Immediate past president of the American College of Cardiology, Dipti Itchhaporia, MD, MACC, FAHA, FESC of Hoag Hospital and professor at University of California, Irvine delivers a keynote lecture on the digital innovations changing the landscape of cardiovascular medicine.
Well, good morning everyone. Um For those of you that were at the Gala last night, I'm, I'm impressed you're here bright and awake with all the, the dancing and drinking. Um But we, we definitely had a really good time. So on the heels of uh a really lovely day yesterday and the ems symposium on Friday, um we're absolutely privileged to kick off today, which arguably is really the cerebral day. Um Talking about a lot of great um cardiovascular prevention, cardiovascular, um the explosion of women's heart disease um as well as congestive heart failure, vascular medicine. And towards the end of the afternoon or mid afternoon when the, when the session ends, I think Jamie Bile as head of our education committee has put together an amazing uh jeopardy session with the fellows, the A PPS. Um And as you can see, we've got some luminaries and educators and in the audience. So it should be really fun. Um But without further ado uh let me now um introduce our um second keynote speaker yesterday morning, Chris White talked to us about really the, the imperative of value based cardiovascular care and we wanted to zoom out again and talk to um or have one of the national leaders in digital Transformation and cardiology. Um really talk to us about the, the revolution that's happening that we need to embrace. And I um as you all know, is an interventional cardiologist and the Eric Sheila Samson and chair in cardiovascular Health Director of Disease Management for HOG Heart and Vascular Institute. She's Clinical Professor at the University of California Irvine and past president of the American College of Cardiology. Um She was the 70th president of the AC C and is the first South Asian American to hold this role before I go on to her professional interests, I wanna say as a member of the AC C. Um and and during her tenure as president, I was really blown away by the efforts and the focus and really the inspiration she gave all of us in terms of digital transformation. Um as we think about it within our own health care system. Um So, professional interests include utilization of technology and innovation to propel prevention of cardiovascular disease. She's been a strong advocate for digital transformation and health care on achieving the quip aim. Most recently, she joined the Board of the World Heart Foundation, assumed the role of associate editor of the Journal of American College of Cardiology Advances and joined the Innovation Oversight work group of the American College of Cardiology. Um As Dr Isaura comes up, maybe the panelists can introduce themselves um, so that you all can know what the discussion is going to be. So, come on up, are they gonna introduce themselves? I'm gonna say, uh I'm Jamie, be, I'm uh the Chair of Education for Georgia Heart Institute and I lead the uh Center for cardiovascular prevention Metabolism and lipids, Georgia Heart. Good morning. I'm Dawn. I'm one of the non-invasive cardiologist with a special interest in lipidology and prevention cardiology. Good morning. Um I'm an with Northeast Georgia Medical Center. Good morning. My name is Joie Sharma. I am a general cardiologist at Piedmont Heart in Atlanta and I'm the medical director of the Women's Heart Program there. Hello, I'm Cindy Grins. I'm uh interventional cardiology and the Chief scientific Officer at Northside Hospital here in the Atlanta area. Hi, I'm Benita Shaw. I'm an interventional cardiologist and co-director of research at NYU LA. Go in New York. Hi, I'm Arthur Ason right now doing preventive uh cardiology in private practice in Miami Beach. And hey, I'm Sean Couch. I'm Executive Director of Communications and Digital Health for Northeast Georgia Health System. Great. What a what a panel, right? So, you know, it's gonna start off early. So this is gonna say thank you for being up early and being, coming to this talk. I can't stand behind a podium too short. Um But I wanna start off by saying first thank you to doctor and the planning committee and Doctor Burke for inviting me during my presidential time because of COVID, I wasn't able to travel. So this is really nice to have a chance to, to interact with the members and just kind of understand what people on the ground are sort of wanting to know uh uh hear about what they, what's on their minds. So I'm gonna talk about digital transformation. I have no disclosures for this talk. I'm gonna just briefly talk to you about the global burden of cardiovascular disease. Introduce the concept of social determinants of health and health equity because that is important when we talk about digital transformation, recognize that this is a digital world and lay down the imperative for digital transformation. Give you some examples of what's coming in cardiology and then just make you think about the digital divide and really hopefully leave you with some food for thought. These types of talks are really meant for you to think about and maybe a call to action. So let's start off with the last 70 years in, in the history of cardiovascular medicine. And it's imperative for all of us to understand that it has been a remarkable 70 years. If you think about the fact that we define the path of physiology of cardiovascular for myocardial infarction to development of statins to VADs, to percutaneous therapies. It's been incredible science. So you have to feel good that we have great science that we can deliver and then think about cardiology as a field. We are a very tech savvy, tech avid field. We seem to adopt technology quite quickly as long as there's evidence. But think about it leadless pacemakers. As I said, percutaneous intervention, even uh even uh you know what we're doing every day in the lab, there are so many technological advances. But yet when we look at the landscape, what we see is this, you know, this wave of death and disability that's coming at us and at the top of it is cardiovascular disease. So this is the the slide that Rob Cali um put showed at the American Heart Association meeting last year. So you have to say if we've got great science and we've got great technology, why is there a wave tsunami of cardiovascular disease coming at us? Well, one of the reasons is that the risk factors of cardiovascular disease continue to increase in spite of all of our efforts, right? If you think about it, diabetes is increasing, obesity is increasing, diet and physical activity is poor. Our one on one interactions don't seem to be enough to change this. And if you look at the projected future cardiovascular risk factors and cardiovascular disease by 2060 look at the the the two red things I know it's hard to read, but diabetes, hypertension, dyslipidemia and obesity all are planned on increasing the the the numbers of of people that are gonna be affected. The second arrow says there's disproportionate increase in cardiovascular risk factors and cardiovascular disease to impact racial and ethnic minority groups. Just something to keep in mind as we talk about it. So, although we have great science, we have great technology, we do great work in the hospital. We don't seem to be improving care longitudinally. So for people at home patients, we just don't seem to carry that on uh when they get home. And as a result, there is this variation in the quality of care, risk factor management, prevention, health and health outcomes. Why is that? Why? Because we're finally starting to really appreciate the impact of social determinants of health. What we realize and this is shocking to most people. Is that what you and I do, what we all do clinically only impacts a patient's wellness and outcome. 20% of their wellness and outcome, 80% of is is all of these other social determinants of health, their socioeconomic factors, their health behaviors, their physical environment. So 20% of what we do, but we're expected to see what the outcomes are 100% of the time. So this is this is a problem that on the bottom is a big dollar sign. It's because this is giving tying in the talk from yesterday war is the fact that this is a very costly problem that we have. Deloitte. This is a, a little depiction by Deloitte that's predicting that we're gonna be at a trillion dollar savings if we can by 2040 if we tackle health equity, the way that it should be tackled. And as you all know, there's national attention to health equity now. So this isn't something that we can ignore and pretend that we can deal with it in another time. So uh this is a paper that I wrote during my presidential time, we must address health equity. In 2007 health care centers uh went around the AAA improved patient experience, better outcomes, lower cost. Who could say no, everybody spent money to try to get the AAA. Then they figured out in 2014, my gosh, we're never gonna hit the AAA. Why? Because we forgot the one big important piece, the clinician and clinicians were getting burnt out. So clinician well being came into, into being and that was why it evolved to the quadruple aim in 2014. And I will tell you that in 2021 when I wrote this piece, I believe that we were at the Quin Aim with health equity as part of it. Why? Because it leads to better health and who during COVID did not want better health? Tell me that and improved economy. So that was the reason for it. Now, let's go back the same 70 years that we made all of those scientific advances in cardiovascular medicine and think about what was happening in the technology field. So this is IBM loading a five megabit hard drive onto their van. Look at that. Ok. Now let's see what's happened in the intervening 70 years. So we bring up 2023 and there's Google Facebook. So the the the incredible amount of computing power, my my cell phone is 256 gigabytes, right? So if you think about the incremental increase in digital power, the ability to transfer that power of digital data over the internet, all of that has transformed many industries. So if you think about a transportation, banking, um entertainment, all of that has gone digital. Ok. Now, I want you to think about 70 years that we've made all this progress, right? What have we done in the way that we delivered care? So this is a hospital waiting room in 1956. What does it look like now? Pretty much the same. So here in lies, one of the problems is the delivery of care. So we need to really think about how we deliver care because if we're gonna do value based care, if we're gonna do all of the things that we want to do to improve that the the tsunami of cardiovascular disease, we're gonna have to change that. Now many people think we've already done digital transformation because of a electronic health record. Did we really do that? No. So this is where I need to pause and tell you what is the definition of digital transformation? Digital transformation fundamentally is a process that will improve the lives of our patients and will improve our lives. So remember that. So let me ask you again, do you think electronic health record improved our lives? No, $36 billion is what we spent in this country on electronic health records. And what did we get a fancy word record, word document? And really, it's perpetuated medical errors and the data shows a paper came out in the annals of internal medicine that said for every hour that we spent with a patient, we spent two hours for documentation. So this was not digital transformation. Um And this is really the imperative for uh for you know, um digital transformation. So again, this digital transformation is a disruptive improvement process that introduces change in information management, computing, communication connectivity. And I think the common misconception is that digital transformation is merely technological, but it is really about improving clinical processes to improve quality of care and improve patient satisfaction. Now, this is data from Cisco. It's not really medicine, but when Cisco introduced digital transformation, they had improved customer satisfaction, employee engagement revenue. And if you do this in health care, we have better system efficiency, patient engagement, clinician efficiency and health outcomes. So that's what we have to keep in mind. Now, the Silicon Valley, I'm from California, California. They've been telling us we've been under digital transformation for a long time. And if you look, there's a kaleidoscope of companies that are doing all of this thing for digital transformation. But the problem is that a lot of times they come up with a solution. So tech solutions in search of a problem, they don't even know what the clinical problem is, but they're finding solutions for us. And then saying, what's the problem? I'm trying to solve that? There's a lot of data that give us a lot of data, right? Patients are already wanting to give us all that data. But is that really what we want more data? No, I think what we want is actionable information. Then clinical insights and integration is often absent when they do provide us this, we need to know how to integrate it in our workflow. And then if you're gonna go and ask your hospital or your system to pay for it, where what are the payment models? And is it cost effective? Is does it really make a difference? We heard Doctor White say show me if it helps when he was asking the surgeons why a particular val they couldn't tell you. So you need to be able to articulate that now. But overnight what happened during COVID? Well, what we did was we went from almost 0 to 5% telehealth use to 90% in April of 2020. Wow. So we medicine woke up all, all of a sudden overnight and just started doing telehealth and now we're down to at least in cardiology, about 30 to 40% use of telehealth. We know that people like telehealth, not everybody does. The older the patient is the less they want to do it. They still want that human interaction because and that's something that for us to keep in mind as we think about digital transformation, there is something in the human interaction, the compassion that we can give the time all of that, that's important. But the fact is that we are in, we have started our foray into digital health. So the AC C had put this um diagnosis, this pictorial out saying this is how we're gonna get to digital transformation virtual care. Well, I can tell you that telehealth is not virtual care, that's just telehealth. And we'll come back to that couple that with remote patient monitoring and couple that with artificial intelligence or artificial augment, you know, in a um augmentation. Uh I think that something that augments our intelligence, augmented intelligence driven care. So when we think about virtual care, wouldn't it be nice if everybody had a box like that, that had a digital stethoscope, be able to get their blood pressure, be able to get all their vital signs virtually. If we can do that, I'll couple that with the platform. That's a true virtual care visit. And that's something that is really possible. I've, I've spoken to the consumer electronics show. These things are possible. We just haven't integrated it into our daily lives. So if we can get to virtual care. So put either a telephone or a video platform, couple that with the remote patient monitoring and then go to management pathways and therapeutic pathways. If we can do that, that's how we're gonna do population health. Now, luckily, for us, it's a digital world. Everybody's got a smart phone, almost everybody on the planet has a smart phone. Um and it may be a low cost effective way for us to utilize it. So we know that web based interventions can help improve health outcomes. Web based secondary prevention outcomes have shown to decrease overall weight, blood pressure and cardiovascular end points. Text messaging programs are the most studied digital health interventions and they're relatively old, right? In the context of cardiovascular disease, text messaging has shown to improve two cornerstones of cardiovascular disease management, lifestyle behaviors and medication adherence. Patients forget to take their medication, not because they don't want to. Some of them like my father, for example, I took him to the neurologist last week and the neurologist says, well, I want to make sure somebody is in charge of taking his meds. I go, oh no, my dad's really great. He takes all his medications and um so he turns to my dad and he says, do you take your medications every day? He goes, I forget sometimes, oh my God. So, um I didn't know that. And so that was something that was, you know, sort of upsetting. But so you realize that even a smart person can sometimes forget text messaging programs have worked very well for a smoking cessation. This was one of the first lifestyle behaviors that was addressed. This was a meta analysis with almost 12,000 patients and it showed that it really made a difference. Um There are currently many emerging wearable technologies. There's the dual ear backing that monitors heart rate, calorie burn activity level. There's smart clothing that you can wear smart socks that can improve your running form. Um So things that you can wear shoes, clothing, fabric, bracelets, rings, necklaces, glasses, almost everything you can use to as a wearable technology that will give you information. And I think what's interesting about this is that you want to know what the patient looks like when they're not sick so that we can truly deliver health care because right now we deliver sick care if you know what somebody looks like when they're well, it's easier to pick up the signal when something goes wrong says hm, something doesn't seem right here. And so we know that wearables and digital technologies have been very successful in heart failure. In fact, there's a kaleidoscope of things that we use CardioMEMS device, all types of devices we can use, but also ways we can monitor to monitor activity, encourage exercise, detect arrhythmias. So we have seen actually something that works in heart failure with, with all of this digital technology, but there's a lot of new things. There's embracing technology for patient monitoring, there's the face, they're using facial recognition to detect pain, depression, uh voice voice biomarker. In fact, I can give a whole talk about voice and what they're doing with voice biomarkers and then ingestible. Remember what I said, one of the issues is patient adherence in terms of medications. These ingestible can help with that. Now, voice as a biomarker is actually becoming quite important. The NIH has funded $14 million to 11 institutions to establish voice as a biomarker, which is a National data bank of deidentified voices. And they've coupled that with artificial intelligence and it's called voice as a biomarker for health. So I think we're gonna get more information about that. There are different adherence monitoring techniques. There's the phone based adherence technology that I mentioned video directed therapy. How many people travel during COVID and use that video directed therapy to make sure they did their COVID test to see what they did. I did that many times. So I know and it actually works. And then the ingestible that I mentioned and as well as the digital pill box, that's what I've been order from my dad is the digital pill box. Um So the other part is data, data, data. We're getting a ton of data my patients want to send me, oh, can I send you the, you know, from a live core? Can I send you that and your answer? Really? Is. No, no, I don't wanna see it. No, because I mean, number one, I'm legally responsible for every page. Do I have the bandwidth after I've done my electronic health record to look at data? No, no, I don't. But uh one thing is true, the big data, new knowledge and medicine, the thinking training and tools needed for a learner health system. Medicine is becoming an information science. We need to take information, decipher it to know when a patient's well, when they're sick all of that. And as Harlan Crum said, it really is a learning health system. So we gotta learn how to deal with data. And I think this is data is the new game changer and how to organize large volumes of data in real time from several sources is really consuming in time and slow. So I think to reduce that human effort, we are gonna need to do uh artificial intelligence and machine learning to help us with that. So this is where artificial intelligence care comes in. I wrote this paper, artificial intelligence and cardiology. Super important. There are many, many examples of A I driven care and cardiology, but the most that we're using it, it it the most effectively has been in the imaging arena, but we're seeing pieces of it in all the different areas that where we work. This is an example of a cardiac CTA I where we know that augmented and intelligence facilitated the reads more efficiently, they reduced the cost and um you know, increase the accuracy. So we think that that can be really helpful. Um This was an example of a I facilitated acute stroke program out of Kentucky. It was a pilot that showed that it reduced the border thrombectomy time, uh really from 100 and 19 minutes to 90 minutes. So really can help. This is a very interesting and I think Jamie, you'll really appreciate this. This is about machine learning that allows you A S CV D risk stratification for primary prevention and diverse populations. We know that that pooled cohort equations doesn't really apply to Asians and uh even the Hispanics. So we can use pooled cohort equations in this study. 48% of A S CBD events occurred in individuals who were ineligible for pooled cohort equation application and otherwise would have been in stratified incorrectly for primary prevention. But yet this could be utilized to say, hey, you need statin therapy. Uh And as an Asian, I can tell you that uh the, the these equations really don't work. But we know the emerging data is that South Asians, they have a, a lot of heart disease and so we need to think differently. Uh Martha Gulati is gonna be talking later this morning and this is a, a use of artificial intelligence and stem management. Uh This uh was a paper that looked at A I being able to use predictive modeling of features of STEM to provide a standardized approach for care. This eliminated the implicit bier bias in caring for women and improve, um you know, the the treatment and improve the sex disparities in women. I have to bring up chat GP T because everybody's got chat GP T on their mind. This was released in November of 2022 was built on the large language model and it's this what we call conversational A I and it really lets you have a human like interaction conversation and it recognizes patterns and creates output based on them. It really took the internet by storm, right? 1 million users in the first five days that it was released. And according to uh a data by Swiss Bank U BS, it was the fastest growing app in all time. But large language models are what we're gonna see more, they can recognize, handle and even generate human text and it's, it's trained on massive massive data sets. That's how we can do the pattern recognition to support decision making. Um But remember it cannot generate accurate answers based on current events because chat GP T was trained on uh on a data from uh previously. So uh it, it can be current but there are some issues. I have a paper coming out on T GP T, but there's training biases because it's all based on what you use as the data set. So there are training biases, there's consensus mirroring meaning that it only projects what the majority opinion is. If the majority opinion happens to be incorrect, then that's gonna be the opinion because it looks at that may not pick up minority opinions. And then what they call hallucination or confabulation, inaccurate information can be presented in a very confident manner sometimes using non existent references. So it may and then it lastly can oversimplify knowledge, losing that nuance of practice. We can say clinical, you know, this is what think based on our clinical day, uh you know, information that we know, but it can simplify knowledge. So I don't think we're ready for T GP T for medicine all the way. I think the future. Yes but not right, not not right. This second plus it will help us to do things but not necessarily um replace us. So automation won't replace physicians, but those using automation will replace those that don't. And I think that's, that's a very true statement. What about the digital divide? You think about your patients? Can they uh if they have digital literacy issues, if they can't afford their devices? So we really need to think as we go forward, how do we develop these digital devices for that? Um And I think we need to start thinking because we have the opportunity for digital transformation to think more upstream, whatever we do in medicine in terms of problem is always downstream. We're fixing problems. Here's an opportunity for us to co create with the people that are doing this, the engineers to say these are the problems I want solved. Can you help us with this? And hopefully we can do that. So I want to conclude by saying, you know, it's really been an amazing time in terms of biomedical science and technology, unfortunately, hasn't really resulted in superior health and health outcomes for the population because we see that evidence with the cardiovascular disease increasing. So we do have to understand the importance of social determinants of health, health equity. And I think we need to start thinking differently about how we deliver care and we need to deliver it through digital transformation. So I really think that that intersection of science and technology combined with an innovative mindset good policies, intentional investment in health really could usher in a new um new era of better health for not only the United States but for the world. And I think that cardiovascular disease is at is at the tip of that sphere. So I'm gonna end with Leonardo Da Vinci's head. I have been impressed with the urgency of doing knowing is not enough. We must apply, being willing is not enough, we must do. And I think it's time for us to do so. Thank you very much. Yeah, I be sitting please. Thank you. I think that was fantastic and um a great overview of uh where we are and where we're going, right So um the panel, do you guys have any questions for? Yeah, fantastic talk. Um I'm very curious to know uh what the data are in underserved populations, particularly. We talk about um you know, access to digital health as a way to improve access across the the spectrum of patients. But you know, I I work at three different hospitals, the classic private hospital. Um uh The city, a city hospital that serves a predominantly underserved population as well as the va and many of my patients at the va or uh the city hospital don't even have access to cell phones. Um And many of them are unhoused. Um And so, so it is, it is difficult. One of my colleagues is just got NIH funding to do um a randomized trial looking at rehab, the traditional form as well as a digital rehab. And here he is utilizing both hospitals since they are side by side and the patients get a tablet that they get to take. Um And so I don't know what that's gonna show, but I'd like to know if you, I mean, you hit one of the things is we don't have data in, in some of those underserved populations. I think we're gonna get data because we're starting to do trials in the rural areas. But I will tell you this is where low and middle income countries come in. And my role in the World Heart Federation, I get to see sort of what's happening around the world and we can learn from these places because they're using things, they, they're doing what we call frugal innovation. And I, I think that we can really learn from that. So for example, uh in India they're doing piloting where they have um all of those digital tools that I talked to you about and you have a community worker with a backpack that has everything on it. and she goes to home to, to homes or community centers in different places and people come to her in a local environment to do that. They don't have to have any device. They just come, Walmart is just um piloting in the United States. Um They have, I think like I 5, 10 or 15 areas where they're gonna have kiosks in all of those Walmarts and certain zip codes. So people can go in and do their telehealth visits there. And you can imagine even having an individual there for that, but there are models out there. It's just, we haven't done it. I do think that the future is gonna be community health workers and going to where people are. We've clearly seen how much, how effective that is and certainly for those patients that are unable to do that, that's how we're gonna be able to do it. Yeah, that hypertension trial specifically going to the barbershops and really, you know, bringing the pharmacists to the barbershops was an amazing way of, um, you know, rethinking how we do clinical trials except that we're not doing, do you see how many barbershops are doing hypertension control? We're talking about it. I mean, we talk about it every time people say, wow, that was such a great study, but we're not doing it. You're right. Absolutely right. Uh Sean, I'm interested uh as director of, of communication and consumer strategy for our health care system. Where do you think we are? Where are we going with this? We've got a lot of work to do, that's for sure. Um We, we're doing work every day but it's never enough. Um I think the two biggest challenges we have with digital health. Um And again, did a great presentation is every conference we go to um every health system we speak with. Um just had a conversation with folks from Piedmont not too long ago. Um Everybody's trying to figure this out every day. The two challenges we have are communication, believe it or not to do this and do it well, you have to create that to use the buzzword, frictionless experience for the consumer, but also for the physician because the first time you go to use any of this new technology, if it's not intuitive, if it doesn't work well, if it doesn't provide you meaningful information, you make immediate snap judgments about it and you move on and it's because the second complication we're into is is time how much time do we all have every day? I mean, how much time do you guys have every day running from meetings, running from appointment to appointment? Constantly feeling like you're behind to understand how to use the technology. It's one thing for it to provide the data. But if you don't have the time to understand, well, how can this help me? How can this help me help my patient? Um It's a challenge. So the two biggest things we're working on right now within our health system are remote patient monitoring and trying to find those right use cases so that it does provide value immediately. So not only for the physician but for the consumer, they see the value to it. Um and the second one which is really simple, it's not that complicated, but it's trying to improve access. It's just trying to remove those barriers to care through things like virtual visits. Um and believe it or not online scheduling um is as simple and as basic as that can sound. Um most consumers today, every person checking into this hotel today did so online and they were able to easily look up and find out. When can I make my, when can I make my reservation? What time am I supposed to show up? And they expect when they walk in the door, the registration desk is ready for them. Their room is ready and they can walk in and ideally, they don't have to talk to a person, they just use the app to open up the door of their room. Um We've got a long way to go in health care just to just provide that foundational basic. Um And I'll open up this Pandora's box and stop talking. The biggest challenge is how do we also incentivize at the community hospital level? Um Financial investment in digital health, um large consortiums, venture capital funds, large academic teaching institutions uh can get al alternate funding sources to explore this technology. But at the community hospital level and at the community health level, um it's a challenge to invest those dollars and those technologies when the reimbursement models aren't totally there. Yeah. But as we're thinking about how we're doing research differently, one thing that the community hospitals are more nimble in terms of being able to do some of this digital health technology research. So co creation, I think with companies helps. So I think a lot of people are partnering with different companies to say these are the solutions. How can we do this? So co creation helps. I think trying to use a different model than traditional academic centers to test some of these digital tools uh in the community as well as in community hospitals, I think will also make a difference because we get the data faster for doing that. Excellent. Any questions from the audience Panelist? Any other questions? Give you extra time back. Thank you. So much. Thank you. Excellent presentation.
