COVID19 Ripping through China, Medicare Spending Bill and AI Chatbots
Written by Dr Nick on January 2, 2023
This month is our final episode of “News you can Use” on HealthcareNOWRadio features news from the month of December 2022 and a close-out to the year
As I did last month I am talking to Craig Joseph, MD (@CraigJoseph) Chief Medical Officer at Nordic Consulting Partners.
We discuss the latest news out of China which is grappling with an explosion of COVID-19 cases as it struggles to find a path after holding out for a zero COVID policy. We review a little history here with the two studies that were published showing how difficult it is to prevent transmission (The importance of airflow and South Korea’s transmission study and long-distance transmission in the Australian Quarantine hotel).
Last year we both had concerns that we would see a loss of Telemedicine capability as the pandemic era restrictions were reversed (Telemedicine – back to the Future) and lose our Remote-based patient monitoring capabilities. But the recent Medicare Spending bill included some positive takeaways with an extension of the pandemic-induced Telehealth flexibilities including hospital care at home through 2024 – an additional 2 years. Perhaps enough time to cement in some of these changes permanently? There was also increased spending for the VA system and increases for the NIH and the CDC.
We touch on our discussion including security issues from last year including my SIM Jacking experience and Privacy-invading pixels and (inadvertent) sharing of patient data via Facebook add-ins.
Craig reviews his AMIA CIC conference AI discussion and comment from Micky Tripathi and his rabbits in the context of the rising interest and apparent capabilities of ChatGPT – probably not a smooth progression but rather a stepwise increase is what we are seeing
And we can’t close out the year without highlighting again the negative impact of Criminalizing Medical Errors and Nurse RaDonda Vaught case and don’t miss Craig’s big reveal at the end of the episode
You can read more about the series here and the concept of keeping up with innovation in healthcare. Please send me your suggestions on topics you’d like to see covered. You can reach out direct via the contact form on my website, send me a message on LinkedIn or on my Facebook page (DrNickvT), or on Twitter by tagging me (@DrNic1) and #TheIncrementalist or you can click this link to generate a ready-made tweet to fill in:
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Raw Transcript
Nick van Terheyden
And today, as I am each and every month, I’m delighted to be joined by Dr. Craig Joseph. He’s the chief medical officer at Nordic consulting partners, Craig, thanks for joining me.
Craig Joseph
Thank you. I’m happy to be here.
Nick van Terheyden
So December 2020, to wrap up of the year. As always, I say this because I’m, I just can’t believe what unfolds each and every year. But it’s been an interesting year for sure. As we’ve certainly had a few of them, and it ain’t over, especially when it comes to COVID 19 as it would appear with China seeming to go through the pandemic, for the first time, perhaps?
Craig Joseph
Yeah, well, they have had a zero COVID policy in China, meaning that they were going to accept no COVID And anyone that got it, they were able to put them in either require them to be at home in quarantine, or more likely actually remove them from their home from their apartment building and, and take them to a facility where whereby they would either get sick or not.
Nick van Terheyden
Just say when you say facility, I almost feel like you’re putting in furtive
Craig Joseph
I am I said a facility. I don’t you know, if you have no symptoms. So these are often these are people that are just exposed, right, and family members or someone that worked with you. And so you don’t have any symptoms. And so the idea of going to a hospital seems incredibly foreign, but they do bring you somewhere where they can keep you away from everyone else. And that was the idea of zero COVID. And and I think in hindsight, we now know that that didn’t work, and it’s not working now.
Nick van Terheyden
Right? I think they’re, they’ve certainly got a struggle on their hands. It reminds me if you recall going back, I think it’s it’s certainly a number of months could be probably over a year. One of the papers that was very seminal for me, through the pandemic, in terms of understanding transmission was the case that there was two cases one that was in a South Korean restaurant, and they demonstrated, they had all of the cameras, they had a lot of security cameras, they’re able to track positions, and noted that the transmission was from somebody I think behind the counter, there was somebody 15 feet away. And it was all to do with airflow and then the other one was in Australia, it was in a hotel. And they absolutely knew that there had been no you know, breaking of the quarantine yet there was a transmission that appeared to just happen through I think it was the opening of a door to receive food. I’m not even sure what it was. But it was very, very my I
Craig Joseph
read about I absolutely read about that last case. And it was they were two I think it was two gentlemen that were in rooms across from one another that’s across the hall. And they were in quarantine because they both been exposed. And they never opened their door at the same time. So food was left for them and then they would open their doors separately at a given time. It was very and it’s all on video so they know exactly what’s happened and and then they they were able to show that it wasn’t that they both got exposed and then both got sick. No no, the person from a gave it to the person from B based on the typing of the of the that’s running the virus and so yeah, that’s kind of crazy. How does that happen?
Nick van Terheyden
And to be clear, this was I don’t know how many variants back but certainly pre where we are now and Omicron seems to be just a little bit more transmissible I would say right,
Craig Joseph
well, especially when you don’t have what most of the world now has which is the majority of folks either having had the disease or having the vaccine or both. And so that you have some if you may not have protection against disease, you have protection against serious disease ending up in the hospital or or dying if you’re if you’re unless you have some chronic medical problems. And so in China the they did have vaccines, most people have had to their vaccines don’t seem to be as effective as To the vaccines that generally Western countries have been using. And there they’ve had low uptake, for of the booster vaccines. So I think I read 50% of their elderly, only 50% of their elderly who are highest risk for dying or having serious injury from COVID have gotten a booster dose and so they’ve got minimal protection now. It’s not good. And I remember a year ago, they there were folks thinking that, hey, China sounds kind of like a tinderbox. And just a lot of lot of people waiting for to get that disease. And it’s now it’s now coming. And so
Nick van Terheyden
there’s no sort of New York Ireland complete isolation possible. And it does remind me of the post tweet, I forget where it was to, to perhaps on No, it couldn’t have been on Mastodon that was pre the era. But it was the video of the massive pool party that was going on in China, and they were essentially raving forgive the pun about how cool it was that they could party whilst we were all locked down.
Craig Joseph
Yeah, it didn’t. It’s not working out well for them now. But I think it was a reasonable, I understand the rationale. And in an authoritarian country, you’re able to do things that we in the West cannot do. And they gave it the old college try, but Mother Nature and the factories have never figured out how to how to reproduce. And it’s, it’s going going crazy.
Nick van Terheyden
We’re gonna have to, at some point, understand that term, because I’ve never, never really understood that the old college try, but let’s not let’s not focus on on on the Ripper of experience, which is going to be unfortunate, but I think you know, at this point is inevitable. The remainder of the COVID virgins in our world are not going to remain that way. And I think it will still be some news, at least, you know, pushing into next year. Let’s move on, you know, recent news. I think, from my perspective, I try and pick out the good. And, you know, as I was looking back in the year, one of the things that I noted in some of the discussions that we’ve had over the last several months, we talked about telemedicine, and the withdrawal of some of the pandemic restrictions that have been in place prior that was allowing the practice of medicine as it should be. And we saw a number of other elements to this. But in fact, the latest spending bill, the Medicare spending bill that’s looking like it will be going through includes I think on the pus plus side this extension of two additional years that we’re going to allow for medicine to be practiced whatever way it should be that’s best for the patient seems like good news. In my view.
Craig Joseph
I think it’s great news. And it’s certainly something that we’ve been concerned about. In the past year, the only reason that most folks were allowed to have telemedicine or telehealth visits was because of the pandemic and the federal government kept saying, Well, during this pandemic, this this emergency, we’re going to allow patients to we’re going to pay in other words for patients to to have telemedicine visits and the private sector followed. And that was great. But we were worried that as the pandemic seemed to be slowly receding into the background, that these nice rules were going to go away and we wouldn’t get paid. Doctors wouldn’t get paid to do telehealth visits, and if they’re not gonna get paid, and they’re not going to happen, obviously. And and so for the federal government to say, Okay, well, we’re at least through the next two years, we’re going to continue to pay for this. That’s great. And now we don’t have to worry so much, month to month because that’s really it was quarter to quarter, every quarter we’re like, is this going to be the end of the pandemic declaration because if it is, then we know we have a few months until telehealth stops and stops as a thing. And I agree 100% with you, it doesn’t really matter where you got to care how you got to care, as long as it’s quality medical care, then should be reimbursed as such. And sometimes that means yes, you do need to have a full medical physical exam and you need to be there in person and that that makes sense. But there are other times where you don’t. And sometimes that’s just because I don’t really need to see you I just need to talk to you. Sometimes if it’s a surgeon who wants to see the wound, they can perfectly well see the wound through the cameras that we have. And so there are a fib times where, you know, the care that you need should vary. And that makes that makes complete sense.
Nick van Terheyden
Yeah, let’s pick on that wound example because I think it’s a good one. In fact, I think in a telehealth setting, it’s improved, in some instances by the telehealth because you can zoom in effectively with some of the technology that is built into this interaction. You know, there are there are improvements. And as you rightly say, it’s, you know, not always the appropriate use of resources, and, you know, see in person if appropriate. The other thing that was included that we talked about, you know, was this remote patient monitoring, the sort of the move out of the acute hospital setting, when people couldn’t come in, were disallowed. And again, we allow for it. And that’s been extended to and of course, as a geek, I’m super excited about this, because this is now all additional monitoring capabilities, all this data that can come in, and importantly, can be reimbursed, which I think is, you know, essential for this. Do we know how we’re going to use all of this data? Absolutely not. But rest assured chat GPT will have the answer.
Craig Joseph
That’s, I think all we need is just the GI app chat GPT and just ask it what what’s wrong with this patient? And it will tell you, No, I agree with you. And I think remote patient monitoring is very important. And in some cases, it does a better job of even if we had a bed for you in the hospital, I wanted to put you in there. Your remote patient monitoring, in certain circumstances is superior. Because there as you as you say, it’s can be constantly monitoring, we could be checking certain values every minute every second, however often however frequently we need. We do though, need that, though, that decision or discussion about, hey, what are we going to do with these data points, right? Who is looking at this because it’s not actually say who it’s not going to be a person, it’s going to be an algorithm, it’s going to be some sort of an AI that’s looking and looking for patterns, looking for values that are outliers, things that are significant, and then reporting those to humans who can can take action. And that’s really, that’s where the the work needs to happen. Now, I think it’s often trivial to get the information but it’s not trivial to be able to sort through it. And we know humans are not going to be good at that. We know they’re not good at that. Now they’re not this is not a skill that anyone’s going to develop. But we will need an algorithm group of algorithms to constantly be looking at these numbers and either responding on their own or sending it escalating to a human.
Nick van Terheyden
For those of you just joining, I’m Dr. Nick the incrementalist today I’m talking to Dr. Craig Joseph, Chief Medical Officer at Nordic consulting partners, we were just talking about the appropriate use and understanding of all this data, and I’m just going to stick my stake in the ground. And here’s my prediction. We’re going to use that term as a verb in the same way that we talk about YouTubing something, we’re going to say well just chat GPT that data and see what comes out.
Craig Joseph
It is amazing. And that app, and it is also scary because it does a great job with many things. But then there are other things were just as wrong as it could be.
Nick van Terheyden
And the funny thing is, nobody’s posted anything about that, right? Oh, they
Craig Joseph
I have seen I’ve seen some I’ve seen some physicians actually. I watched a video of a physician say Hey, can you respond to this insurance company that is refusing to get to let me order an echo for my patient who’s on this medication. And please cite the appropriate literature. And the the AI responded with a very nice form letter in response to the formal letter from the insurance company and cited references, which apparently were completely made up. So that’s,
Nick van Terheyden
that sounds entirely appropriate. I’m just gonna, well, maybe
Craig Joseph
that’s maybe it was playing, you know, multi level chess there might be you might be right. But it was noted that, that those those articles really didn’t exist. And
Nick van Terheyden
even better is my view.
Craig Joseph
The authors were researchers in the fields and had and had written similar articles saying similar things, but the articles that they cited didn’t didn’t actually exist. So so there’s some work to be done. And then we all know what we’re what we’re looking at, or at least we should so yeah, right now, I think it’s probably best to get your health care from a human at this point.
Nick van Terheyden
I I’m certain that that’s true. But I think that’s a great story. And I’m just going to say if they come back and say we can’t find those articles, you just say it’s alright because it’s behind a paywall. You can’t see behind them. So
Craig Joseph
now you’re thinking you’re Thinking several, several,
Nick van Terheyden
I’m definitely a multilayered chess aficionado. eautiful. So I’m thinking about some of the things that we talked about last year. Obviously, one of the big ones, for me, it was very personal, I think I shared it with you, you know, the whole sim jacking experience, you know, that continues to unfold. In what I consider a very, it’s stressful. I mean, this is a constant thought, in fact, it’s proved useful in some instances where people have wanted to do things, you know, I now I’m sorry, I’ve been sim jacked, I won’t give you that information. So I’m taking the positive out of it. But it does raise this. And, you know, I’m hoping that we’ll see some better approaches, we’ve certainly got some improved approaches, and we need them in healthcare from a ransomware, you know, the big target that we talked about last year. That’s on health care’s back. But, you know, some of the other things that I thought were interesting, you know, tied a little bit to this was all the privacy invading activities that were going on, just so you know, more in depth coverage of this release of personal information. And I’m gonna be as charitable as I can. I think this is true. I don’t think it was fully intentional, I think it was just, you know, lacks oversight with the integration of tools that came along in, you know, healthcare websites.
Craig Joseph
Yeah, well, it is. When we were all on paper, this was not a problem. Because your information was in the file in the doctor’s office, and it was not accessible to the bad people. It was also not accessible to the good people. And so making everything digital, certainly is moving us in the right direction. But, but you’re right. And as we move to more kind of cloud infrastructure, meaning that that the data is for almost all hospitals, not for almost all for many hospitals, and is not going to be stored on servers or computers in their basement anymore. That’s the way it has been done. It is now being moved to other people’s servers that are protected. And that’s great. And if you if you set up all of that information in the right way, it’s safe, it’s as safe as it could be. But not all of us are experts on moving information from from our computer to computer that could be anywhere. And that’s where these, that’s where some of these hackers are are utilizing tricks that are small little loopholes, that they’re able to kind of squirm through that, that others aren’t. And so, yeah, it’s, I don’t know that it’s going to get better. I think, in the meantime, it’s going to get better, ultimately, but we do need all, you know, all of us need to kind of think about our security, both personal through our phone, but also the way our hospitals and our physicians are managing the security for for their information. So if you’re able to call up and get information without proving who you are, that’s probably a sign that that the information that that hospital or doctor’s offices storing on you may not be as safe as you would want it to be.
Nick van Terheyden
Yeah, it’s it. It’s a challenging area. It’s one that continues to create enormous difficulties, because it’s a nuclear arms race. I mean, I one of the first areas that I recall using AI effectively was in fact, the hacking community that was using it to break passwords and find alternatives. And you know, healthcare is such a rich domain of information, it’s an inevitable target that causes no end of problems. We have to stay alert, I’m willing to bet we’ll be talking about some stories and some ugly, expose A’s of data in particular, that’s going to cause some problems. We talked a little bit about AI and I think you had raised the whole area of success or how far we could get with AI early on in the year when you went to the CIC conference. In fact, I think you quoted Miki true, or you didn’t quote you showed his visual which was all about rabbits. And then in fact, more recently, we saw the challenge of AI where one of the conferences I went to they presented an AI device that was interacting with on the stage. We’re always away. What do you think’s going to going to happen in the coming year? Where are we with that?
Craig Joseph
Well, you know, I think we’re going to go from zero to 52 Use a an automobile term. I’m still wondering about that old college try thing, and I’m not really sure where that came from. So I’ll work on that for next time. Dr. Nick. You know, it feels to me like we’re this is not a gradual approach. This is really a step approach. And, and we You had mentioned chat GPT that came kind of out of the blue where you could, you could ask it to do things, and it got them mostly right, you know, hey, can you write me I actually asked this, that, that, that algorithm to write me a or whatever it is, to read me a five, five paragraph blog post explaining why doctors progress notes are much longer now than they used to be. It was not half bad. It was pretty good. And that’s, that’s amazing. Now, it’s not something that I would just copy and paste and put up on the on the web. Oh,
Nick van Terheyden
I was just going to make sure that our viewers could read your latest missive.
Craig Joseph
I actually wrote a blog post about this, which is why I thought it would be fun to see what it what it came up with. But that that that seems to me, like that was not a gradual change. Like it wasn’t like, oh, well, now we have an AI that can write one paragraph. But it really can’t put paragraphs together. Like no, we were we we really didn’t have anything. And then we had this amazing, we could just kind of put anything in a prompt and we’re going to get at least in the ballpark, it’s not going to be all right. It’s not going to be all great. But it’s going to be in the ballpark. And so we I think we’re still in that. That early phase, at least in the in the in the way, AI works with electronic health records, the way that physicians use it. During the day, we’re still not really good at at predicting who’s going to get sick, right? There’s lots of algorithms looking constantly looking at everyone that’s in the hospital, in many places, trying to predict who’s going to get sick, who’s going to get sepsis or some other disease that we can prevent in in real time. And we’re the problem is not that it’s not identifying folks, the problem is that it’s over identifying, and so you can’t check on every patient every time. So we’re still we’ve got some ways to go. And I don’t know when we’re going to hit that point. If that seems more where we’re hitting magic, right? I don’t think any doctor thinks that we’re at magic level now, in terms of predicting illness or following large populations of patients. I don’t think anyone thinks of that as magic that chat GPT. And there’s another program that you know, can draw art, it can create art for you, given a prompt, that’s kind of magical to me, at least where we’re at now. And so I don’t I don’t know when I don’t know if it’s gonna be this year or next year. When are we going to hit that where your your regular run of the mill physician goes? Wow, that’s magical what you just did?
Nick van Terheyden
Yeah, and you bring up a couple of other examples. In fact, a while back, I heard AI generated music, and I was super impressed. I actually really enjoyed it. Which, you know, is a little bit concerning. Maybe there’s something wrong with my brain, but it synced with my brainwaves. And so I think you’re right step wise kind of function. And we’ve seen a big step up. Certainly that was my sense of it. There’s, there’s examples of failure. But you know, some of the examples of success are truly astounding with that particular example. And it’s generalized. That was the big issue. You could get AI into narrow segments, we were able to do that extensively, but not not in a generalizable form. And I’ve tested it, and I was super impressed. So I’m excited about that. I think the capabilities and I’m looking to see if I can try some experiments. And I think that’s the big thing for me with chat. GBT is it’s opened up the door to people to try things that previously had no programming and nothing. And actually, it can teach you programming. It’s very good at that if you have programming challenges, you know, Python questions, whatever. Very good at that no surprise, because of the people that are potentially creating it. But it goes much beyond that. So we’re sort of running out of time, or at the end of the year, we’re looking forward to 2023. Any closing predictions or thoughts from you in what you expect to see?
Craig Joseph
Well, I’m always hopeful that we’ll we’ll see our doctors and nurses, the burnout that they’ve been experiencing over the last three years get better. And so I think some of that we have some tools to help to help improve some of the things that are causing the burnout. It’s just that we’re not using that. Often. We’re not using those tools to either not using them at all or not using them as effectively as possible. So I’m hopeful that next year that nurses and doctors and therapists will start to take up some of the new tools and leverage the policies that are out there to to make their lives better instead of trying to push against the change.
Nick van Terheyden
Yeah, I’m, I’m with you. 100%. I mean, I think one of the things that we saw last year, which you know, really bothered both of us, I’ll speak for you. But you know, Redonda vol, the nurse that was essentially criminalized, and that was definitely a burnout stress related issue should never have been the case, we need to do better, we can remove friction, as you say, tools exist, let’s actually implement them, use them and use them for the purposes of actually removing what I call scut work predominantly that challenging. And I can tell you, it hasn’t changed because living through my daughter’s experience as a resident just feels like mine, but almost worse with more technology, more computer time less FaceTime with patients. And that was already a challenge for me. But good news. You know, it’s a new year, new opportunities, excited to explore it and look forward to 2023. As usual, we’ve run out of time just remains for me to thank you, not just for this episode, but you you’re willing to take the time and spend it with me each and every month. And I’m very grateful for that. So thanks, Craig, for joining me.
Craig Joseph
It’s my pleasure. And maybe now’s a good time to announce that I’m actually an AI. And so
Nick van Terheyden
yeah. Oh my god. You didn’t have to let everybody know. Oh, sorry.
Craig Joseph
Are we still recording? Thanks, Greg. All right. It’s been great.
