels good But for other patients, maybe older or different cultural backgrounds It doesn't feel like they saw the doctor like there's something about being in person There's something about the physical exam The physical touch etc that makes them feel like they actually saw the physician and got medical care And I think we have to be cognizant of that don't treat every person the same right like allow those differences to exist In order for the outcomes to be equitable One more thing Oh, yeah, um, so it's a ted talk by I'm going to show you here It's a ted talk by uh, abraham burgasi Why does it do that? So you could just uh on the importance of touch or the physical exam I'm losing the The doctor's touch Ted global 2011 saw it here first um, all right. Well, I I left no minutes for questions and commentary But if you have any I'll stay