Going Digital: How Technology will Change Healthcare

Welcome to Massachusetts College of Pharmacy and Health Sciences Podcast, the Secret to Living to 200. My name is Jennifer Perons and I'm your host. In each episode of this series, we will explore different aspects of health and the factors that allow us to live longer, healthier lives. With the help of a thought leader from the university this year, M C P H S is celebrating its 200th birthday, and what better way to kick off our bicentennial celebrations than with a podcast about longevity and wellbeing. Joining me today is Dr. Timothy Angst. He is an associate professor of pharmacy practice at M C P H S. Worcester, welcome. Hey, thank you for having me. Really excited to be here today. We're so excited to have you. Before we dive into our conversation, we're going to start with an icebreaker. So my question for you is, if you had a time machine and could travel 200 years into the future or 200 years into the past, which would you pick and why? You know what? I love food and I love cooking. I want to go back and just see is food better today or worse? And then from probably a personal standpoint, I probably want to go back and just see what was pharmacy really like in the past? How much has things changed and gone from there? Yeah. Multiple different reasons to kind of go there and explore. Right? Yeah. So as you mentioned, you are a professor of pharmacy. You have been a clinical pharmacist. Just to start, could you tell us a little bit about your background and your career and how you got into pharmacy? Sure. So I graduated from Wilkes University in Pennsylvania. So if you like the office, then that's where I spent a lot of my time. Then I went to a PGY1 hospital practice residency down in St. Luke's University campus on outside Philadelphia. Then I came up to actually MCPHS and did a clinical geriatric outreach fellowship on the Worcester campus. So that was all the clinical training, but during that process, the iPhone came out. Android systems were launching when I was doing my residency was when the iPad came out. I love that device. I was like, I want this thing. So I bought one, and this was the time around the time period. You had a lot of people wearing the white coats that had medical references in the pocket. They were huge. They're like 400 pages big, and they'd make your jacket go sideways. But what it turned into was I started carrying the iPad and I had all my medical references on the palm my hand, and then I actually started doing electronic health else coming in through the pharmacy. And people were like, why are you so fast? And I was like, because I can use this thing. And I started showing YouTube videos to patients. I started downloading apps and showing them the patients at a bedside about their health and such, and it just grew from there. I then got started with a company called iMedical Labs where I served as an editor for a while, and during the time period I probably reviewed about 3000+ apps on the market. And we actually started writing and publishing about that we had this new technology coming up. There was no way to evaluate what was good and what was bad. And then some of the, in our group actually started talking to the FDA and other organizations. So a lot of our work actually passed on to other organizations about consideration around technology, mobile apps, devices. We actually started playing with early health devices that are now very common around, we were explaining telehealth over a period of 10 years all this stuff. So you're what we would call an early adopter in that space and the use of technology with clinical care. Yeah, but the problem was it was too early. Okay. So it's nice to be early, but when you're too early, people think that you are into something that means nothing. I've had many people tell me that they don't think this technology had any merit. I had people to actually tell me, stop researching this stuff. And probably the biggest shifting point was the pandemic that I would say was what really changed it because overnight it turned into, I started getting calls and emails being like, Hey, what do you know about telehealth? What do you know about rural patient monitor, remote therapeutic monitor? What do you know about world devices? What do you know about apps? Transitions from digitalization of healthcare, from physical to digital? And that was a validation for me, yes, but it took a while for me to get to that point. Well, that's a long gap from when you got your first iPad to the pandemic. It's a lot of time and you just advocating for this technology. What kept you going and saying, this is the future, eventually everybody else will get on board. We know this. The reality is every person is tied digitally these days. We have a digital persona. We are on social media, we shop. Anyone that's listening to this is probably going to and shopping on an app. It's just a part of our lives. So I can't imagine healthcare would be so special it's separate from that capacity. You don't call it digital banking. I mean, let me ask you, Jennifer, when was the last time you went to a physical bank? Can't remember. When was the last time you wrote a check? Can't remember. But you've done everything through an app, right? Yes. But do you call it digital banking? No, it's my bank app. I use it every day almost. And that's the thing, why can't we get to the point where we say, I'm going to go see my provider, and that just means I'm going to go through an app. Why do you have to go in person? And I think there's two sides of the coin. You have traditional healthcare practitioners that And it's like we're special versus the reality is the business will switch this. It's going to be cost, it's going to be the payer, it's going to be all these other individuals are going to say, why spend all this resources trying to keep up a brick and mortar business when it's cheaper to run it digitally, possibly at the end of the day. And if it delivers the same outcomes, you still cash your checks, you still get paid, you still pay your bills, your money's still there. What makes in person for healthcare so much different that it all has to be done in person. And then it's that kind of question that pops up and then you start saying, well, how do you achieve it? And that's what kept me interested for a long time. Interesting. So I want to focus in on telehealth and the idea of healthcare apps and storing data from a consumer perspective. I think it's just something so personal and that people feel they need that connection with their doctor. They don't necessarily just want to get the notification of test results on their app because to be honest, not many people can interpret them. So maybe they're worried about what they might say or just having all of that personal information about your medicine, your weight, all of that in the palm of your hand. I think what you're saying it's people aren't used to it. What would you say to those people who are nervous? I think it's also the fact that it's that transition period. We go back and we look when ATMs came out and still that thing, we still get people who are scared of digital banking. Most of the population now use it, but I come across that there's always a shift in design in order to actually get people used to these concepts. There's laws, there's regulations for laws stuff, so not every health app has it. That's a key thing. Not every app has to follow certain security things. If you're accessing information through your EHR portal from Epic or something else like that from our MyChart, yeah, it's following actually rules and regulations similar stuff like that, but I think it's because most people don't know they have to have trust, but what do you trust at the end of the day? Part of it thinks it's like a design aspect. So let me ask you this quick question. When did you get your first smartphone? 2013. 2013. So a decade ago. Was it an iPhone? Was it Android? It was an iPhone. Okay, so you would've been around iOS 5 or so. So do you remember the old YouTube app? It looks like a television, and it was designed that way because early adopters would not recommend the UI or user interface today. So how do you get people from a interface towards a modern interface? There's a term called skeuomorphism. Skeuomorphism is where you take something that's design around an everyday idea or concept, and over time in each itineration you update the UI little bit by bit to push them towards another way of thinking. So the play button's still a play button, but maybe it's somewhere else, or maybe now the play button's shift into a different color. So the YouTube app is now just the right triangle. That's the default. Before in the past it actually said YouTube. It looked like an old modern television, but that was just to get people to realize what I did, and the reason why I bring this into play is because even early banking apps made it look like you're writing out a check. You make a payment. Nowadays, you don't think like I'm writing a check. It's because it's all handled and it's going to take us a decade plus to digitalize the whole process. So telehealth to me is just a digitalization of a process. You or me are supposed to be in person in a studio having this conversation, but instead we're going through Zoom to actually record. Yeah. Is there a big change in terms of what that outcome achieves is a question. And I think that's the issue is telehealth to me is just you just digitalize the process. It didn't make the process any better. The only thing I could think better might be the experience of I didn't have to drive somewhere. I didn't have to wait in a waiting office. I didn't get stuck in traffic. I didn't have to spend $15 on parking. There's that logistical approach that meets a patient where they're at for telehealth that I think is very nice, but in terms of making care any more advanced, I don't see it. Okay. So is that where apps come in beyond that, do you think? I think that's where apps and wearables and other stuff comes in. Where I get excited about some telehealth companies that are coming out. You can actually have home otoscopes. You just put it on your camera, on your phone, and you hold it up to the kid's ear and you can actually look into the ear and take a picture. Oh my goodness. Exactly. And that sends a picture to the pediatrician. There's skin scanners that you can buy at home. There's like all these different devices that you can use at home. This turns into what's called remote patient monitoring, and to me that's much more exciting. Now you're digitalizing the process, but you're adding on the technology for more objective measurements that the provider doesn't have that makes you actually, I think, push the level of care that wasn't done in the past. And that's where I think I see a huge possibility for pharmacist in certain diseases and management going forward. How, specifically for pharmacists, how do you think that technology that could help when you're making decisions about what medication to prescribe and how much? I think there's a lot. I think there's efficacy and the safety component. If I have a patient who just got a heart attack, they're going to come out of the hospital minimally on a stat and the beta blocker, possibly an ACE inhibitor and stuff like that. The beta blocker caused your heart rate to drop and develop what's called bradycardia. Patients don't feel that often. They don't feel like, oh, my heart rate something just went down this many beats. But if you have a wearable device that suddenly tracks heart rate and let's suppose hypothetically it puts up that number and it sends it to the EHR and it dings it in the health system saying, Hey, patient part rate just dropped 20 beats per minute for the past three days, and that patient's now reporting that they feel sluggish and everything else, well, let's intervene now maybe back off on the dose, consider different medication. Let's optimize therapy so that this patient doesn't come back in the hospital. I think pharmacists from monitoring the medications can help secure safety. Conversely, we could optimize care from dosing. I have a good friend that's working down in the Gulf and she runs a team of about 30 pharmacists that see thousands of patients remotely for blood pressure. So these patients don't even go into a clinic anymore for blood pressure care. Wow. They get a Bluetooth blood pressure cuff at home. They measure a few times a day and the pharmacist gets all the data coming in, they see it on their records and they're like, oh, your blood pressure's staying where it's at. They send a message, good job, keep going and SMS or texting. If they don't, they'll call the patient, did you take your medications? Yeah, no, I didn't. How's your diet? Blah, blah, blah. Okay, we'll check this for a week. Try daily lifestyle changes. No, okay, we see the blood pressure still rising up. Let's increase the dose, and they do it. So you had this team of pharmacists that basically are managing people's blood pressure remotely using a mixture of telehealth, wearable devices, and everything else just to track, and they're getting the care. The patients aren't going to see a physician, the patients aren't coming in to get it done. I think that's amazing. It is. I think for some people it's a little scary that there can be a doctor monitoring my heart rate or my blood pressure, but it seems like at this point it has to take the right kind of provider and the right patient to buy into this to see the benefits and the opportunities coming with it. It's not for the general public, and this will not develop into a place where somebody out there is monitoring everybody in the world because of their I mean, why would they care? I think it's where people get caught up in data, and I think data does matter. Most of the data's out there is de-identified and I think the privacy around healthcare is going to turn into, oh, someone may have access to this, but what are they going to do with it? I'm not too sure. Yeah. So it's one of those avenues where we'll probably see interesting things pop up because humans will be humans and we'll do crazy stuff with whatever we get access to. I guess the bigger question is, does the ends justify the means? Yeah. I think in the United States with our healthcare costs being stupid, be quite frank, you'll see a lot of people invest in this because they're going to look at it, say, whatever you going to do, dry down costs is better than nothing. We'll deal with the individual problems as they pop up, but the cost of healthcare is unsustainable going. Forward. And as with anything, do you see it as more of a risk benefit analysis and that yes, there will be things that will come up that might cause issues that might make people uncomfortable, but ultimately the final result is better for everybody? Yeah, I think for me it's like I don't seek perfectionism. I know it won't be perfect because healthcare as it thinking that providers in healthcare, invaluable is that's a flaw. We make mistakes every day. We do. I've made mistakes. Other people make mistakes. I don't know. Any person that works in healthcare did not make a mistake. That's just inevitable. We're humans. And that's it. And I think people thinking the way they currently healthcare is fashioned is the best and that we can't change it. I think that's where we get stagnated and I think the reason why we see so many people outside healthcare trying to do it because they've had experiences where they're not happy with how healthcare is run. Why would Apple want to make these devices? Well, it's probably because they're engineers at one time or another be like, why can't we do this? So if they're not going to do it, well let us do it. And that's the innovation curve. But it's a matter of how do we combine best practices with what can be done and make something that works and addresses all stakeholders concerns at the end of the day. Yeah, it's not just data for the providers, but it's also data for individuals to make better choices and change things about their life. When you were speaking, it also made me think it could resolve some of the issues we're having with access. Yes. That's always been the goal around digital health is that it should increase access, it should increase access to care, scalability of care, and it should drive better precision medicine at the end of the day towards individuals because it's based around their data. Can you talk a little bit about what it will take to get people widely on board? So my working theory is that one, you have to buy in from patients. I think what's going to be the driving force is you have a lot of, let's say millennials or Gen X. Yeah. They're going to basically say, I don't want mom to go into a nursing home. What can I buy? Or what can I do to help support? They're willing to buy and put money into it next. Then that goes with it is then we'll need the practitioners. How do we educate ourselves to know what is best practice workflow and such? When should a patient come in? When should a patient be seen remotely? When should you prescribe an app? When should you prescribe a device? Which device should you use? I would probably mimic what we currently see with continuous glucose monitoring for diabetes. Diabetes, probably lean to charge in healthcare technology and how we have certified diabetes educators handling this. That's going to be our mimic. Then the last one's going to be payers. That's the group that I've been working with a lot as of late, and they are interested, but we need data showing at the end of the day, it reduces total cost of care. So we need more financial data. They need the proof. That's it. So we're going to need more clinical data, larger studies, just saying, where is the best fit for this technology? And that's going to take until the 2030s to really roll out for the payers to sit back and say, yeah, it's worth covering this and doing this because there's a financial plus to it at the end of the day, and then we'll create billing codes for it. We'll decide who to pay, how to pay, how to make this all work, and then you get that nice little circle that can occur. But if we just focus on one group over the other, you can't do all of that. Right? It has to happen and just to look into the future, it's hard to imagine, but it's coming and that's going to be our reality within the next couple decades. I think the example right now, we'll see if that's faster, is AI. Yeah, I wanted to talk to you about it. What do you see is possible uses for it in the healthcare world? A lot. So it takes a lot. I say the busy work out some things like we're seeing some people create the ability to drop your whole EHR or your notes about patient into a thing and it just reads all the content and spits out a summary report. So what may have taken a person like an hour or two to crank down, look through all their data, it can just do in seconds. So these large language models, these visual stuff, I see increasingly taking on a lot of the cognitive work that people do. And I think it's inevitable as well because we love time. To me, time is always the one commodity in like you can't bank, you can bank food, you can make toilet paper. We did that, you know, can bank money, but you can't bank time. So time isn't one thing. We will pay money and resources to claw back. I spend an hour writing a report when you can just give it to an AI system and write for you in a minute. I know what I want. I know my desired end product. I just don't want to spend the time creating that end product. And I think it's very key is if you know what you want, you have something, they can create it for you. You have to sign off and say, do I or do I not approve of the outcome that's delivered? This is the issue we're facing pharmacy school though. We have students that are taking assignments that we give. They know what they want. They want a good grade. So they put in ChatGPT and ChatGPT spits out something, but they don't have the clinical knowledge yet to assess was it a good or bad product. So AI is going to be very powerful for the people who know how to use it and know what they desire. So for now, where AI is, you think there still needs to be a human at the beginning and end of it? AI is not at a place where it's replacing any kind of jobs, it's just saving people time and getting them to their end goals faster. For now, I think the biggest thing that I would probably take that would shift my outlook, if we got to the point where a vehicle could be controlled by AI was in a motor vehicle accident and the company that created the AI system was held at fault, not the driver. Then I would say that we moved the bar because most of the time when it's happened so far, we don't hold the company that made the AI system at fault. So at the end of the day, you can choose to use ai, you can use it to make it work faster and such, but there's always been a human element at the end that has to assume then the risk because they chose to engage in the AI system in this process and in healthcare, to be quite frank, we always want a human to assume responsibility. It can't be completely autonomous at this current time In the future, could it be maybe if the laws and other things and regulations change, but as it stands right now, I think most people would want to say you're using AI as a person overseeing it? Yes. Okay, well I feel more comfortable about that. Yeah, using it as a tool, as just another thing that you're using in your daily life to, like you said, make things easier. But now that's another thing professionally that you assume risk on. The AI's wrong, you didn't catch that, well then I'm still liable for whatever negative outcome that comes from it. So in the case of the student, they assume responsibility for using an AI. What is their consequence? Do they have to do it over again? Do they get faulted for using ai? What's the end result in that situation? I actually encourage the use of it. I think we should spend time like saying, you can use this. Just recognize that you're responsible for checking if it's right or wrong, and we need really take a step back in terms of how we do assessments with AI out there because I don't think it's fair if you want to be on a cutting edge and keeping students up to speed about where healthcare, everything else is going to deny them the use of a tool that's going to be the equivalent of a calculator or a smartphone in their lives. This stuff isn't going to go away. Yeah. I think that that sets a great precedent for teaching them that they assume the risk and they take responsibility for whatever they use it for. That's it. And if it makes your work go faster, it's great. If it does well and they learn how to do it, that's great. If they choose to use it and not use it well and it gives a bad response, then that's their fault. But then again, I think it's a matter for us as educators also to show them that yes, this is why I also have been telling my colleagues we should be practicing having discussions about how to use this stuff because we can mix our own knowledge, our practice with this and pass it up to students because we're all kind of learning at the same time. Right. It's a unique kind of time. So I know this might be hard considering the scope of things we talked about, but if you could pick one piece of technology or excited about the future of this digital healthcare landscape, what would it be? I really like remote therapeutic monitoring. I really like the idea that we're going to get to the point where we can remotely monitor conditions. And I think my hope for that is that we stop a lot of diseases from spiraling out of control for diabetes, for instance, I do think CGM will get to the point where that just evolves further. Maybe it's not even a device that's invasive like a needle. It's something you can just wear like a watch. And I would love it if would give feedback to people like your blood sugar's trending up and if you keep doing what you're doing, you will develop diabetes. Wow. I would really like to see that availability. We preempt conditions way before they happen because I look at a car you like your car will send you signals saying, Hey, your engine's lights, your oil's low, your tire pressure is low and you can choose to ignore it, but you know that you're at fault then if something bad happens. The human body, like I don't get warning saying my cholesterol's high. I don't like, I have to go in at certain points assigned because from a population health standpoint, that's the best way to treat most people. Not everyone, not the individual. So I'm looking forward to, as we get to that more individualized care, it's like, hey, you know what? You're doing great or something's going on with you and we should probably look at it faster just so just to be sure. I think that would be amazing. Tim, thank you so much for this conversation. I've learned a lot. I've thoroughly enjoyed it and I hope you have as well. No, thank you. And thank you for having me. Appreciate it. We have one more part of our show and it's called Red's Rapid Fire. So I'm going to ask you a short series of questions and the goal is to answer them as quickly as possible. Are you ready? Yes, let's go for this. Okay. What is your favorite month? March. What was the last movie you saw? I think Toy Story. Me too. Actually. Oddly enough. Coffee or tea? Coffee. If you could have a superpower, what would it be? Time control. What was your dream job growing up? I wanted to be a history teacher. What is one meal you'll never get sick of? Prime rib. If you could live in any decade, which would you choose? Now. Where is your happy place? Sleeping. What is one piece of advice you would give to your younger self? Invest in Google. And on that note, that wraps up our show. Thanks again, Tim. And thank you for listening to this episode of The Secret to Living to 200. We hope you'll join us next time. And as always, stay curious, Cardinals.