Welcome to the Clinical Center Grand Rounds, a weekly series of educational lectures for physicians and health care professionals broadcast from the Clinical Center at the National Institutes of Health in Bethesda, MD. The NIH Clinical Center is the world's largest hospital totally dedicated to investigational research and leads the global effort in training today's investigators and discovering tomorrow's cures. Learn more by visiting us online at http://clinicalcenter.nih.gov TODAY WE HAVE THE GREAT PLEASURE TO HERE FROM DR. HORVATH SENIOR DIRECTOR OF CLINICAL TRANSFORMATION AT THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES IN WASHINGTON, D.C. AS AN ANC THEY WORKED ON IMPROVING OUTCOME AT THEIR MEDICAL CENTERS AND AFFILIATES ACROSS THE UNITED STATES BY ASSISTING THEM IN FOSTERING VALUE-BASED HEALTH CARE AND IMPLEMENTING INNOVATIONS IN ELECTRONIC HEALTH RECORDS, TELEHEALTH AND CLINICAL CARE COORDINATION. DR. HORVATH HAS A LONG-STANDING INTEREST IN CLINICAL CARE TREATMENT WITH OVER 22 YEARS SERVICE ON THE SOCIETY OF THORACIC SURGEONS DATABASE AND CODING LITERATURE AND POLICY COMMITTEES AND HAS BEEN INVOLVED IN THE CRAFTING OF EVIDENCE-BASED GUIDELINES FOR THE NATIONAL HEART, LUNG AND BLOOD INSTITUTE'S CARDIAC CENTER AND MEASURES INSTITUTED BY THE NATIONAL CAUGHT -- QUALITY FORUM. HE WAS HEAD OF THE CARDIOTHORACIC PROGRAM AND CHIEF OF AT THE NATIONAL INSTITUTES OF HEART CENTER IN BETHESDA, MARYLAND. AT NHLBI HIS LABORATORY HAD A SCIENTIFIC MISSION INVESTIGATING MYOCARDIAL CELL THERAPY AND BIO ENGINEERING AND TRANSPLANTATION WITH IN VIVO MODELS WITH A TEAM OF STAFF SCIENTISTS, FELLOWS, RESEARCH NURSES, VETERINARIANS AND BIO MECHANICAL ENGINEERS. AS CHIEF OF CARDIOTHORACIC SURGERY AND TRANSLATIONAL RESEARCH METHODOLOGIES. BOTH RESEARCH AND CLINICAL ENTERPRISES WERE STARTED DE NOVO BY DR. HORVATH WHEN HE ARRIVED AT THE NIH IN 2004. HE RECEIVED HIS MEDICAL DEGREE FROM THE UNIVERSITY OF CHICAGO PRITSKER SCHOOL OF MEDICINE AND TRAINED IN GENERAL IN CARDIOTHORACIC SURGERY AT THE BRIGHAM AND WOMEN'S HOSPITAL IN BOSTON AND A MEMBER OF THE AMERICAN COLLEGE OF CARDIOLOGY, AMERICAN COLLEGE OF SURGEONS AND THE AMERICAN HEART ASSOCIATION. HIS MEMBERSHIPS INCLUDE THE SOCIETY OF THORACIC SURGEONS AND THE SOCIETY FOR MINIMALLY INVASIVE CARDIAC SURGERY AND THE AMERICAN HEART ASSOCIATION. AND HE IS ON EDITORIAL BOARDS AND HAS CO-AUTHORED OVER 200 PUBLICATIONS IN THE BIO MEDICAL LITERATURE. MOST IMPRESSIVELY HOWEVER, HE HAS 77,000 MILES WATCHING, PLAYING AND COACHING THAT'S AN ACHIEVEMENT. THE TITLE OF DR. HORVATH'S PRESENTATION TODAY IS IT'S AN ARTIFICIAL INTELLIGENCE WORLD AND WE ARE ALL JUST LIVING IN IT. NOW WE'RE PLEASED TO GIVE HIM A WARM VIRTUAL WELCOME BACK TO THE NIH. >> THANK YOU FOR THE NICE INTRODUCTION. I PUT IN A FUN FACT ABOUT MY SOCCER-RELATED ACTIVITIES PRIMARILY TO SEE IF PEOPLE READ TO THE END OF THE BIO SKETCH. CONGRATULATIONS. SERIOUSLY, I AM VERY HONORED AND PLEASED WITH THE PRIVILEGE TO PRESENT TO ALL OF YOU TODAY AND TALK ABOUT A.I. AND HOW IT IS RAPIDLY IMPACTING HEALTH CARE NOT ONLY IN THE UNITED STATES BUT ACROSS THE WORLD. I HAVE NO COMMERCIAL INTERESTS TO DISCLOSE. THE OBJECTIVE OF TODAY'S DISCUSSION ARE TO ANSWER THESE QUESTIONS, ARE WE HEADING FOR A.I. AND I MEAN A.I. IN THE PAST HAS HAD HEIGHTENED PROMISE BUT IN MANY CASES THAT HAS BEEN COOLED BY AN A.I. WINTER, SO TO SPEAK, WHERE THE PROMISES HAVE NOT BEEN ACHIEVED. WHERE WE ARE RIGHT NOW IS AT ANOTHER PERHAPS PEAK OF THAT CYCLE AND WE'LL SEE. REGARDING ELECTRONIC HEALTH RECORDS WHICH ARE A KEY PART OF ANY [NO AUDIO] A.I. AND WE HAVE A FEW COMMENTS TO MAKE AND THEN PROBABLY FOR ALL THE CLINICIANS INVOLVED IN THIS PARTICULAR LECTURE IF NOT IN THE FRONT CERTAINLY IN THE BACK OF THEIR MIND THERE'S CONCERN ABOUT WILL A.I. TAKE MY JOB. SO ONE OF THE REASONS WE'RE NOT ABOUT TO HAVE AN A.I. [INDISCERNIBLE] IS A.I. IS TELLING US WHAT TO WATCH, WHAT TO LISTEN TO, HOW TO GET FROM PLACE TO PLACE, WHAT TO BUY. IT'S PROVIDING A SOCIAL RELATIONSHIP WITH A DEVICE AND EVEN MAYBE MORE INTERESTINGLY IT'S CLEANING UP AFTER US. IT'S VACUUMING OUR HOMES AND APARTMENTS. THIS CONTINUES TO EXPAND. ONE OF THE MOST RECENT INTERESTING DEVICES I CAME ACROSS WAS THIS WHAT I'LL CALL A MOOD WATCH. THIS DEVICE TAKES THE INTONATION AND INFLECTION FROM A SPEAKER AND ALLOWS THE WEARER OF THE WATCH TO GET AN IDEA OF THEIR MOOD THE SPEAKER MAY HAVE AT THE PRESENT TIME. YOU CAN ENVISION WHERE THIS WOULD BE IMPORTANT FOR SOME CLINICAL CONDITIONS LIKE ASPERGER'S. I'M SURE MY TEENAGE DAUGHTERS WISH I HAD SOMETHING LIKE THIS TO PICK UP ON THE SOCIAL CUES BUT IN TERMS OF A.I. ANOTHER FRAMING SPACE IS WIDESPREAD USE IN OUR DAILY LIVES. I'LL TALK ABOUT SPECIFIC ARTIFICIAL INTELLIGENCE AND NOT THE GENERAL TYPES. ONE YOU MAY REMEMBER FROM THE 2001 SPACE ODYSSEY, THAT CONTROLLED EVERYTHING WITH REGARD ONLY TO THE SPACE SHIP AND THE ASTRONAUTS' LIVES. IN MORE RECENT MOVIE IS SKY NET THE ARTIFICIAL INTELLIGENCE THAT WAS KEY PART OF THE TERMINATOR MOVIES. THAT'S NOT GOING TO BE OUR FOCUS. THAT'S PROBABLY STILL A LITTLE BIT OF A WAYS OFF. SPECIFIC A.I. HAS BEEN AROUND FOR A WHILE AND A GREAT EXAMPLE OF THAT IS DEPICTED ON THE PICTURE ON THE RIGHT. THAT IS DEEP BLUE A PLAIN COMPUTER THAT WAS THE FIRST TIME A MACHINE QUOTE UNQUOTE BEAT A HUMAN AND THIS IS A PICTURE FROM THAT HISTORIC MATCH IN 1997 WITH THE CHAMPION AT THE TIME. SO THAT GIVES YOU AN IDEA WHERE WE'RE HEADED IN TERMS OF A.I. AND HOW SPECIFIC A.I. MAY BE INVOLVED IN SPECIFIC SKILLS. BUT IS THIS SORT OF THE BROAD SPECTRUM OF THE TYPES OF ARTIFICIAL INTELLIGENCE THAT ARE AVAILABLE AND YOU CAN ENVISION IN LOOKING AT THIS HOW A.I. WILL PLAY A MAJOR ROLE WITH TASKS INVOLVING AUTOMATED IMAGING, ON THAT MOL GY AND ALL THE AREAS OF HEALTH CARE. IT DOESN'T TAKE MUCH OF A LEAP TO SEE WHERE A.I. CAN BE INVOLVED AND INVOLVED IN SIGNAL PROCESSING SUCH AS ELECTROCARDIOGRAMS OR ELECTROENCEPHALOGRAPHY AND IN TERMS OF IMAGES, IT'S GOING TO BE ABLE TO INTEGRATE WITH OTHER DATA SETS AND ARRANGE RESULTS WITH CLINICAL DATA TO HELP THE CLINICAL WORK FLOW. HOW DOES THAT OCCUR? IF YOU WANTED TO GET AN OVERVIEW OF HOW A.I. MODEL DEVELOPMENT OCCURS, THIS IS A DEPICTION OF THAT. SO YOU HAVE TRAINING DATA THAT MAY BE OBSERVATIONS OR PATIENTS IN THIS CASE AND THEN IT'S RUN THROUGH A REGRESSION ANALYSS OR A DIFFERENT TYPE OF ANALYTIC COMPUTATIONAL APPROACH THAT THEN IS CONNECTED TO A TARGET IN THESE CASES THE ACTUAL PATIENT OUTCOME. FROM THAT CORRELATION THAT INFO INFORMS THE MODEL OF WHAT HAPPENS WHEN ME PATIENTS ARRIVE AND WHAT THEIR PREDICTED OUTCOMES MAY BE. THIS GIVES AN OVERVIEW, IF YOU WILL, HOW THIS CAN OCCUR. WHAT I ILLUSTRATED WAS A SUPERVISED TRAINING MAPPING FROM A SPECIFIC INPUT TO AN OUTPUT AND LIKE CANCER DETECTION WITH MRI OR CT. IN ANOTHER TYPE IS USING UNSUPERVISED TRAINING WHERE YOU'RE USING MASSIVE DATA SETS FOR THE COMPUTER TO THEN SORT THROUGH AND MAKE DIAGNOSES AND PERHAPS COME UP WITH PREDICTIVE ANALYTICS SUCH AS SEPSIS OR IDENTIFYING SUBJECTS FOR RESEARCH TRIALS. THERE'S NO CORRECT ANSWER PROVIDED AND NOT TAGGED WITH ANY KIND OF DATA. THEN THERE'S A THIRD BROAD WAY DEVICES COULD BE TRAINED OR MACHINE LEARNING CAN OCCUR USING REENFORCEMENT TRAINING AND THIS IS A HYBRID OF SUPERVISED AND UN UNSUPERVISED AND USES GUIDANCE AND A TRIAL AND ERROR METHODOLOGY TO SOME DEGREE ANOTHER WAY PERHAPS IS SOMETHING I'M SURE YOU'RE FAMILIAR WITH I GIVE YOU THE SOCIAL DISTANCING EDITION IT'S EASY TO FIND WALDO IN THIS CASE. IF YOU RECALL WHAT THE TYPICAL WHERE'S WALDO IS LIKE IT'S SOMETHING LIKE THIS. FOR MACHINE LEARNING TALKING ABOUT DETECTION, WELL, [AUDIO DIGITIZING] AND WHAT IS FOUND IS ACTUALLY WALDO. YOU CAN IMAGINE A SERIES OF IMAGES FROM A CT OR MRI BEING USED TO NOT ONLY DETECT BUT DIAGNOSE BUT YOU ALSO HAVE PAGES LIKE THIS ONE DEPICTED HERE AND WALDO'S IMAGE MAY ONLY BE ON FOUR OF THOSE PAGES. THERE'S AN EXAMPLE OF WHERE MACHINES CAN PROBABLY DO THIS IN A MORE EFFICIENT AND EXPEDITED WAY THAN HUMANS CAN EVER DO. WHEN YOU CONSIDER THE AMERICAN CANCER SOCIETY MENTIONED 280,000 NEW CASES OF BREAST CANCER THIS YEAR ALONE IS LIKE SEARCHING THROUGH 70 MILLION PAGES FOR THE ONE CANCEROUS WALDO WHICH COULD BE A PROBLEM. IS IT ALL THAT EASY? WELL, NO, NOT REALLY. IF YOU'RE USING UNTAGGED DATA AND ONE DEFINED FEATURE IS THE PROGRAMMING DOESN'T INSTRUCT THE COMPUTER TO PERFORM A SPECIFIC TASK BUT INSTRUCTS THE COMPUTER TO LEARN A DESIRED TASK SUCH AS DISTINGUISHING BETWEEN IMAGES. THESE ARE EXAMPLES WHERE THE COMPUTER FAILED. IT COULDN'T TELL BETWEEN A PARROT AND GUACAMOLE AND PART HAS TO DO WITH THE NEED FOR A HUMAN OVERRIDING OR HUMAN EXPERTISE TO HELP THE COMPUTER UNDERSTAND THIS BETTER. THAT'S WITH UNTAGGED DATA. IF YOU LOOK AT TAGGED DATA, THE IDEA WAS THE COMPUTER WOULD BE ABLE TO IDENTIFY BETWEEN A WOLF AND A HUSKY DOG IT WAS PROVIDED AND THE IMAGES ARE HUSKY DOGS NOW HAVE NEW IMAGES. TELL US WHAT'S WHAT. IT PREDICTED CORRECTLY EXCEPT IN THE RIGHT BOTTOM IT WAS A HUSKY DOG. WHY DID IT MAKE THAT MISTAKE. YOU SEE THE SNOW IN THE BACKGROUND AND ALL THE IMAGES GIVEN TO THE COMPUTER THAT WERE ASSOCIATED WITH WOLVES AND ONES WITH HUSKY DOGS DID NOT HAVE SNOW. SO THE FOLKS WHO DESIGNED THIS HAS A SNOW DETECTER IS WHAT THE A.I. WAS DOING BUT THE POINT I'M GETTING AT IS YOU HAVE TO BE CAREFUL OF INTRODUCING BIAS INTO THE ALGORITHMS. [AUDIO DIGITIZING] AND FIGURE OUT HOW TO USE THAT IN THE LAST FOUR YEARS OR SO THERE'S BEEN A FUSION OF DATA AND COME UP WITH USES NOR DATA AND WAYS TO MODEL THAT DATA AND THIS HAS BEEN [INDISCERNIBLE] FROM THE 100% ADOPTION OF HR AND WE'LL SEE COMMERCIALIZATION OF THIS AND THIS WILL ALLOW A.I. TO ENHANCE THE CAPABILITIES WE HAVE AND MAKE IT MORE PERSONALIZED AND SPECIFIC AND COULD POTENTIALLY BE COMBINED WITH OTHER TYPES OF DATA OUTSIDE HEALTH DATA SUCH AS DATA FROM YOUR HOME AN EVENTUALLY WE'LL GET TO THE POINT WHERE A.I. APPLICATION IMBEDDED IN OUR ADMINISTRATIVE WORK FLOWS AND A.I. IS THOUGHT OF BEING A SOLUTION TO PROBLEMS THAT MAY OR MAY NOT EXIST. WHEN IT WORKS, IT'S JUST CALLED GOOD SOFTWARE. SO PERHAPS THAT'S WHAT WE'LL BE TALKING ABOUT IN THE FUTURE IS JUST GOOD SOFTWARE NOT SO MUCH USING THE A.I. WHY DO I THINK IS THIS ALL GOING TO HAPPEN? IT IS AN EXAMPLE OF ONE OF THE REASONS THERE'S A LOT OF PEOPLE INVESTED IN THIS NOT ONLY FROM A FINANCIAL PERSPECTIVE BUT FROM A WORK PERSPECTIVE. THIS IS DESIGNED TO BASICALLY PROVIDE AN OVERWHELMING IMPRESSION THAT THIS IS THE PROBLEM WITH THE PRESENT HEALTH CARE DATA ECO SYSTEM AT LEAST IN THE UNITED STATES [NO AUDIO] AND LABORATORIES ETCETERA THAT ARE CONTRIBUTING TO THIS DATA THAT WE ARE POTENTIALLY GOING TO BE ABLE TO INCORPORATE INTO A.I. AND IT'S CRITICAL FOR DELIVERING EVIDENCE-BASED HEALTH CARE AND DELIVERING ALGORITHMS. WITHOUT THE DATA THE PROCESS AND OUTCOMES ARE UNKNOWN AND THIS IS A WAY A.I. CAN BRIDGE THAT. IT'S NOT COMMON WITH MASSIVE AMOUNTS OF DATA TO BE GENERATED FROM A VARIETY OF SOURCES SUCH AS CLAIMS DATA, GENETIC INFORMATION AND TALK ABOUT RADIOLOGY, IMAGING, ICU, SURVEILLANCE, MEDICAL DEVICE SENSING SURVEILLANCE. ALL THE STUFF IS BEING CAPTURED AND U.S. CONSUMERS USE THREE PET PETABYTES OF DATA A DAY AND THAT'S 13 YEARS OF HIGH DEFINITION TV VIDEO. SO 3 PETABYTES IS A LOT OF STREAMING EVERY MINUTE OF EVERY DAY. SO THIS RAPID EXPANSION OF OVER 300,000 OF APPLICATIONS AND 200 HAD IT EVERY DAY HAS LED TO THIS MASSIVE GROWTH IN THE GENERATION OF DATA. ON TOP OF THAT WHAT HAS FACILITATED IS A DECREASED COST OF STORING AND MANAGING DATA. SO LET'S TALK ABOUT ONE OF THE MAIN SOURCES OF THE DATA ON WHICH IT WILL FEED AND SOME HAVE SAID IT'S A WELL SPRING OF DATA AD OTHERS THOUGHT OF IT AS SUCCESSFUL DATA. SO FAR BY AND LARGE HAS BEEN EASIER TO BASICALLY PUT DATA IN THAN TO GET DATA OUT. REGARDLESS OF YOUR OPINION WHETHER IT'S FUNCTIONAL WITH THE OUT TAKE OF DATA IT CERTAINLY HAS BEEN ADOPTED AT A FAIRLY RAPID RATE. MANY REASONS IS THERE'S BEEN A HUGE INFLUX AT LEAST IN THE UNITED STATES OF CAPITAL TO SUPPORT THIS DISSEMINATION AND ADOPTION. THE SO-CALLED HIGH-TECH ACT PASSED OVER A DECADE AGO INFUSED $36 BILLION INTO THE SYSTEM IN FISCAL YEAR 2009 AND SOME IN 2014 TO SPUR THE ADOPTION. WHERE DO WE GET FOR THAT THAT MONEY? IF YOU LOOK AT THE PRESS WE GET DEATH BY 1,000 CLICKS AS DESCRIBED IN THIS FORBES MAGAZINE ARTICLE BUT AN UNHOLY MISS AND IF THAT'S NOT ENOUGH NEGATIVE PRESS YOU CAN LOOK AT NOT ONLY THE LAY PRESS BUT FOR EVERY ONE OF THOSE TYPES [NO AUDIO] THERE'S PROBABLY A PETABYTE. THIS IS A RECENT ONE [INDISCERNIBLE] OF THE RELATIONSHIP. THE STANFORD UNIVERSITY CONDUCTED A POLL AND ASKED IMPRESSIONS OF EHRs AND 71% AGREED EHRs GREATLY CONTRIBUTED TO [AUDIO DIGITIZING] RATHER THAN A CLINICAL CARE TOOL. THIS HAS HAD A SIGNIFICANT IMPACT ON CLINICAL WELL BEING AND CLINICIANS WELL BEING AND IN THE ACADEMIES OF MEDICINE AND ACTION COLLABORATIVE IDENTIFIED CLINICIAN WELL BEING AND THE CLINICIAN/PATIENT RELATIONSHIP AND WELL BEING THE NEXT LAYER OF FOCUS. THERE'S A NUMBER OF FACTORS THAT IMPACT CLINICIAN WELL BEING AND THE RELATED RELATIONSHIPS. WHERE DOES EHR AFFECT THESE FACTORS? IT'S OBVIOUSLY IT HAS AN IMPACT ON THE PRACTICE ENVIRONMENT. I THINK THAT GOES WITHOUT SAYING. BUT IF YOU START LOOKING AT THESE OTHER FACTORS YOU CAN SEE WHERE THE EHR BASICALLY HAS AN IMPACT EVERYWHERE. THERE'S RULES AND REGULATIONS IN RELATION TO IT USED WHERE EHR ARE USED TO CONTROL THINGS THAT ARE PERSONAL FACTORS AND PHYSICIANS ARE SPENDING MORE TIME WITH THE EHRs NOT ONLY AT WORK BUT ALSO AT HOME. CANNOT ESCAPE, IF YOU WILL, YOUR DUTIES AND A LOT OF THESE ARE AUTOMATED DUTIES THAT REALLY DON'T HAVE A WHOLE LOT WITH DIRCT PATIENT CARE AND THAT IMPACTS YOUR PERSONAL LIFE TREMENDOUSLY AND WILL CHANGE YOUR HEALTH CARE RESPONSIBILITIES AND MANY CLINICIANS FEEL THEY'RE DATA ENTRY CLERKS AND NOT PATIENT CARE FOLKS. IT'S GOING TO HAVE A SIGNIFICANT IMPACT ON YOUR SKILLS AND ABILITIES. THE KNOCK ON EFFECT IS REGARDING THE PATIENTS AS WE TALKED ABOUT WITH REGARD TO SOCIETY AND CULTURE AND IF IT'S DEGRADATION OF YOUR OWN WELL BEING IT WILL HAVE A TREMENDOUS IMPACT ON SOCIETY AND CULTURE AND NOT ONLY THE PRACTICE BUT THE ORGANIZATIONS IN WHICH YOU WORK THE AMOUNT OF TIME AND PERSONNEL AND MONEY THAT HAS BEEN ALLOCATED TO EHRs HAS HAD A SIGNIFICANT IMPACT. WE'VE HAD A NUMBER OF SUMMIT MEETINGS TRYING TO OPTIMIZE THE EHR AND CONDUCT A COUPLE POLLS. 57% OF THE ACADEMIC MEDICAL CENTERS WE WORKED WITH SAID THEY HAD OVER 1500 PHYSICIANS USING THEIR EHR SYSTEMS. ANOTHER 44% SAID THEY HAD SPENT $50 MILLION TO $250 MILLION INITIALLY TO SET UP THEIR EHRs AND THEN ANOTHER $50 MILLION ANNUALLY TO MAINTAIN THEM. 97% ARE USING CLINICAL DECISION TOOLS PART OF THEIR EHRs. 66% ARE USING EHR SIMULATION FOR TRAINING AND WE'LL GET INTO THAT IN A MOMENT AND 44% SAID IT'D BE EIGHT PLUS YEARS BEFORE THERE'S A USER CENTER EMBRACED BY ALL INVOLVED IN PATIENT CARE. SO WE'VE MADE THIS CONVERSION FROM ANALOG TO DIGITAL EHRs AND THAT'S ALSO HAD OTHER CONVERSIONS IN OTHER AREAS OF HEALTH CARE THE ICU PATIENT GENERATES MORE THAN 200,000 DATA POINTS AND ALL BE CAPTURED AND OVER 4,000 CHARACTERS AT LEAST IN THE UNITED STATES WHICH IS YES, WE'RE NUMBER ONE, FIVE TIMES HIGHER THAN THE REST OF THE WORLD AND YOU CAN SEE IN THE CHARD BELOW THAT VIRTUALLY ALL IN THE UNITED STATES ARE FAR MORE [INDISCERNIBLE] WITH REGARD TO THEIR NOTES. THIS MAY BE EVIDENCE AS SOMEONE SAID TO UNDER SCORE EHR IS A BILLING DEVICE AND NOT A CLINICAL CARE DEVICE. THE FACT PHYSICIANS ARE SPENDING TWO HOURS OF EHR TIME FOR EVERY HOUR OF DIRECT CLINICAL CARE AND FREQUENTLY ANOTHER HOUR OR TWO AT NIGHT DOESN'T SEEM TO BE VERY GOOD. LET'S PUT IT THAT WAY. CERTAINLY NOT THE BEST WAY TO CONDUCT THEIR CARE. SO WHAT DID WE DECIDE TO DO? WHAT IS THE SOLUTION TO THIS? WE DECIDED TO GO WAY BACK IN TIME AND TAKE A SOLUTION FROM THE EGYPTIANS. WE HAVE SCRIBES AND I HONESTLY THINK THAT THAT'S NOT NECESSARILY THE BEST SOLUTION. I THINK WE CAN DO BETTER AND PERHAPS IT'S ANOTHER EXAMPLE OF [AUDIO DIGITIZING] THE TRAINING IS CONTEXT INDEPENDENT. THE TRAINING IS SHOWING YOU HOW TO NAVIGATE THROUGH A DIFFERENT SYSTEM. IT HAS NOTHING TO DO WITH PATIENT MANAGEMENT OR YOUR DAY IT DAY WORK FLOW AND AS THE IMPORTANT HOW YOU'LL BE ABLE TO USE A DEVICE LIKE AN EHR FOR THOSE TYPES OF CARE-RELATED ACTIVITIES. AGAIN, IN ADDITION TO THE INITIAL TRAINING, SIMULATION IS AN IDEAL WAY TO ENGRAIN NEW HABITS AND UNDERSTAND NEW SYSTEMS. SO WHAT'S BEING DONE IN THIS REGARD AND -- REGARD? ONE OF OUR CLEEGSZ -- COLLEAGUES HAS ESTABLISHED A VIRTUAL EHR OR SIMULATED EHR AS HIGH FIDELITY FOR ICU PATIENTS CONSTANTLY BEING UPDATED AS IF THERE WERE REAL PATIENTS IN THE SYSTEM. THEY BASICALLY COPY THEIR EHR SYSTEM WIPED DOWN PATIENT IDENTIFIABLE DATA AND SPENT A TON OF EFFORT CONTINUALLY UPDATING IT AS IF IT WAS FOR REAL PATIENTS. WHAT THEY HAVE DONE IS THEN CONDUCT MULTIDISCIPLINARY ROUNDS OF CAREGIVERS, PHARMACISTS, PHYSICIANS AND NURSES THAT ARE CONDUCTING SIMULATED ROUNDS ON ICU PATIENTS. AND IN THOSE CASES OR FOR THOSE PATIENTS THEY HAVE SAFETY LOVE RELATED ISSUES AND OTHER PROBLEMS THAT SHOULD BE IDENTIFIED. AND AS YOU CAN SEE, THE COMBINED MULTIDISCIPLINARY APPROACH IS BASICALLY SUPPORTED BY THESE DATA INDICATING THEY'RE COMBINED EFFORTS ARE BETTER THAN ANY GROUP BUT YOU'LL ALSO NOTICE A BLIND SPOT IDENTIFIED IN THESE TYPES OF SIMULATION ACTIVITIES. AND YOU CAN THEN USE THIS TO GO BACK AND TRAIN AND REINSTRUCT FOLKS ON WHERE THEY MISSED THESE PROBLEMS. IT'S IN A SIMULATED ENVIRONMENT NOT INVOLVING REAL PATIENTS. NOW, THEY'VE BEEN ABLE TO TAKE THIS IN MANY DIFFERENT DIRECTIONS. AND BECAUSE IT'S DIGITAL, YOU CAN GET A LOT OF INFORMATION AFTER RUNNING THE SIMULATED SCENARIOS. THE ACTUAL SCREENS THE VARIOUS GROUPS ARE LOOKING AT AND AS YOU CAN SEE, THE PHARMACIST BY AND LARGE ARE LOOKING AT THE MEDICATIONS OF LIGHT GREEN AND A LITTLE BIT OF THE LABS DARK GREEN AND SOME SUMMARIES AS THEY'RE ROUNDING ON THESE PATIENTS IN THE SIMULATED SETTINGS. THE PHYSICIANS ARE LOOKING AT THE SCREENS FOR THE MOST PART AND THE NOTES AND THAT'S THE PINK COLOR YOU SEE AND THE LABS IN GREEN AS YOU SAW FROM THE PHARMACIST AND FOR THE NURSES THEY'RE PRIMARILY FOCUSSING ON PURPLE SCREENS WHICH ARE ORDERS AS WELL AS THE LABS AND MEDICATIONS AND MOST IMPORTANTLY WITH THE BLUE BARS DEPICTED HERE THEY'RE SPENDING TIME ON THE DATA ENTRY AS WOULD BE EXPECTED IN A GIVEN ROUNDING SITUATION. YOU CAN'T ASSUME EVERYBODY WILL HAVE THE SAME WORK FLOW AND IT'S AN IMPORTANT DISTINCTION TO MAKE TO OPTIMIZE THESE VARIOUS WORK FLOWS. NOW THERE'S SOMETHING I FIND PARTICULARLY INTERESTING AND IN ADDITION TO LOOKING AT THE SCREENS HE'S USED EYE TRACKING TO ACTUALLY NOT ONLY DOCUMENT WHAT THE CAREGIVER IS LOOKING AT AS FAR AS THE SCREEN IS CONCERNED BUT WHERE AND HOW THEY MOVE FROM SCREEN TO SCREEN AS THEY'RE TRYING TO DEFINE THE VARIOUS FIELD FROM WHICH THEY'RE TRYING TO EXTRACT INFORMATION TO MAKE IMPORTANT CLINICAL DECISIONS. THE INTERESTING PART ABOUT THIS IN ADDITION TO JUST SEEING WHERE FOLKS ARE ACTUALLY NAVIGATING THROUGH THE EHR IT'S LIKE A PROFESSIONAL ATHLETE LOOKS BACK AT THEIR PERFORMANCE YOU CAN LOOK BACK AND SEE WHAT YOU WERE THINKING WHEN YOU LOOKED AT THIS AND WHAT WAS THE QUESTION BEING RAISED AND IS THERE A BETTER WAY TO FIND THE INFORMATION MORE DIRECTLY AND AGAIN I THINK IT'S A GREAT WAY TO FURTHER ADVANCE HOW WE CAN USE THE EHR TO IMPROVE CARE. AND HE'S DONE THAT BY SHOWING THAT YOU CAN IMPROVE PERFORMANCE. THEY'RE TAKING VARIOUS LEVELS OF RESIDENTS AND PUTTING THEM THROUGH THE SIMULATION DESCRIBED AT THE OUTSET LOOKING AT PROBLEMS EITHER SAFETY ISSUES OR CLINICAL ISSUES WITH PATIENTS. THEY DON'T DO AS WELL PGY2 OR 3 BUT IF YOU TAKE THE SAME PGY1 THROUGH 3 RESIDENTS AND RUN THEM THROUGH IT THE FIRST TIME BUT THEN REPEAT IT SAY WEEKS TO MONTHS IT'S NOT THE SAME CASE. IT'S A DIFFERENT CASE BUT THEY MAY HAVE SIMILAR PROBLEMS THEY NEED TO IDENTIFY. THE PRESUMPTION IS A LEVEL BETTER THAN THE FELLOW. YOU CAN TO SOME DEGREE OR WITH REGARD TO THE UNDERSTANDING OF THE EHR AND GETTING INFORMATION ON WHICH TO BASE CLINICAL DECISIONS YOU CAN SEE WHERE THE INFORMATION WILL HELP TREMENDOUSLY. AND THE RESULTS THAT OHSU HAS BEEN ABLE TO SHOW WITH REGARD TO THIS IS [INDISCERNIBLE] DATA IS MISREPRESENTED IN ROUNDS. THAT'S SOBERING. THE SIMULATION IS USEFUL IN UNDERSTANDING THE CONTEXT OF NOTES AND DIAGNOSING STRUGGLING LEARNERS AND THE IMPLEMENTATION O NEW EHR WORK FLOWS VERY IMPORTANT AND WE'VE BEEN ABLE TO DEMONSTRATE THAT AS WELL BECAUSE THEY CONTINUE TO CHANGE AS DO THE WORK FLOWS. ANOTHER WAY A.I. AND EHRs CAN HELP IS WITH REGARD TO CLINICAL DECISION SUPPORT. THIS IS AN EXAMPLE OF ONE SUCH TOOL THE HEART PATHWAY IS A MOBILE APP DEVELOPED AT WAKE FOREST AND IT'S BEEN AROUND A WHILE YOU CAN DOWNLOAD YOURSELF. IT'S BEEN DESIGNED TO EVALUATE PATIENTS WITH CHEST PAIN OR ACUTE CORONARY SYNDROME AND IT TAKES YOU THREE A SERIOUS OF QUESTIONING IN DETERMINING THE RISK OF THE PATIENT AND NOT ONLY THAT BUT WHAT SHOULD BE DONE. IN THIS CASE THE PATIENT IS AT RISK AND THEY GET ADDITIONAL LAB TESTS AND STRESS TESTING OR ANGIOGRAPHY AND YOU CAN SEE WHAT THE LAB TEST SHOWS AND IF THEY'RE NEGATIVE YOU CAN PROBABLY SAFELY DISCHARGE THEM AND IF THEY'RE LOW RISK YOU CAN CONSIDER DISCHARGING. [NO AUDIO] [AUDIO DIGITIZING] THERE WERE NO ADVERSE EVENTS NOTED. IT'S THE SAFE WAY TO NOT ONLY HELP PATIENTS GET THEIR TREATMENT IN EXPEDITED FASHION BUT [AUDIO DIGITIZING] AN EXAMPLE OF CLINICAL DECISION SUPPORT WITH THE PRESENT OPIOID EPIDEMIC. THIS IS FROM A PATIENT CHART. THE CURRENT OPIOIDS ARE LISTED THERE BUT WE HAVE A PHYSICIAN WHO WANTS TO GET PARTICULAR OPIOIDS AND THEY THINK IT MAY HELP SOLVE SOME PROBLEMS. AS THEY GO TO SIGN OUT THERE'S A DECISION SUPPORT CHECK THAT AUTOMATICALLY IS DONE AND OUT POPS THE BEST PRACTICE ADVISORY FROM WHICH A FAIR BIT OF INFORMATION IS GIVEN. AS YOU CAN SEE WITH ALL THE PREVIOUS PRESCRIPTIONS THAT MAY BE ACTIVE AND OR THE -- THOUGH THEY'RE PRN IT'S PRESUMED THE PATIENT WILL TAME TAKE THEM AND THIS IS THE AMOUNT AND THIS SHOULD BE CUT BASED ON THE OPIOID RECOMMENDATIONS AND THERE'S A LINK YOU CAN SEE MAYBE UP TO 90 MILLIGRAMS BUT REGARDLY 365 IS TOO MUCH AND HAVING THIS READILY AVAILABLE YOU CAN SEE WOULD MAKE A SIGNIFICANT IMPACT. IT ALREADY HAS. ANOTHER EXAMPLE THAT IS MAYBE I THINK MORE INTERESTING BECAUSE IT'S EVEN MORE COMPLEX THIS WAS DEVELOPED BY THE UNIVERSITY OF UTAH FOR INFANTS THAT HAVE [INDISCERNIBLE] AT BIRTH. IT COMBINES A NUMBER OF VARIOUS DATA THAT ARE ALREADY IN THE EHR AND PUTS THEM INTO ONE EASY TO UNDERSTAND REFERABLE STATE AS DEPICTED HERE. THE BLUE LINE SHOWS THE BILLIRUBIN LEVEL SINCE BIRTH AND CAN CORRELATE THAT WITH POINT OF CARE ITEMS AND THERE ARE TREATMENT THRESHOLDS.IRUBIN LEVEL SINCE BI RTH AND CAN CORRELATE THAT WITH POINT OF CARE ITEMS AND THERE ARE TREATMENT THRESHOLDS. IF THE BILIRUBIN LEVEL IS ABOVE THE RED LINE EXCHANGE TRANSFUSION MAY BE NECESSARY. AND IT ALSO PULLS FROM THE CHART THE ACTUAL PHOTO THERAPY THAT WAS PROVIDED EARLIER IN THE PATIENT'S COURSE AND IT SHOWS THE GEOGRAPHY AND HOW LONG IT OCCURRED AND GUIDELINES AUTOMATICALLY POPULATE THE PAGE AS FROM ANOTHER PATIENT'S CHART. IN THIS CASE THE MOTHER OF THE BABY HER INFORMATION IS AUTOMATICALLY IMPORTED INTO THIS PRTICULAR DISPLAY OR DASHBOARD. THERE'S A PREDICTION FOR ANEMIA EMBEDDED INTO ALL THIS SO RISK CAN BE GENERATED FROM THE DATA PRESENTED AND YOU CAN ALSO INVESTIGATE OTHER WAYS, OTHER RECOMMENDATIONS DEPENDING ON THE PROFILE DEPENDING ON THE GESTATION THE PROFILES CAN CHANGE AND WHETHER IT'S POSITIVE OR NOT. AGAIN, IT GIVES YOU NOT ONLY THE RECOMMENDATIONS BUT ALSO THE RISK FOR PROBLEMS THAT OCCUR IN THE FUTURE. THOSE ARE EXAMPLES OF CLINICAL DECISIONS. AS PATIENTS YOU MAY BE FAMILIAR WITH THE USE OF PATIENT PORTALS AND BEING ABLE TO ACCESS YOUR EHR AND I THINK MOST PEOPLE UNDERSTAND THIS VERY WELL IN THE OUT PATIENT SETTING IN REVIEWING SOME OF THE MATERIALS. YOU MAY SEE SOMETHING IT'S BEEN ADDED BUT WHAT ABOUT INCLUDING THE ACUTE CARE SETTING. SO THAT'S BEEN DONE AND RESULTS FROM THAT HAVE BEEN QUITE ENCOURAGING. SO THE PATIENT HAS ACCESS TO THE RECORD WHILE IN THE HOSPITAL. THEY'RE BENEFICIAL AND IT HELPS TO IDENTIFY PROVIDERS WHICH IS QUITE UNDERSTAND YOU CAN SEE WHY THAT WOULD BE THE CASE IN INSTANCE WHERE'S THERE'S HUGE GROUPS OF PHYSICIANS COMING IN TO SEE THEM AND ALLOWS ACTIVITY NOT ONLY THEY CAN PARTICIPATE IN AND ENTER COMMENTS AND RECORD PAIN LEVELS. IF YOU LOOK AT WHAT [INDISCERNIBLE] THEY FIND IT BENEFICIAL AS WELL AND IT HELPS THEM SEE WHAT THE PATIENTS ARE THINKING AND UNDERSTAND THEIR PROBLEMS FROM THEIR PERSPECTIVE. IT CERTAINLY IS A POSITIVE ABILITY WITH REGARD TO COMMUNICATION OF THE PATIENTS AND AS A WAY FOR THEM TO ENHANCE THAT COMMUNICATION AND DELIVER INFORMATION. THERE'S MIXED RESULTS WHETHER IT MADE IT EASIER FOR OTHER PROVIDERS BUT OVERALL IT'S BEEN FOUND TO BE USEFUL TO HAVE PATIENT HAVE THIS TYPE OF ACCESS. SO IF YOU WERE TO DESIGN A FUTURE EHR WHAT WOULD THE GOALS BE? WE DECIDED IT'S FAIRLY STRAIGHTFORWARD. NEED TO DECREASE THE ADMINISTRATIVE BURDEN. THIS IS PARAMOUNT AND CRITICAL. IT SHOULD HAVE SEAMLESS USABILITY FOR ALL AND THERE ARE WAYS REGARDING INTEROPERABILITY THAT ARE IN THE PIPELINE AND RECENT REGULATIONS THAT ARE GOING TO CONTINUE TO INCREASE THIS USABILITY AND SHOULD LEVERAGE KNOWLEDGE AND IT'S NOT ONLY THE CLINICIAN BUT THE PATIENT AND EVEN THE PATIENT'S CAREGIVERS TO A DEGREE AND MER IMPORTANTLY SHOULD BE ABLE TO GO BEYOND THAT AND SHOULD BE ABLE TO GIVE US EVIDENCE-BASED RESULTS FROM THE LITERATURE. SO THE FEATURES THEN WOULD BE IS WORK FLOW AND REAL-TIME DECISION MAKING AND EVIDENCE-BASED AND INPROSPECTIVE PREVENTIVE ISSUES AND CLINICAL PROBLEMS AND AND IN REGARD TO THE PATIENT TO THEIR ACTIVITI ACTIVITIES AND NEEDS TO CONNECT TO HEALTH APPS AND DEVICES AND ANALYSIS AND RESEARCH AND SHOULD HAVE A LONGITUDINAL REPRESENTATION OF HOW IT SHOULDN'T BE A PIECE MEAL FASHION MANY CHARTS ARE SET UP AND EVENT-RELATED. IT SHOULD BE AS I DEPICTED HERE A TREND LINE THAT GIVES YOU AN IDEA OF WHAT HAS HAPPENED TO THE PATIENT OVER THE COURSE OF THEIR HISTORY AS NOTED YOU CAN HOVER OVER AND GET SUMMARY INFORMATION OR GET DETAILED INFORMATION AND OBVIOUSLY ADD A NEW ENTRIES. THIS WORKS NICELY WITH THE WAY A.I. MODEL DEVELOPMENT CAN OCCUR AND USING DISEASE CODES, MEDICATIONS AND PROCEDURES AND WHAT IS RELATED TO THE CARE OF A PATIENT BASED ON CLAIMS DATA YOU MAY HAVE AN OBSERVATION WINDOW FOR A PATIENT OR THOUSAND OF%S AND COLLECT THIS INFORMATION THAT WILL LEAD TO A BEST TIME TO INTERVENE AND MULTIPLE INTERVENTIONS THAT MAY OCCUR AND SEE WHAT THAT IS LIKE OR THE OUTCOME OVER TIME AND THIS WOULD REINFORCE THIS AS TIME GOES ON DEPENDING ON WHAT THOSE OCCURRENCES ARE. SO A.I. AND EHRs SHOULD HAVE THIS SYMBIOTIC RELATIONSHIP AND TECHNIQUES OF EXTRACTION AND AUTOMATIC SUMMARIZATION. THERE'S WAYS TO TRANSFORM THE STATIC PIECES OF INFORMATION INTO CLINICAL EVIDENCE TO BE SEAMLESSLY ACCESSED BY EHR. IT WOULD BE A LIVING SYSTEMATIC REVIEW THAT UPDATES AND ALERT GUIDANCE WHEN TREATMENT CHANGES ARE NECESSARY. AND IF THE CLINICAL PRACTICE GUIDELINES DON'T INDICATE A PREFERENCE WITH REGARD TO TREATMENT, A.I. WOULD BE USED TO USE RELATE -- RETROSPECTIVE DATA FOR THERAPIES THAT ARE SIMILAR TO WHAT YOU ARE CONSIDERING. THE COGNITIVE SUPPORT AND DECISIONS AND REAL-TIME LITERATURE REVIEWS IS WHERE A.I. CAN SIGNIFICANTLY HELP AND NOW THE INFORMATION MANAGEMENT SIDE. AND ONE KEY THING EVERYONE SAID WOULD BE A HUGE ADVANCE IS TO DITCH THE KEY BOARD AND ELIMINATE THE DATA ENTRY FOR THE INTERFACE BETWEEN THE PHYSICIAN AND PATIENT AND USE CONVERSATIONAL AGENT, CAPTURE THE CONVERSATION OR EITHER WITH REGARDINGS BY VIDEO OR HAVE IT INTERACTIVE AND HAVE CUES THAT ARE IN THE CONVERSATION THAT CAUSE A DASHBOARD TO POP UP OR BEST PRACTICE ADVISORY AVAILABLE TO PHYSICIANS AND PATIENTS CAN HAVE DECISION MAKING IN HOW THEIR CARE SHOULD BE CONDUCTED. AND I'D BE REMISS IF I DIDN'T [AUDIO DIGITIZING] NIH HAS PARTNERED WITH [INDISCERNIBLE] AND IT'S INTERESTING IT'S LISTED HERE THE CHIP MAKER IS MORE INVOLVED IN A.I. AND HAS DONE A GREAT DEAL OF WORK IN THE GAMING INDUSTRY WITH REGARD TO VIDEO GAMING AND USING LUNG SCANS FROM FOUR COUNTRIES TO HELP DEVELOP A DIAGNOSTIC SYSTEM THAT IS BASICALLY A [AUDIO DIGITIZING] AND YOU CAN NOW ALSO FIGURE OUT DEMOGRAPHICS AND THEREFORE GET AN IDEA OF FOLKS AT RISK. MORE IMPORTANTLY, WITH REGARD TO THE RECENT PANDEMIC A.I. HAS BEEN USED, FOR EXAMPLE, IN CHINA TO DETERMINE THE IMPACT OF DIFFERENT CONTROL MEASURES. THEY WERE ABLE TO TRACK MOBILITY OF THE POPULATION AND THEN ONCE A CONTROL MEASURE WAS INTRODUCED AND SEEN AS VERTICAL LINES IN THE GRAPHS THEY COULD TRACK NOT ONLY WAS THERE A DECREASE IN MOBILITY AS NOTED BY THE TOP BUT THEY COULD ALSO NOTICE A DECREASE IN THE SPREAD OF THE DISEASE AS A RESULT OF A CONTROLLED MEASURE. SO THERE'S A DIRECT ALMOST REAL-TIME ABILITY TO SHOW THE IMPACT A.I. CAN HAVE ON PATIENT CARE IN THIS CASE CONTROL OF A PANDEMIC. AND THERE'S A HEALTH SYSTEM IN DES MOINES THAT HAS BEEN USED BY PATIENT TO DETERMINE THEIR RISK FOR A.I. BASED ON THEIR SYMPTOMS AND HAVE WHAT'S CALLED A COVID COMPANION WHICH INTERESTINGLY DOES NOT REQUIRE INTERNET OR COMPUTER OR DOWNLOADING IT'S BASICALLY A TEXT MESSAGING SYSTEM, SO IF YOU HAVE A PHONE IT WILL PROVIDE INFORMATION YOU NEED GIVING YOU GUIDANCE AND CONNECTION TO PUBLIC HEALTH AND OTHER AGENCIES RELATING TO YOUR NEED FOR OTHER SERVICES. IN ADDITION, HAVE EXPANDED TO TELEHEALTH IN A GREAT WAY. THE LIVE TRIAGE OF PATIENTS VIA 24/7 AND A STEP FURTHER TO VIRTUAL VISITS AS NEEDED AND YOU CAN SEE IT ACROSS THE BOARD THIS WAS IN THE FIRST TWO MONTHS OF THE PANDEMIC FOR THIS SYSTEM FOR 61,000 TOTAL ENGAGEMENTS AND IT HAS IMPACTED VIRTUALLY ALL THE RELATED ACTIVITIES INVOLVED IN PATIENT CARE. SO THE BLUE BOXES INDICATE CARE DELIVERY AND FOR THE RED BOX FOCUSSING ON CARE DELIVER HAS BEEN INTEGRATED WITH INNOVATION WHETHER IT NEEDS TO BE A FACE TO FACE VISIT OR DEALT WITH WITH ANOTHER APPROACH. WE DOCUMENTED ALL OF AND THAT GIVE YOU AN IDEA WHERE A.I. IS PLAYING A ROLE IN COVID, WHERE IS ALL THE MONEY BEING SPENT IN THE HEALTH CARE APPLICATIONS? WELL, NOT SURPRISINGLY A HUGE AMOUNT PUT TO WORK TOWARDS ROBOTIC ASSISTED SURGERY LARGELY BECAUSE OF THE DEVICES INVOLVED THERE AND AS YOU SAW VIRTUAL NURSING ASSISTANCE HAVE BEEN WORKED ON AND CLINICAL TRIAL PARTICIPANTS IDENTIFIERS. WHERE DOES THAT LEAD IN USE OF THE ALGORITHMS? IT GIVES YOU AN IDEA OF THE FDA APPROVAL FOR USE IN MEDICINE AND NO GIVE YOU DETAILS FOR EACH BUT TO SAY THERE ARE A FAIR NUMBER THEM AND MORE IMPORTANTLY TO GIVE YOU AN IDEA OF THE DISTRIBUTION. AT THE OUTSET MORE THAT ARE ONCOLOGY ARE RADIOLOGY OR IMAGING RELATED BUT ALSO IN PSYCHIATRY AND CARDIOLOGY. THINGS THAT ARE MAYBE NOT SPECIFICALLY THOUGHT OF AS BEING OUGHT MATED OR IMAGE -- AUTOMATED OR IMAGE RELATED. YOU CAN UNDERSTAND WHERE A.I. CAN BE INVOLVED IN LOOKING AT HUNDREDS OF THOUSANDS OF SCANS AND THAT'S ASYNCHRONOUS AND STATUS AND THIS IS A STUDY DURING A COLONOSCOPY AND WHAT THEY FOUND IS THERE WAS A 50% INCREASE IN THE DETECTION RAID USING THE A.I. AND MORE IMPORTANTLY THE DETECTION RAID FOR [INDISCERNIBLE] WAS INCREASED WITH THE A.I. AGAIN, RELATED TO IMAGING, VERY RECENTLY THE FDA HAS APPROVED A.I. THAT ALLOWS FOLKS THAT ARE USING DIFFERENT IMAGING DEVICES TO CAPTURE THOSE IMAGES EVEN IF THEY'RE NOT TRAINED. SO YOU CAN ENVISION A NON-ECHO TACT FROM PERFORMING AN ECHOCARDIOGRAPHY AND THE SIXT A.I. WILL TELL YOU WHETHER YOU'RE PERFORMING THE IMAGES CORRECTLY AND THIS CAN IMPROVE THE CARE AND MAYBE EXPAND IT AND MAKE A SIGNIFICANCE DIFFERENCE IN THAT REGARD AND BEYOND IMAGING USING DEEP NEURAL NETWORKS A GROUP STUDIED THE USE OF PALLIATIVE CARE. USING THE EIGHT NETWORKS THEY LOOKED AT PREDICTIVE MORTALITY AND THOSE THAT NEED PALLIATIVE CARE CAN BE IDENTIFIED AND THAT REFERRAL OR CONNECTION CAN BE MADE AT AN EARLIER TIME POINT WICH AGAIN IS TO A PATIENT'S BENEFIT. THERE ARE ISSUES WITH A.I. A SINGLE ORGANIZATION [AUDIO DIGITIZING] AND WE HAVE TO NOT WORSEN INEQUITIES AND AUGMENTED INTELLIGENCE IS IMPORTANT AND THE ABILITY THOUGH AND THE GOOD NEWS IS TO PERSONAL CARE DETERMINING SOCIAL DERM -- DETERMI DETERMINATES OF HEALTH AND A.I. CAN BE USED TO HELP PATIENTS AND WILL CLINICIANS BE REPLACED BY A.I.? THE WAMC PUTS OUT PROJECTIONS AS TO PHYSICIAN SHORTAGES NOR FUTURE AND THEY SHOW THEY'LL HAVE SIGNIFICANT SHORTAGES AS TIME GOES ON AND THERE'S A VARIETY OF REASONS FOR THAT. REGARDLESS OF WHAT THINK OF THE BROAD NUMBER OF SHORTAGES EVERYONE WILL AGREE THERE'S A MALDISTRIBUTION OF PHYSICIANS. CAN IT CLOSE THE GAP? WHILE THERE ARE WAYS AS WE JUST DISCUSSED IT COULD POTENTIALLY ENHANCE AND EXPAND THE USE OF HEALTH CARE IN BENEFICIAL WAYS, THERE ARE SOME THAT DISAGREE OR ARE NOT QUITE READY OR FEEL THEY'RE READY FOR PRIME TIME AND THAT WOULD BE A AS WAS POSTED A COUPLE WEEKS AGO BY THE AMERICAN COLLEGE OF RADIOLOGY REGARDING AUTONOMOUS A.I. WHICH IS DIFFERENT THAN WHAT WE'RE TALKING ABOUT TODAY BUT FEELS THERE NEEDS TO BE MORE HUMAN INVOLVEMENT IN THE WAY A.I. IS CONDUCTED. SO THERE ARE AT LEAST FIVE REASONS WHY A.I. WILL REPLACE PHYSICIANS. AND THERE'S POTENTIAL A.I. SYSTEMS TO REPLACE JOBS IS A FALSE DICHOTOMY. THE COMBINED CAN ACCOMPLISH WHAT NEITHER CAN DO ALONE AND THERE'S A DEEP LEARNING ALGORITHM VERSUS AN EXPERT PATHOLOGIST THERE WAS BETTER DETECTION AND THAT WAS IMPRESSIVE AND MORE COMPELLING TO COMBINE THE ALGORITHM WITH THE HUMAN EXPERT. WE HAVE TO MAKE SURE THAT PHYSICIANS UNDERSTAND THESE A.I. PERFORMANCE CAN DETERIORATE OVER TIME SO AS PRACTICES CHANGE THAT NEEDS TO BE INCORPORATED INTO THE ALGORITHM AND A METHOD THAT IS GOING TO BE SOMETIMES DIFFICULT TO PUT TO A MACHINE AND THAT THERE BE ANOTHER KEY WHERE PHYSICIANS WILL ALWAYS BE IN THE DRIVER'S SEAT. COMPLEX TECHNOLOGIES REQUIRE COMPLEX PROFESSIONALS AND THIS IS ANOTHER EXAMPLE WHERE THE ABILITY TO OVERRIDE THE SITUATION WILL BE KEY AND THERE ARE CERTAIN TASKS ALGORITHMS CAN'T COMPLETE AND MOST IMPORTANTLY A.I. CANNOT REPLACE EMPATHY. WE ALL KNOW THE FIRST THING IN CARING FOR THE PATIENT IS CARING NOR FOR THE PATIENT. THAT'S AN EXAMPLE OF WHERE I THINK PHYSICIANS WILL ALWAYS BE VERY IMPORTANT IN HEALTH CARE DELIVERY. I DON'T THINK A.I. WILL REPLACE PHYSICIANS BUT I THINK PHYSICIANS WHO USE A.I. MAY REPLACE THE PHYSICIANS THAT DON'T AND THAT COULD BE THE CAUTIONARY TALE. IT WILL INCREASE EFFICIENCY AND DECREASE COSTS BY SWITCHING THIS TO MORE COMPLEX TASKS AND COULD REDUCE MEDICAL WASTE AND I MEAN FAILURE OF CARE DELIVERY OR COORDINATION OR OVER TREATMENT OR LOW-VALUE CARE AND CAN AUTOMATE SOME OF THE HIGHLY REPETITIVE PROCESSES BY AND LARGE MOSTLY ADMINISTRATIVE AND ALLOW THE PHYSICIANS AND CLINICIANS TO FOCUS ON ACTUAL CARE OF THE PATIENTS. SO WITH THESE IMPACTS OVERALL WILL HAVE TWO EFFECTS. THERE WILL BE MORE TIME AVAILABLE AND LESS INFRASTRUCTURE. TIME IS ESSENTIAL TO THE QUALITY RECEIVED AND IT'S BEEN DOCUMENT AND RELATEDLY BETTER FOR WORK/LIFE BALANCE FOR CLINICIANS IS CRITICAL TO THE SUCCESS OF EVERYONE. LESS INFRASTRUCTURE. IT'S POSSIBLE YOUR USING THE A.I. WILL TRANSFER CARE TO THE HOSPITAL SETTING. IF IT HELPS IN ADMISSIONS THAT'S ONE WAY AND IT'S POSSIBLE THIS CAN ALLOW THIS CARE TO BE CONDUCTED AT HOME AND WE SPENT 90% OF OUR TIME OUT OF THE HOSPITAL AND POSSIBLY MORE AND THAT'S PROBABLY WHERE SOME OF THE CARE AND INTERVENTIONS NEED TO TAKE PLACE. I CLOSE WITH WHAT I HAVE TAKEN FROM NATIONAL ACADEMIES OF MEDICINE MONOGRAPH ON ARTIFICIAL INTELLIGENCE AND THE NINE COMMANDMENTS FOR A.I. WE HAVE FOR -- TO BE AWARE OF THE MARKETING HYPE BUT WE CONDITION HAVE A TECHNO CHAUVINISM SAYING IT WILL SOLVE ALL PROBLEMS BUT IT COULD HAVE A BENEFICIAL EFFECT AND RESTORE SOME OF THE PROBLEMS AND ISSUES PHYSICIANS ARE FACED WITH REGARD TO WELL BEING. WE NEED TO SEEK OUT ROBUST MODIFICATIONS OF PERFORMANCE AND BIAS AND THAT GOES TO THE NEXT COMMANDMENT BEING RESPECTIVE OF THE EFFORT THAT SHOULD BE DELIBERATELY ALLOCATED TO IDENTIFY AND MITIGATE BIAS AND A.I. SHOULD NOT BE A BLACK BOX AND FDA IS CONTINUING TO ADDRESS THIS. AND SHOULD BE DEVELOPED WITH BAD ACTORS IN MIND WE HAVE TO KNOW WHERE THEIR WEAKNESSES ARE AND STRENGTHS AND PRIORITIZE EDUCATION REFORM AND WORKFORCE DEVELOPMENT AND MAKE THIS TRANSITION TO AN A.I. EMBEDDED WORLD AS STRAIGHTFORWARD AS POSSIBLE AND IDENTIFY WHETHER THE SYNERGY BETWEEN CLINICIANS AND A.I. RATHER THAN LOOK FOR A NEED FOR REPLACEMENT BECAUSE WE KNOW THEY WORK BETTER TOGETHER. THESE A.I. SYSTEMS NEED TO ENGAGE RATHER THAN STIFLE AND GETTING BACK TO OTHER RELATED ACTIVITIES PHYSICIANS AND OTHER CLINICIANS PERFORM AND REACH PATIENTS FOR EXISTING HEALTH SYSTEMS DO NOT AND THIS IS VERY IMPORTANT IN THE WAY BETWEEN TELEMEDICINE AND OTHER APPROACHES WHERE IT'S GOING TO BE CRITICAL TO IMPROVE NOT ONLY HEALTH CARE. WE'VE DONE A GOOD JOB OF TAKING CARE OF ACUTE PROBLEMS AND THE PREVENTIVE ADDITIONS AND IT WILL BE VERY IMPORTANT. AND WITH THAT I WILL SAY THANK YOU. I CERTAINLY APPRECIATE YOUR ATTENDANCE AND INTEREST IN THIS TOPIC AND [AUDIO DIGITIZING] . OVER TO YOU. >> THANK YOU VERY MUCH. IT WAS FANTASTIC. WE HAVE ONE QUESTION AND THAT QUESTION IS HOW DO WE DEAL WITH THE SECURITY RISK ASSOCIATED WITH CONDENSING ALL PATIENT INFORMATION INTO ONE VIRTUAL PLACE? >> IT'S A GREAT QUESTION. I THINK WE CAN TURN TO SOME DEGREE AND THERE ARE OTHER AREAS WHERE A.I. HAS BEEN USED IN ECONOMIC AND FINANCES WHERE THOSE PROBLEMS HAVE ALREADY BEEN ADDRESSED TO A SIGNIFICANT DEGREE AND THERE'S A SIGNIFICANT CASH OUTLAY WITH REGARD TO CYBER SECURITY. IT'S VERY IMPORTANT ISSUE. I'M NOT TRYING TO UNDERPLAY IT BUT IT'S BEEN ACKNOWLEDGING AND THAT'S WHERE ADDITIONAL EFFORT WILL CONTINUE. >> VERY GOOD. WE'RE AT AND THE OF OUR PRESENTATION AND AT THE END OF OUR TIME TODAY. WE DO WANT TO THANK YOU AGAIN FOR COMING AND GIVING THIS GRAND ROUNDS AND WE HOPE EVERYBODY WILL BE HERE FOR THE SECOND EDITION OF OUR SERIES. THANKS VERY MUCH.