Hi, this is Nick Webb and welcome to another episode of the Healthcare Cure podcast. You know, in my career, I’ve had the opportunity to meet some amazing people and to learn from their journey. And that’s what I love about this podcast is to be able to really spend some time with some incredible people that are actually making a difference. And there’s a name that kept on coming up to me over and over again when I started my work at the university. And it was Dr. Pakia. And Dr. Pakia is not a theorist. What he talks about isn’t conceptual. It isn’t ideas without foundation. He’s a practitioner. And you know, I read so much about the impact of technology and the and the impact of emerging trends from people who really are not seeing patients and are not living this on a humanistic level, the impact on the on the patient and the way in which we have this beautiful convergence between technology and emerging resources and the human. And that’s really what I’d like to talk to Dr. Pakia about today. And, but what I’d like to first say first of all, welcome to the program, and I’d love for you to introduce yourself and tell us a little bit more about your journey.

Nick, thanks for having me on board. Pleasure to be here. It all started out about 35 – 40 years ago, off to medical school, I went after looking at different careers pathways, I was fortunate enough to be admitted to Michigan State University trained in osteopathic medicine. There did postgraduate moving back out west, I was born and raised in the greater LA area. Focused on primary care and met up with some folks in Orange County, California spent 25 years there and then private practice private group practice, practicing in a variety of different settings everything from standard ambulatory care medical office to the admitting of patients to the trauma center next door. And, and then in the outpatient or remote setting, nursing homes, rehab centers, house calls, etc. So I was fortunate to have that that type of experience prior to moving out to the desert area with a health system that was beginning the process of starting an advanced primary care model for its you know, Health System strategy started with five physicians there are about 10 years ago now with with a view toward implementing a primary care residency program as well and 10 years later, and 240 clinicians later and 90 residents in training. It’s been an interesting and informative run. So that brings us up to today. Thank you for asking.

That’s terrific. You know, it’s interesting, I remember you and I talking a few years back about the inevitable impact of telemedicine and, and I think, you know, we were both sort of surprised that the adoption of telemedicine was so slow and it felt like that most people when they thought about telemedicine, they saw the interaction telemedicine of having some degree of sterility between the patient and the caregiver. And it’s interesting we we were lucky enough to have scripps in our in our documentary film, and you know, they were very much ramping up, they understood the inevitable benefits of being able to provide access to patients quickly. You know, if somebody has a urinary tract infection rather than sitting in the emergency room or an urgent care for hours, they could quickly see a caregiver, get diagnosed and get intervention in a way that was frictionless. And of course, that’s one of the big movements as we think about these four big trends in healthcare that I talked about in my upcoming book, The Healthcare Mandate that’ll be out this September, is that we see hyper consumerization patients are demanding not just efficacious, safe and beautiful care. They also want amazing experiences. They want it to be friction free, they want it to be convenient and relevant. And of course, the the trends of connection architecture and enabling technologies and new economic models and new business models mean the entire landscape has changed. But in looking at scripp, you know they’ve been prepared for a very, very long time. They’re a great organization. And they really built out a very robust strategy for implementing telemedicine. But, you know, you don’t do it until you have to. And of course COVID-19 came along and they went from, I think four to five tellemedicine consults per day, do something north of 3000 a day, I mean, literally instantaneously. And from talking to their caregivers, what they found was, is that this is actually a pretty good way to deliver care in most instances. Now, obviously, some interactions clinically require, you know, physical contact and physical exam. But what what’s your take in the in the sort of telemedicine Renaissance? Is this a good thing for healthcare in your view?

My experience with this is that yes and no depending on what component of what we call telemedicine and the practice of it is how it’s deployed and who’s deploying it. So, my experience with the personalization component that you mentioned and always the the fear that digitizing a relationship of any sort, medical in particular, might put at risk the, what we call the doctor-patient relationship and the important aspect of it, if appropriately deployed, and if the, the philosophy of care is, is focuses on maintaining that relationship. I’ve seen that that actually can be magnified. So the humanistic components of that the intangible component of practicing medicine, once you knock down the barriers that are associated with, I guess we would call this, old school medicine, medical model based out of medical offices, hospitals, etc. When components of that are replaced, made more efficient, and actually the patient and the doc or other caregivers are brought closer, including leveraging that capability to bring a team to bear for the treatment of the patient, and the client actually magnifies the relationship and takes some doing lessons learned and takes leadership to recognize the importance of that, but properly deployed with the right tools and the right software environment, keeping in mind always the importance of security confidentiality of the relationship and the data. It can go, it can go quite well.

Yeah, you know, it’s interesting when we were doing the research or the research with some of my researchers on the health care mandate, what we found is that when it’s done, right, the bottom line is patients like a lot, it provides access to care more quickly. The other thing that we found that was kind of interesting is that, you know, the patients had this sort of mono, you know, view that was there was no peripheral, you know, nurses coming in, there’s no traffic lights in the, in the exam room, there’s none of the pressures of that you would typically see in a traditional clinical setting and and or the caregivers himself, a lot of them really liked the idea of what they felt feels actually more one on one it felt to them oftentimes, like it was more of a personalized relationship. And now some of the technologies that we’re working on, which is really exciting is where we’re actually able to use facial AI and facial colorization AI and of an area I’m very excited about which is head movement AI is understanding incremental movements of the head and their potential association with neural pathology is is likely a thing. And the research is yet to prove that but it’s just begun. When you combine it to with voice AI and facial AI, we already have good algorithms to show that we can determine mood state. And so you know, from our perspective, the future of telemedicine will be enabled by a dashboard on the caregiver side that will provide information that’s leveraging existing technologies like the camera and the actual microphone. Because voice AI is actually starting to get pretty interesting we can determine you know, inflection modulation, pitch, key, pausing, the clarity of speech and determine lots of interesting things. I think those algorithms on facial coloration, facial AI, voice AI and head movement AI could add a lot of depth to the you know the actual diagnostic pathway. The other thing is now we’re seeing kits that are being developed that basically include an otoscope, an opthomoscope, a dermiscope, a device that connects for to get acoustic to acoustically listened to the chest. We have the ability to do all kinds of things with really inexpensive sensors, because we’re counting on the computer to do the computation. And all we need is really some pretty simple acoustic and optical sensors and some are looking to be maybe $15. So you get your health insurance you get your kit and that kit is available to plug into your smartphone or to your USB device to be able to provide some additional diagnostic tools. That’s, that’s one of the issues that a lot of caregivers are concerned about is not being able to get better physical exams. Are you seeing the emergence of those kinds of technologies in your practice?

I am on an incremental basis. So as the technologies come along and prove themselves out as having value, and simultaneously as the recognition of that value by the leadership of any particular medical group, and the individual practitioners, their buy in to the importance of remote patient monitoring RPM, including the value of placing that important information, which is quite a bit of incoming data onto an AI driven clinical decision support system that’s an always on 24/7, 365 environment. Absolutely can make a huge difference. The challenges, how to deal with and categorize and actualize that tsunami of data that’s incoming and how to design AI piece to analyze that data. So it becomes actionable, everything from the ability to leverage that for wellness and preventive practice of preventive medicine, as well as the sort of the other end of healthcare which is the ability to respond on a timely basis. And, and, and be tooled up to deal with the separating amount of information that’s important and that which is not so using examples of a patient who may become maybe on their way to becoming septic in geriatric medicine A good example would be urinary tract infections. They are common, they’re varied. They come at different rates and different intensities different people at different times, and without the ability to monitor individuals for that for an early detection strategy for urinary tract infections. One of the more common causes of hospitalization and rehospitalization. In our health system, which is a urinary tract and driven urosepsis, and can be much more effectively managed and addressed, as opposed to what we typically would without these tools would be faced with, which would be perhaps a late phone call from a nursing home. Perhaps a late notification from a family member or friend who notices a change and mentation or mental status or general condition of the individual with that condition. So, having a well thought out sensor strategy for optimized RPM is absolutely going to be part of our future. We’re in the midst of implementing it as we speak. And it’s exciting.

Yeah, I think that the average person doesn’t really realize just how far down the line we are. I mean, ultimately, and I talked about this in some detail in the book, but ultimately, we’re going to monitor 20 – 30 different bio signals with a combination of an in ear technology and some adjuncts. And then, of course, they’ll be prescribed wearables based on known medical conditions right. So essentially that patient is being is in a situation where there it’s even greater than being in an ICU, they’re getting more continuous data sent to the machine than they would in a normal acute setting. And that information will get looked at by the by artificial intelligence to determine, determine, you know, what exactly the course of action is. And I think ultimately part of that has to be around care plans. I think that sending people back to the to their primary care doctor may not be the strategy that this method ultimately follows. It may send them directly if it’s emergency and then directly to somebody that could care for them without delay. I think there are abilities to leverage game mechanics, social engagement, social collaboration, some of these other tools also to help them comply to wellness and preventative regimens. One of the things we talk a lot about in the film is the importance of reestablishing a relationship with the with the physician and the patient in a way where there is better freedom to operate, especially in the area of focusing on prevention and wellness. You know, the problem that we have is that the economic incentives that have been created in the machinery of healthcare, punish prevention and wellness, and they reward gratuitous intervention. And I think until we we change those economic models, we’re not likely going to have drug companies, device companies, even hospitals and clinics. And in some cases, physicians really change behaviors. We there, it’s just somebody comes in, they’re 35 pounds overweight, they’re hypertensive. They have a wide range of other problems associated with that. You know, they’re that their physician is typically going to dark them with some prescription because the reality is we know we could affect upon a positive change their weight loss. But where’s the incentive? And that’s a big part of what we talked about in this film is can we change the economic models, we’ve been inventing around the wrong things as we transition from modern medicine into this next, this next phase. Do you what does prevention mean in your practice? Is that something that you’re able to realistically fold in given the time constraints and the economic models?

Well, the strategy of prevention really looks like this when it’s facilitated by a digital platform. And again, if appropriately deployed, goes something like this that the client patient seeks out a care team, a leader of that of that team, which is typically a physician or mid-level practitioner. And from that point forward, that the leader of that team then can apply, the offering if you will 24/7 365 to that patient through a starting with a patient portal, my experience has been that’s an important component of what we call telemedicine, the essentially the audio visual platform that is is the underpinnings of what your digital in nature so that for all of us both as providers and as patients, you know prevention of disease and or restoration of health and or reversal of diseases and condition, you know should be our focus at least at the primary care level and having a starting with a portal that is designed to facilitate an always on environment, whether it be in real time or asynchronously delivered, patient sending messages, non urgent messages that are triage and managed by a team on the provider side gets us, gets us started on the right track or how to leverage a digital platform toward health and wellness. And at the same time, build a bridge for a rapid response capability of the clinical team appropriately reimbursed and incentivized of course, to be there for that patient and or particularly in pediatrics and or geriatric medicine, the advocate for that patient in many cases on the geriatric medicine side, some of our better examples of how to make a difference for a client is interacting with their family, their caregivers, that they’re in a facility, facility staff, etc. That really identify the opportunity to communicate directly in real time in like a classic kind of live telemedical encounter, but more so a synchronously delivering information, data, photographs, lab results, status reports that may not be considered emergent but have an importance and and the necessity to deliver that information to the leader of a team that’s been identified and been incentivized to be there 24/7 365 for that patient because without that, when things go sideways, in in medical care paradigm, typically if not designed to address issues appropriately and timely. That’s where we find our emergency rooms become crowded again. And and the readmission rate to hospitals goes so much higher than it than it should.

Yeah, you know, absolutely Rich Milani from Ochsner from Ochsner health system, their chief transformational officer, really a bright guy. He did a program, gosh, years ago with Apple it was five years ago now, where they used just an Apple Watch to report back blood pressure readings and a few other a few other things. And through a very cryptic system by our standards today. And this is just five years ago, he was able to reduce readmissions in the hospital by 50%. And, and it was really interesting and of course, now Rich’s on some really other amazing products. he’s a he’s a cardiologist by training, but he was able to realize that here are the things that we can monitor. If these start to go south, we need to intervene. And I think that’s the beauty of continuous monitoring is if you look at it from a purely economic perspective, we can find disease processes and problems well before they become symptomatic. Well before they become expensive, and from a quality of care perspective, we can leverage connected technology and AI to be able to deliver a far higher degrees of safe and efficacious care. I mean, just last week, my car told me that there was a recall notice on my car and told me to go to the dealership. I mean, it’s talking to somebody you know, and my wife’s car, the other day was telling her, giving her this all this rich information about when her next service B was due and everything right and so it doesn’t just look at the miles like you would used to think what it’s actually looking at is how you’re driving your car, the patterns of how you drive your car, what it anticipates the the the need for that car, to be healthy in the future. And something as cryptic as those monitoring systems are having an incredible impact in an automotive prevention. Why can’t we do that in healthcare? And of course, the answer is we really truly can. Well listen, we’re so excited that you chose to be in our documentary, film Fixing Healthcare, and know that your contribution will help us do something that really is what the film is all about. And that is to change the conversation. Can we improve the relationship in the end that coveted time that doctors and patients need to be able to reestablish? Can we stop having the machine run the relationship and look at the caregiver and the patient run the relationship? Can we stop talking just about the access of healthcare and start talking about something that’s far more interesting, and that is the access of health. And you know, we talked about underserved communities and their inability to get access to health, and that’s rural communities and inner cities. Everybody wants them to have medicines, but we haven’t really had robust deep discussions about quality food and prevention. And I hope that our film will have some impact and it at least changing the dialouge from this old fashioned, let’s make more medicine to to what we believe the fix is. And that is to have more health. What would you say as we close up would be the big fix if one there is one thing that we could do to fix health care, what would that be.

You know, having a philosophy of reengineering healthcare based on, focusing on the team patient relationship on a platform that most of us are quite comfortable with using as well as our patients. That always holds high as a priority, the relationship component of medicine. And with, with the platform there to help us in the background, kind of under the hood, if you will, that’s always dependably monitoring the status of our clientele and our population so that we can really deliver care and or receive care with a sense of security and confidentiality, as well as confidence that we’re being managed by a team that cares knows what they’re doing is well trained and the core principles of how to use technology to again, deliver care in a personalized fashion. We’re headed toward that there are some forks in the road. We need to be careful about taking the fork of commoditization of data and, and having the incentives in that process go in the wrong direction. But I think the crisis that we’re currently still dealing with is it has the silver lining of pointing us in the right direction.

I think that’s right. Well, listen, I know you’re busy. I really appreciate you taking the time to share your ideas with us again. We’re so excited to have you in the film. And thanks again for joining us today.

My pleasure now.


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